Basic Emergency Care

Basic Emergency Care 20091st Edition

DR.Mohammmad A.Ghany 5/5/2009

Basic Emergency Care (Cardiopulmonary Resuscitation and First Aid)

Edited by: Dr. Mohammad A. Ghany Ismail Master of general surgery May, 2009

Preface All thanks to Allah for giving me the courage and patience to achieve this work. This manual is designed to provide medical students with an updated and concise knowledge in the first aid and CPR .It is designed in a clear and easy manner to understand for the average student. Carefully selected illustrations and photographs are included. I hope my students will realize my effort and meat that with a similar effort from their sides to achieve success and progress. And I hope that this book will provide an experience that is instructive and enjoyable and I would be very happy to receive your comments and please excuse any errors and omissions. Many thanks to the beloved members of my family whose support is essential in accomplishing this formidable task. I want to express my gratitude to my colleagues for their valuable help and suggestions.

The Editor: Dr∕Mohammad A.Ghany

‫سةْ نَفسْي كَما‬ ‫علّمني أنْ أدَا ِ‬ ‫"يا َربْ عَلمّنْي أنْ أدةّ النَاسْ كَما أدةّ نَفسْي وَ َ‬ ‫علّمنْي أنْ التسَامخ هَوأكْثَر مَراتة القوّج وَأنّ دةّ االنتقام هَو أولْ‬ ‫سةْ النَاسْ وَ َ‬ ‫أدَا ِ‬ ‫مَظاهِر الضعْفَ‪ .‬يا َربْ ال تدعني أصَاب تِالغرور إذا نَجَذْت وَال تاليأس إذا فْشلت تَل‬ ‫ذكّرني دائِـماً أن الفَشَل هَو التجَارب التي تسْـثِق النّجَاح"‬

Table of Contents Introduction to Emergency Medical Care……………………1 Part One: Cardiopulmonary Resuscitation...................3 Chapter 1:Cardiovascular and Respiratory Anatomy and Physiology…………………………………………………….4 – Respiratory system…………………………………..…..5 – Cardiovascular system………………………………...11 Chapter 2: Cardiovascular emergencies………………18 – – – – –

Risk factors of CV diseases…………………………..19 Coronary artery diseases……………………….……21 Acute myocardial infarction………………………..22 Congestive heart failure……………………………..24 Arrhythmia ………………………………………….…….26

Chapter 3:Patient assessment and early management………………………………………….……...….28 Chapter 4: Basic Vital Signs……………………..……..….35 – Pulse………………………………………………………......36 – Respiration……………………………………………..…. 37 – Blood pressure……………………………………...……38 Chapter 5: Cardiopulmonary Resuscitation (CPR).39 – – – – –

Chain of survival……………………………..…………..40 Introduction to CPR……………………………………..42 CPR, know what to do? .................................43 Infant CPR……………………………………………………49 Child CPR…………………………………………………….50

Chapter 6: Choking……………………………………………51 – Choking; causes, management…………………….52 – Choking; conscious infant…………………….……..54 – Choking; unconscious infant………………….…….55 Chapter 7: External Defibrillation………………………56 – Automated external defibrillator (AED)………57 Part Two: first Aid………………………………………………….61 Chapter 1: The Human Body Anatomy and Physiology………………………………………………………….60 – Integumentary, skeletal, muscular, nervous systems………………………………………………………63 – Survival needs…………………………………………….64 – Anatomical position…………………………..……….64 – Body cavities………………………………………..…….65 Chapter 2: Trauma……………………………………………..66 – Introduction to trauma management………….67 – Trauma assessment……………………………………73 Chapter 3: Shock and Bleeding ………………………..80 – – – –

Shock …………………………………………………………81 Bleeding……………………………………………………..86 Epistaxis……………………………………………….…….87 Internal bleeding………………………………………..88

Chapter 4: Soft Tissue Injuries…………………………..90 – Contusion, Haematoma………………….…….…….91 – Abrasion……………………………………………….……92

– Laceration, Puncture, Avulsion……………..……93 – Amputation……………………………………………….94 – Evisceration, Neck wound, chest wound…….95 Chapter 5: Musculoskeletal Injuries……………….….96 – Fracture………………………………………………….….97 – Dislocation, Sprains, Strains………………………100 Chapter 6: Burns………………………………………………103 – – – –

1st degree burns…………………………………..…..105 2nd degree burns……………………………….…….106 3rd degree burns……………………………………….107 Management of burns………………………………111

Chapter 7: Head Injuries……………..……………………116 – – – – – – – – –

Scalp laceration………………………………..……….117 Skull fracture……………………………………….……118 Brain concussion……………………………………....118 Cerebral contusion……………………………………119 Epidural haematoma………………………………...119 Subdural haematoma…………..……………………120 Cerebral laceration…………………………………….120 Assessment of head injury…………………………121 Management of head injury………………………122

Introduction

INTRODUCTION TO EMERGENCY MEDICAL CARE History and Origins of EMS (emergency medical service)  Accidental Death & Disability is the Neglected Disease of Modern Society.  Emergency care developed during warfare at the beginning of the 20th century. 

By the 1960s, domestic emergency care lagged behind.



Staffed emergency departments were often limited to large urban areas.

Now it is the duty of everyone to know some basic emergency care Components of the EMS System Prehospital Care – First Responders/EMT(emergency medical technician) – Intermediates/EMT-Paramedics Emergency Departments – Patient Care Technicians/Nurses/Physicians Specialty facilities – Cardiac center – Stroke center – Trauma centers -1-

Introduction – Burn centers – Pediatric centers – Others Roles and Responsibilities – Personal safety – Safety of crew, patient, and bystanders – Patient assessment – Patient care – Lifting and moving patients safely – Transport/transfer of care – Record-keeping/ data collection Basic emergency care includes:  Basic Life Support: - Airway management & CPR - Automated External Defibrillation - Emergency Oxygen  Basic First Aid: Care for Injuries and Sudden Illness

-2-

Part One Cardiopulmonary Resuscitation

Chapter 1

Cardiovascular and Respiratory Anatomy &Physiology

Respiratory System

CPR

The purpose of the respiratory system is to move oxygen (0 2) into the bloodstream through inhalation and pick up carbon dioxide (C02) to be excreted through exhalation. Basic Respiratory Anatomy(Fig.1-1) Air enters the body through the mouth and nose. It moves through the oropharynx (the area directly posterior to the mouth) and the nasopharynx (the area directly posterior to the nose). Air then proceeds on a path toward the lungs passing through larynx ,trachea and bonchi. Upper respiratory tract (outside thorax):  Nose.  Pharynx.  Larynx. Lower respiratory tract (inside thorax):  Trachea .  Two main bronchi,  Bronchial tree.  Two lungs and pleura. Larynx(Fig.1-2) Consists of 4 main cartilages: a. One Thyroid cartilage. b. One cricoid cartilage. c. One epiglottis. d. Two arytenoid cartilages.

Fig.(1-1)Respiratory system

Fig.(1-2)Larynx

A leaf-shaped structure called the epiglottis closes the larynx to prevent foods and foreign objects from entering the trachea during swallowing. The larynx contains the vocal cords. The cricoid cartilage is a ring-shaped structure that forms the lower portion of the larynx. The trachea Is the tube that carries inhaled air from the larynx down toward the lungs, It is formed of 15-20 C shaped cartilages, incomplete posteriorly At the level of the lungs, the trachea splits (bifurcates) into two branches called the bronchi. One to each lung. Inside each lung, the bronchi continue to branch and split and the air passages get smaller and smaller. Eventually, each branch ends at a group of alveoli. The alveoli are the small sacs within the lungs where gas exchange takes place with the bloodstream. The lung Are two large spongy organs, occupying the thoracic cavity. They are cone-shaped having apex, base and two surfaces: – Apex: located above the clavicle. – Base: resting on the diaphragm. – Surfaces: 1- Costal: is convex related to the ribs and costal cartilages. 2- Medial: is concave, containing the hilum.

Hilum of the lung: It is triangular in shape, lying on the medial surface. Structures that enter and leave at hilum are: 1-The primary bronchus. 2- One pulmonary arteray 3- Two pulmonary veins

The right lung consists of 3 main lobes (superior,middle and inferior).The left lung consists of 2 main lobes(superior and inferior). The diaphragm Is the muscular structure that divides the chest cavity from the abdominal cavity. The intercostal muscles fill the intercostal spaces. During normal respiration, the diaphragm and intercosals work together to allow the body to inhale and exhale. Pleura Two layers 1- Visceral pleura: covers the lung. 2-parietal pleura: lines thoracic cavity and upper surface of Diaphragm. Both are separated by a space (pleural cavity) filled with few drops of pleural fluid.

Basic physiology Rate of respiration in adult is 16-20 cycle/ minute. This rate is faster in children and slower in adult. Respiration consists of 2 phases: Inspiration (inhalation) is an active process. The diaphragm and the intercostals contract,

the diaphragm lowers and the ribs

moves upward and outward, this leads to decrease intrathoracic pressure

expansion of the lung and air flow in the lung.

Expiration (exhalation) is a passive process. . The diaphragm and the intercostals relax, the diaphragm rises and the ribs moves downward and inward, this leads to decrease of chest size and elastic recoil of the lung and air flow out of the lung. Air moves into the lungs through the series of airpassages (the airway). During inhalation, air is moved into the alveoli. These small sacs in the lungs are where gas exchange with the blood takes place. The alveoli are very small. The blood vessels around the alveoli are capillaries. Oxygen is transferred from the air in the alveoli to the bloodstream through the very thin walls of the alveoli and the capillaries. At the same time carbon dioxide and waste product of the body's cells, moves from the bloodstream into the alveoli. Oxygenated blood is carried from the lungs to the heart so it can be pumped into the circulatory system of the body. Oxygen carried by the blood is given up to the cells. Waste carbon dioxide is picked up from the cells and returned through veins to the heart and then the

lungs where it moves from the bloodstream into the alveoli and out of the body through exhalation. Infants and children (Fig.1-3)

There are a number of special aspects of the respiratory anatomy of infants and children: 1-

In general, all structures in a child are smaller and more easily

obstructed than in an adult. 2-Their tongues take up proportionally more space in the phatynx than do an adult's. 3- The trachea is relatively narrower than in adults and, therefore, more easily obstructed by swelling or foreign matter. 4- The trachea is also softer and more flexible in infants and children, so more care must be taken during any pressure

on the

neck, such as in applying a cervical collar or during procedures to place a tube in the trachea. 5- The cricoids cartilage is less developed and less rigid in infants and children. Fig.(1-3)

Cardiovascular System (circulatory system)

CPR

The cardiovascular system consists of the heart and the blood vessels through which blood is circulated throughout the body.

Basic Anatomy of the Heart(Fig.1-4) The human heart is a muscular organ about the size of your fist; located in the center of the thoracic cavity.

The heart has four chambers: Two upper chambers called atria and two lower chambers called ventricles. The atria both contract at the same time. When they contract, blood is forced into the ventricles. Both ventricles contract simultaneously to pump the blood out of the heart. The path the blood through the body is as follows: right atrium to right ventricle to lungs to left atrium to left ventricle to body, then back to the right atrium to start its journey all over again.  Right atrium: The superior vena cava and the inferior vena cava are the two large veins that return blood to the heart. The right atrium receives this blood and sends it to the right ventricle. 

Right ventricle. The right ventricle receives blood from the right atrium. When the right ventricle contracts, it pumps this blood out to the lungs via the pulmonary arteries, this

blood is very low in oxygen and high in carbon dioxide in the lungs, the carbon dioxide is excreted (taken out of the blood ), and oxygen is obtained (taken into the blood from air the person has inhaled). The oxygen-rich blood is now returned to the left atrium via the pulmonary veins.  Left atrium. The left atrium receives the oxygen rich blood from the lungs. When it contracts, it sends this blood to the left ventricle. 

Left ventricle. The left ventricle is the most muscular and strongest part of the heart. It receives oxygen rich blood from the left atrium. When it contracts, it pumps this blood into the aorta, the body's largest artery, for distribution to the entire body.

Fig.(1-4)

Valves and openings: (Fig.1-5) A. Opening between Atria and ventricles guarded by tricuspid valve on the right and mitral (Bicuspid) valve on the left side. * Both valves arc called atrio-ventricular valves (A- V valves). B. Opening from the right ventricle into pulmonary artery guarded by pulmonary valve. C. Opening from the left ventricle into Aorta, guarded by aortic valve. *Both pulmonary and Aortic valves are called (semilunar valves). Function of valves: All valves allow flow of blood in one direction and prevent its regurge.

Fig.(1-5):Valves of the Heart

Circulation of the Blood

The kind of vessel that carries blood away from the heart is called an artery. Arteries begin with large vessels, like the aorta, they gradually branch to smaller and smaller vessels. The smallest branch of an artery is called an arteriole .These small vessels lead to the capillaries. Capillaries are tiny blood vessels found throughout the body.

the

products

capillaries are

are

exchanged

where between

gases, the

nutrients, body's

cells

and

waste

and

the

bloodstream. From the capillaries the blood begins its return to the heart by entering the smallest veins, small veins are called a venules. The kind of vessel that carries the blood from capillaries back to the heart is called a vein.

Important arteries to know:(Fig.1-6) • Coronary arteries (right and left): The coronary arteries branch of the aorta and supply the heart muscle with blood. Although the heart has blood moving through it, it receives its own blood supply from the coronary arteries. Damage or blockage to these arteries usually results in severe chest pain. • Aorta: The aorta is the largest artery in the body. It begins at its attachment to the left ventricle, travels superiorly, then arches inferiorly in front of the spine through the thoracic and abdominal cavities, then splits into 2 iliac arteries.

 The pulmonary artery: The pulmonary artery begins at the right ventricle. It carries oxygen-poor blood to the lungs, an exception to the rule (arteries carry oxygen-rich blood, and veins carry oxygen-poor blood). It does, however, follow the rule that arteries carry blood

away from the heart while veins

carry blood to the heart.  Carotid artery: The carotid artery is the major artery of the neck. You will be familiar with this vessel from your CPR class. It is the artery that is palpated during CPR pulse checks for adults and children. . It carries the main blood supply of the neck one on each side. Never palpate both at the same time because of the danger of interrupting the supply blood to the brain.  Femoral artery:"femoral" to the bone in the thigh, the femur. Pulsations for this artery can be felt in the crease between the abdomen and the groin. This artery is the major source of blood supply to the thigh and leg.  Brachial artery. The brachial artery is in the upper arm. It is the pulse checked during infant CPR. Its pulse can be felt anteriorly in the crease over the elbow

and along the medial

aspect of the upper arm. It is also the artery that is used when determining blood pressure with a blood pressure cuff and a stethoscope.

 Radial artery. This artery travels through and supplies the lower arm. The radial artery is the artery felt when taking a pulse at the thumb side the wrist. Again, you can relate the name "radial to the radius, a bone in the forearm.  Dorsalis pedis artery The dorsalis pedis artery lies on the top (dorsal portion) of the foot, lateral to the large tendon of the big toe.

Important veins to know(Fig.1-6)

there are two venae cavae. The superior vena collects blood that is returned from the head and upper body. The inferior vena cava collects blood from the part of the body below the heart. superior and inferior venae cavae return blood to the right atrium. Basic physiology

The contraction (beating) of the heart is involuntary. The heart has its own pacemaker and special conducting system(modified cardiac muscles initiate and propagate impulses). Regulation of the heart beat rate,rhythm and force is under control of the brain: a - Cardiac acceleratory center (C.A.C): This center sends

stimulating

impulses

to

the

heart

causing

(Tachycardia).

b - Cardiac inhibitory center (C.LC): This center sends

inhibitory

(Bradycardia).

impulses

to

the

heart

causing

Fig.(1-6) Main Arteries and Veins of the body

Chapter 2

Cardiovascular Emergencies

Cardiovascular Emergencies

CPR

Cardiovascular Emergencies Risk factors of cardiovascular disease What are the major risk factors that can't be changed? 

Increasing age — Over 83 % of people who die of coronary heart disease are 65 or older.



Male sex (gender) — Men have a greater risk of heart attack than women.



Heredity (including Race) — Children of parents with heart disease are more likely to develop it themselves. African Americans have more severe high blood pressure than Caucasians and a higher risk of heart disease.

What are the major risk factors you can modify, treat or control by changing your lifestyle or taking medicine? 

Tobacco heart

smoke — Smokers'

disease

is 2–4

risk

times that

of of

developing

coronary

nonsmokers.

Cigarette

smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. 

High blood cholesterol — As blood cholesterol rises, so does risk of coronary heart disease.



High blood pressure — High blood pressure increases the heart's workload, causing the heart to thicken and become stiffer.



Physical inactivity — An inactive lifestyle is a risk factor for

heart disease. Regular, moderate-to-vigorous physical

activity helps prevent heart and blood vessel disease. 

Obesity and overweight — People who have excess body fat — especially if a lot of it is at the waist — are more likely to develop heart disease and stroke even if they have no other risk factors.



Diabetes mellitus — Diabetes seriously increases your risk of developing cardiovascular disease.

What other factors contribute to heart disease risk? 

Individual response to stress



Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It contributes to obesity, alcoholism, suicide and accidents. Prevention of Heart Disease a. Regular exercise b. Optimal body weight c. Sound nutrition d. Nonuse of tobacco and other drugs e. Nonuse use of alcohol f. Dealing constructively with stress a. Periodic medical examinations

Coronary Artery Disease

CPR

Coronary Artery Disease Myocardium (heart muscle) requires continuous oxygen and nutrient supply Myocardial blood supply passes through coronary arteries Atherosclerosis (Fig.2-1)  Is Narrowing of lumen of blood vessel – plaque formation - related to Risk Factors – results in decreased myocardial perfusion  Poor tissue perfusion causes: a. tissue damage (ischemia) b. Tissue death (infarction)

Fig.(2-1):Atheroma or Plaque

Acute Myocardial Infarction

CPR

Acute Myocardial Infarction ―Heart Attack‖  Inadequate perfusion of myocardium causes: – Death of myocardium

=

Infarct

– Damage to myocardium = Ischemia Symptoms of acute myocardial infarction (AMI) 1. Chest Pain - cardinal sign of myocardial infarction – Occurs in 85% of MI’s – Substernal – ―Crushing,‖ ―squeezing,‖ ―tight,‖ ―heavy – May radiate to arms, shoulders, jaw, upper back, upper abdomen back – May vary in intensity – Unaffected by: Swallowing,coughing,deep breathing or movement – Unrelieved by rest/nitroglycerin – Pain lasts longer (up to 12 hours) 2. Shortness of breath 3. Weakness, dizziness, fainting 4. Nausea, vomiting

5. Pallor and diaphoresis (heavy sweating) Important Notes: – (50% of deaths occur in first two hours) – (Average patient waits 3 hours before seeking help) – Changes in pulse, BP, respiration are not diagnostic of AMI – Early recognition of MI is critical – When in doubt, manage all chest pain as MI Management of Cardiac Chest Pain a. Position of Comfort: sitting or lying down b. Patent Airway c. High concentration O2 d. Reassure the patient e. Obtain a brief history and physical exam f. Aspirin 325mg oral. g. Nitroglycerin 0.4mg tablet sublingual h. transport immediately: – Do not walk patient to the ambulance – Do not use lights/siren if patient is awake, alert, breathing without distress – Monitor vital signs every 5-10 minutes

Congestive Heart Failure

CPR

Congestive Heart Failure(CHF)  CHF = Inability of heart to pump blood out as fast as it enters. 

May be left-sided, right-sided, or both.

Causes 1. Coronary Artery Disease 2. Chronic hypertension (high blood pressure) 3. AMI 4. Valvular heart disease Symptoms of CHF 1. Weakness 2. Dyspnea 3. Dyspnea on exertion 4. Orthopnea=Difficulty breathing on lying down 5. Congested neck veins 6. Tachycardia 7. Pulmonary Edema  Noisy, labored breathing  Coughing  Rales, wheezing  Pink, frothy sputu

Management 1. Sit patient up 2. Administer high concentration O2 3. Monitor vital signs ∕ 5-10 minutes

Arrhythmia

CPR Arrhythmia

Arrhythmia means any abnormality of rate, regularity or site of origin of cardiac impulse.  Normal sinus rhythm =60-90 bpm  Bradycardia (slow rhythm): <60 bpm  Tachycardia (fast rhythm): >100 bpm

Sinus Tachycardia Heart rate exceeding 100 per minute Physiological 1. Exercise 2. Strong emotion 3. Anxiety states 4. Pain Pathologic 1. Fever-Infection 2. Hemorrhage-Shock 3. AnemiaCongestive 4. heart failure

Sinus Bradycardia Heart rate is less than 60 per minute Physiologic 1. athletes 2. Emotional states leading to syncope 3. Sleep Pathologic 1. Systemic disease: – Obstructive jaundice – myocardial infarction(inferior wall or atrial infarction) – high intracranial pressure

Chapter 3

Patient assessment and early management

Patient Assessment and Early Management • What is Patient Assessment? • Why is Patient Assessment important? Phases of patient assessment – Scene Survey – Initial Assessment – Focused History and Physical Exam – Detailed Physical Exam – Ongoing Assessment – Communication – Documentation

Scene Size Up – Location – Incident – Injured/Injuries – Observe  Smoke?  Fire?  High line wires  Possible Mechanisms of Injury

CPR

– Ensure Safety  Yourself  Partner  Other rescuers/Bystanders Scene Safety & Personal Protection • Body Substance Isolation – Hand washing – Gloves & eye protection – Mask & gown • Protective Clothing – Cold weather clothing • Dress in layers – Gloves • Use proper gloves for job being performed Your personal safety is of the utmost importance. You must understand the risks of each environment you enter! Initial Assessment • Purpose – To rapidly identify & correct life threats – To identify those patients who need rapid evacuation • Minimum Time on scene - Maximum Care En Route Include: A. General Impression – Using the facts gathered to this point, what is your first impression of the patient’s condition?

B. Chief Complaint C. Mental Status (Level of Consciousness) – A - Alert – V - Verbal – P – Painful – U - Unresponsive D. Identify Life Threats (A-B-C-D) – Airway • Control C-spine (If trauma suspected) • Open-Clear-Maintain – Breathing • Look • Listen • Feel • Bare chest if respiratory distress apparent – Circulation • Major Bleeding • Pulse (Rapid/Slow : Weak/Bounding) • Capillary Refill • Skin Color • Pale • Ashen • Cyanotic • Mottled

• Red • Skin Temperature • Hot (warm) • Cool • Skin Condition • Moist • Dry – Disability – Expose • Head/Neck • Chest • Abdomen Rapid Evacuation Criteria for Rapid Evacuation – Poor General Impression – Unresponsive - no gag or cough reflex – Responsive - unable to follow commands – Cannot establish / maintain patent airway – Difficulty breathing / Resp. distress – Uncontrolled bleeding – Severe pain in any part of the body – Severe chest pain – Inability to move any part of body

Focused History & Physical Exam - Trauma • Purpose – Obtain Chief Complaint • What happened to the patient? – Evaluate Chief Complaint • What circumstances surround this incident? • Is the Mechanism of Injury a high risk for injury? – Conduct Physical Exam – Obtain Baseline Vital Signs • Re-evaluate Mechanism of Injury (MOI) Focused History & Physical Exam - Medical • Patient Responsive? Yes/No AVPU • A - Alert • V - Verbal • P - Painful • U -Unresponsive Responsive Patients - Medical • Assess Chief Complaint • Signs & Symptoms Unresponsive Patients - Medical • Rapid Medical Assessment • Baseline Vital Signs

• Transport Detailed Physical Exam • More detailed Head-to-Toe examination • Time sensitive • Required for any unresponsive patient • If the patient cannot communicate what is wrong, you must seek out the problem(s) • Required for any multi-trauma patient • Victims of multiple trauma must be assessed for less obvious or ―masked‖ injuries On-Going Assessment • Purpose – Determine if there are any changes in the patient’s condition – Identify any missed injuries or conditions – Assess the effectiveness of treatment given and adjust if necessary • Performed on both the trauma or medical patient • Procedure – Repeat Initial Assessment – Reassess Vital Signs – Repeat Focused Assessment – Check Interventions

Chapter 4

Basic Vital Signs

Vital signs

CPR VITAL SIGNS

Vital signs are an outward clue to what is going on in the patient’s body • DO NOT TREAT NUMBERS - - - - - - TREAT PEOPLE!!!! Pulse • Pulse Points (fig.4-1)

Dorsal Pedal Posterior Tibial (Posterior and slightly inferior to medial Malleolus)

Fig.(4-1) pulse Points

Rate – Adult • 60-90 Beats/minute – Child • 80-110 Beats/minute – Infant • 120-150 Beats/minute Rhythm • Regular or • Irregular Quality • Full • Weak (Thready) • Bounding Respirations Rate – Adult • 12-20 Resp/min – Child • 20-28 Resp/min – Infant • 30-70 Resp/min @ birth • 30 Resp/min @ 6 months

Rhythm • Regular or • Irregular Quality • Full • Deep • Shallow • Labored • Noisy Blood Pressure • Systolic - Pressure on the arterial wall when the heart contracts • Diastolic - Pressure on the arterial wall when the heart is at rest • Auscultated BP - Listening for both the systolic and diastolic values • Palpated BP - Feeling for the systolic pressure Auscultated Blood Pressure • Adult – Male 100+ Age (up to 50) 80 – Female 90 + Age (up to 50 80

Chapter 5

Cardiopulmonary Resuscitation (CPR)

Chain of Survival

CPR Chain of Survival

The American Heart Association has summarized the most important factors that affect survival of cardiac arrest patients in its chain of survival concept The chain has four elements: (1) early access, (2) early CPR, (3) early defibrillation, and (4) early advanced care.Fig.(5-1) Where each of these links is strong is much more likely to bring back a patient from cardiac arrest than a system with weaknesses in the chain.

Early access

early CPR

early defibrillation

early

Advanced care

Fig.(5-1): Chain of Survival

Early Access Early access means that the person who sees someone collapse or finds someone unresponsive calls a dispatcher who quickly gets EMS responding to the emergency. The public, unlike EMS provider used to recognizing emergencies, takes time to realize that an emergency exists and they should call for help . Early CPR Early CPR can increase survival significantly the only time it does not help is when defibrillation reaches the patient within approximately 2 minutes. Early Defibrillation This is the single most important factor in determining survival from cardiac arrest. The hard part is getting it to the patient in cardiac arrest early enough to be effective. If the response time of the defibrillator (time from call received to arrival of the defibrillator) is longer than 8 minutes virtually no one survives cardiac arrest. This is truley even with early CPR. Early Advanced Care Early advanced care is second only to defibrillation,(endotracheal tering

intubation,

medications

starting

into

an

an IV

responsible for a higher survival rate.

intravenous line)

are

line, also

adminisapparently

Cardiopulmonary Resuscitation

CPR

INTRODUCTION to CPR Facts about CPR 1. 75% of all cardiac arrests happen in people's homes. 2. CPR doubles a person's chance of survival from sudden cardiac arrest. 3. CPR provides a trickle of oxygenated blood to the brain & heart & keeps these organs alive until defibrillation can shock the heart into a normal rhythm. 4. Effective CPR provides 1/4 to 1/3 normal blood flow. 5. Rescue breaths contain 16% oxygen (21%). 6. If CPR is started within 4 minutes of collapse & defibrillation provided within 10 minutes, a person has a 40% chance of survival. 7. Brain damage starts in 4-6 minutes of cardiac arrest. 8. Brain damage is certain after 10 minutes without CPR CPR KNOWLEDGE QUESTIONS 1. The proper way to determine unresponsiveness is? 2. The preferred way to check for breathing is? 3. What is the best position for the victim to be in when you are doing CPR? 4. Where do most out of hospital cardiac arrests occur? 5. What is the best way to open the airway prior to giving mouth to mouth ventilations? 6. What is the recovery position? 7. What is the ratio of chest compressions to ventilation in one person adult CPR?

8. What is the ratio of chest compressions to ventilation in child and infant CPR? ANSWERS 1. Shake & Shout at the person 2. Look at chest to see if it rises & listen & feel for air coming from person's nose or mouth 3. Flat on the floor 4. In the home 5. Tilt head back & lift chin up 6. Placing victim on his or her side 7. 30 to 2 8. 30 to 2 CPR; KNOW WHAT TO DO? IT CAN BE AS EASY AS ( RAP- A- B- C) Survey The Scene, then: R – check Responsiveness (Fig.5-2) Tap shoulder and shout ―Are you ok?‖

Fig.(5-2)

A - Activate EMS (emergency medical service) if unresponsive= call 997

P - Position on back – All body parts rolled over at the same time – Always be aware of head and spinal cord injuries – Support neck and spinal column – victim must be on a hard surface – Place victim level or head slightly lower than body

A - AIRWAY • Head-tilt/chin-lift (Fig.5-3) Open victims' airway by tilting head back with one hand while lifting up chin with your other hand

Fig.(5-3):Open Airway, Head-tilt & Chin-Lift

B - BREATHING (Fig.5-4) 1. Position your cheek close to victim’s nose and mouth, look toward victim’s chest 2. Look, listen, & feel for breathing (5-10 seconds) 3. If not breathing, pinch victim's nose closed & give 2 full breaths(one

second

length)

into

victim's

mouth

(use

microshield) 4. If breaths won't go in, reposition head & try again. If still blocked,

suspect

choking,

perform

(Heimlich maneuver)

Fig.(5-4):Give 2 Full Breaths

abdominal

thrusts

C - CIRCULATION(Fig.5-5) 1. Check for carotid pulse by feeling for 5-10se conds at side of victim’s neck 2. If there is a pulse, but victim is not breathing, give Rescue Breathing at rate of 1 breath every 5 seconds 3. Check for return of pulse every minute

(Fig.5-4):Check Breathing, Carotid Pulse

4. If no pulse, begin chest compressions as follows: a) Place heel of one hand on lower part of victim's sternum between the nipples. With your other hand directly on top of first hand, depress sternum 1.5 to 2 inches(4-5 cm). b) Perform 30 compressions to every 2 breaths. c) After 30 chest compressions give: 2 slow breaths d) Continue until help arrives or victim recovers e) Chek for pulse after 2 minutes (5 cycles) 5. If the victim starts moving: check breathing When Can I Stop CPR? 1. Victim revives 2. Too exhausted to continue 3. Unsafe scene 4. Physician directed (do not resuscitate orders) 5. Cardiac arrest of longer than 30 minutes(controversial) Why CPR May Fail? 1. Delay in starting 2. Improper procedures (ex. Forget to pinch nose) 3. No ACLS follow-up and delay in defibrillation u Only 15% who receive CPR live to go home u Improper techniques

4. Terminal disease or unmanageable disease (massive heart attack) Complications of CPR  Vomiting- Aspiration  Rib fractures Prevention of Stomach Distension – Don’t blow too hard – Slow rescue breathing – Re-tilt the head to make sure the airway is open – Use mouth to nose method

Infant CPR

CPR INFANT CPR (Fig.5-6)

1. Tap baby's feet 2. Carefully tilt forehead back & lift chin. Open airway only slightly. 3. Check breathing for 5 seconds. Look, listen, & feel. 4. Give 2 slow breaths(Place your mouth over nose & mouth of baby). 5. Check for pulse for 5 seconds on the inside of upper arm against bone. 6. If no pulse, start CPR. a. Do a cycle of 30 compressions & 2 breaths for two minutes, then call 997. b. If another rescuer helps you, give 15 compression & 2 breaths. c. Use middle and ring finger. d. Compress below the line between the nipples, ½ to 1/3 of chest depth.

Fig.(5-6):Compress by 2 Fingers below the line between 2 Nipples

Child CPR

CPR CHILD CPR

1. Shake victim very gently & shout "Are You OK?" 2. Tell someone to call 977. 3. Carefully tilt forehead back & lift chin (open airway). 4. Check Breathing for 5 seconds (Look, listen, & feel). 5. If not breathing, give 2 slow breaths. 6. Check pulse for 5 seconds. If no pulse, start CPR: – Compress chest 30 times and give 2 breaths. – Compress with 1 hand on chest and ½ to 1/3 of chest depth Important notes  Even With Successful CPR, Most Won’t Survive Without ACLS (Advanced Cardiac Life Support) ACLS includes defibrillation, oxygen, and drug therapy

Chapter 6

Choking

Choking

CPR Choking

Causes 1. The tongue is the most common obstruction in the unconscious victim (head tilt- chin lift) 2. Vomit 3. Foreign body (Foods) 4. Swelling (allergic reactions/ irritants) 5. Spasm (water is inhaled suddenly) How to Recognize Choking? 1. High pitched breathing sounds? 2. Can’t speak, breathe or cough 3. Universal distress signal (clutches neck) 4. Turning blue Management of choking If victim is coughing strongly, do not intervene Conscious Choking A. Give 5 abdominal thrusts (Heimlich maneuver)(Fig.6-1) – Place fist just above the umbilicus (normal size) – Give 5 upward and inward thrusts

B. Continue until successful or victim becomes unconscious

Fig.(6-1): Heimlich maneuver

If Victim Becomes Unconscious After Giving Thrusts 1. Try to support victim with your knees while lowering victim to the floor 2. Assess 3. Begin CPR 4. After chest compressions, check for object before giving breaths breaths

You Enter An Empty Room And Find An Unconscious Victim On The Floor 1. Assess the victim (RAPABC) 2. Give CPR if needed 3. After giving compressions: –

look for object in throat

– then give breaths Choking: Conscious Infants (Fig.6-2) 1. Position with head downward 2. 5 back blows (check for expelled object) 3. 5 chest thrusts (check for expelled object) 4. Repeat

Fig.(6-2):Choking Infant

Choking: Unconscious infants 1. If infant becomes unconscious: 2. RAPABC 3. When the first breaths don’t go in, check for object in throat then try 2 more breaths. 4. If neither set of breaths goes in, suspect choking 5. Begin 30 compressions 6. Check for object in throat (no blind finger sweep) 7. Give 2 breaths

Chapter 7

External Defibrillation

Automated External Defibrillation

CPR

Cardiac arrest and Early Defibrillation Facts about defibrillation  The Most frequent initial rhythm in adult cardiac arrest: ventricular fibrillation  The Most effective treatment for VF: defibrillation  Increased VF time = Decreased survival probability  BLS cannot convert VF to normal sinus rhythm  BLS only increases time available to defibrillate Automatic External Defibrillators (AED) (Fig.7-1) Definition External defibrillator that incorporates rhythm analysis system, it contains a computer that analyzes the patient's heart rhythm after the operator applies two monitoring-defibrillation pads to the patient's chest. Types 1. Fully Automatic does not advise the EMT-B to take any action. They deliver the shock automatically once enough energy has been accumulated . 2. Semi- Automatic the more common type, advise the EMT-B to press a button that will cause the machine to deliver a shock through the pads. Semiautomatic defibrillators are sometimes called "shock advisory defibrillators."

Fig.(7-1):Automated External Defibrillator(AED)

Operational Steps 1. Assess scene and patient 2. Confirm cardiac arrest 3. Turn on power 4. Attach device 5. Initiate rhythm analysis 6. Deliver shock if indicated Do NOT use AED if patient is: 1. < 8 years old 2. Weighs < 55 pounds

1. Assess scene for safety – Water – Explosive atmosphere – Patient on conductive surfaces 2. Assess patient – ABCs – Presence of transdermal medication patches (nitro patches) 3. Confirm arrest – Unresponsive – Apneic – Pulseless 4. Start BLS 5. Attach defibrillator 6. Stop CPR, analyze rhythm(Avoid patient contact during analysis) 7. If machine says ―shock,‖ – ―Clear‖ patient – Deliver shock – Immediately reanalyze

Post-Resuscitation Care 1. Continue to support airway, ventilation 2. Supplemental O2 3. Clear airway if vomiting occurs 4. Monitor vitals 5. Stabilize, transport, meet ACLS team

Part Two First Aid

Chapter 1 The Human Body Anatomy and Physiology

Human Body

First Aid

The Human Body Anatomy and Physiology Integumentary System �Forms the external body covering �Composed of the skin, sweat glands, sebaceous glands, hair, and nails �Protects deep tissues from injury and synthesizes vitamin D

Skeletal System (Fig.1-1) �Composed of bone, cartilage, and ligaments �Protects and supports body organs �Provides the framework for muscles �Site of blood cell formation �Stores minerals Muscular System(Fig.1-1) �Composed of muscles and tendons �Provides locomotion and facial expression �Maintains posture �Produces heat �Provides protection and support Nervous System �Composed of the brain, spinal column, and nerves �Is the fast-acting control system of the body �Responds to stimuli �Interprets environmental stimuli

(Fig.1-1)

Survival Needs 1. Nutrients – needed for energy and cell building 2. Oxygen – necessary for metabolic reactions 3. Water – provides the necessary environment for chemical reactions 4. Normal body temperature –necessary for chemical reactions to occur 5. Atmospheric pressure – required for proper breathing and gas exchange in the lungs

Anatomical Position Body erect, feet slightly apart, palms facing forward, thumbs point away from body (Fig.1-2)

Directional Terms �Superior �Inferior �Anterior �Posterior �Medial �Lateral �proximal �Distal �Superficial �Deep

Fig.(1-2) Anatomic position

Body Cavities (Fig.1-3) A. Dorsal cavity protects the nervoussystem, and is divided into twosubdivisions �Cranial cavity – within the skull; encases the brain �Vertebral cavity – runs within the vertebral column; encases the spinal cord

B. Ventral cavity houses the internal organs (viscera), and is divided into two subdivisions �Thoracic

(Fig.1-3)

�Abdominopelvic 1. Thoracic cavity is subdivided into �Pleural cavities (two) – each houses a lung �Mediastinum – between the pleural cavities, Houses esophagus, rachea, etc �Pericardial cavity – encloses the heart. 2. Abdominopelvic cavity is separated from the thoracic cavity by the diaphragm �It is composed of two subdivisions  Abdominal cavity – contains the stomach, intestines, spleen, liver and other organs  Pelvic cavity – lies within the pelvis and contains the bladder, reproductive organs, and rectum

Chapter 2

Trauma

Introduction to Trauma Introduction to Trauma Management Facts about trauma Trauma is  The Leading cause of death at ages 1-40  Third leading cause in all age groups  50,000,000 injuries/year need medical attention  12% of all hospital beds occupied by trauma  350,000 permanently disabled/year  100,000 to150,000 deaths/year  One-fifth to one-third of all deaths may be preventable When does trauma death occur? See the following diagram

First Aid

Causes of death Immediate deaths (<1 hour) 1. Loss of Airway

3. Brain Stem Laceration

2. High C-Spine Lesion

4. Aortic/Heart Rupture

Early deaths (1-3 hours) 1. Epidural Hematoma 2. Subdural Hematoma 3. Hemo/Pneumothorax 4. Intra-abdominal Bleeding 5. Pelvic Fractures 6. Femur Fractures 7. Multiple Long Bone Fractures z Why do these patients die? Late (2-4 weeks) 1. Sepsis 2. Multiple Organ System Failure z How can these deaths be avoided? Trauma Care Conclusions z Definitive Trauma Care = Surgeon’s Knife z Short time to surgery = Improved survival z EMS improves survival by: o Recognizing critical trauma o Supporting oxygenation, ventilation, perfusion o Transporting rapidly to definitive care

Types of Trauma 1. Penetrating 2. Blunt – Deceleration – Compression Motor Vehicle Collisions Five major types – Head-on – Rear-end – Lateral – Rotational – Roll-over Head-on Collision  Vehicle stops  Occupants continue forward  Two pathways – Down and under – Up and over i.

Down and under pathway(injuries) – Paper bag pneumothorax – Aortic tear from deceleration – Head thrown forward • C-spine injury • Tracheal injury

ii.

Up and over pathway(injuries) – Chest/abdomen hit steering wheel • Rib fractures • Flail chest

• Cardiac/pulmonary contusions • Aortic tears • Abdominal organ rupture • Diaphragm rupture • Liver/mesenteric laceration – Head injuries • Scalp lacerations • Skull fractures • Cerebral contusions/hemorrhages – C-spine fracture Lateral Collision l

Car appears to move from under patient

l

Patient moves toward point of impact

l

Chest hits door

l

l

Lateral rib fractures

l

Lateral flail chest

l

Pulmonary contusion

l

Abdominal solid organ rupture

Upper extremity fracture/dislocations l

Clavicle

l

Shoulder

l

Humerus

Rotational Collision l

Off-center impact

l

Car rotates around impact point

l

Patients thrown toward impact point

l

Injuries combination of head-on, lateral

l

Point of greatest damage = Point of greatest deceleration = Worst patients

Roll-Over l

Multiple impacts each time vehicle rolls

l

Injuries unpredictable

l

Assume presence of severe injury Falls

l

Critical Factors – Height • Increased height = Increased injury • Always note, report – Surface • Decreased stopping distance = Increased injury • Always note, report Assess body part that impacts first Fall onto Buttocks (injuries)

l

Pelvic fracture

l

Coccygeal (tail bone) fracture Lumbar compression fracture Fall onto Feet(injuries) – Bilateral heel fractures – Compression fractures of vertebrae – Bilateral Colles’ fractures Stab Wounds Facts about:  Damage confined to wound track o Four-inch object can produce nine-inch track  Gender of attacker o Males stab up; Females stab down

 Evaluate for multiple wounds o Check back, flanks, buttocks  Chest/abdomen overlap – Chest below 4th ICS = Abdomen until proven otherwise – Abdomen above iliac crests = Chest until proven otherwise l

Small wounds do NOT mean small damage Gunshot Wounds

l

Damage CANNOT be determined by location of entrance/exit wounds

l

Severity cannot be evaluated in the field or Emergency Department

l

Severity can only be evaluated in Operating Room Conclusion  Look at mechanisms of injury  The increased index of suspicion will lead to:  Fewer missed injuries Increased patient survival

Trauma assessment

First Aid TRAUMA ASSESSMENT

I-Scene Size-Up l

Ensure Safety of – Yourself – Your partner – Other responders – Bystanders – Patient

l

Scene survey – Location? – Appearance? – Where is patient? – What is condition of vehicle? – Mechanism of Injury? Amount of force? – II-Initial Assessment

 Find life threats  If life-threat is present, DEAL and CORREC  If you can’t correct it: – Oxygenate – Ventilate – Transport –

Most obvious or dramatic injury usually isn’t what’s killing the patient

– Listen to patient’s chief complaint

Initial assessment include i.

Asses mental status (Level of Consciousness) – A - Alert – V - Verbal – P - Painful – U - Unresponsive

ii.

A-B-C-D A. Airway (with C-Spine Control) OPEN - CLEAR - MAINTAIN – Noisy breathing = Obstructed breathing – But all obstructed breathing is NOT noisy – Manual stabilization of C-Spine – Assume airway problems with: » Head, face, neck, thorax trauma » Low O2 tension B. Breathing LOOK - LISTEN - FEEL – Is patient breathing? – Is patient moving air adequately? – Give O2 immediately if: o Change in O2 saturation o Possible shock o Possible severe hemorrhage o Chest pain

o Chest Trauma o Dyspnea o Respiratory Distress If you think about giving O2, GIVE IT! – Assist ventilations if: o Rate is <12 o Rate is >24 o Decreased tidal volume o Increased respiratory effort If you can’t tell if ventilations are adequate, THEY AREN’T! – If breathing is compromised: o Expose o Palpate o Auscultate Try to find, and correct the cause C. Circulation – Is heart beating?=pulse assessment o Rate o rhythm o force – Serious external hemorrhage ? – Skin color, temperature o Cool o Pale

o Moist – If circulation is compromised: o Expose o Palpate o Auscultate Try to find, correct cause – If carotid pulse absent: o CPR o Transport D. Disability – Level of consciousness = Best indicator of brain perfusion – Pupils--Eyes are windows of CNS – Asses Head injury and fractures Important notes about Initial Assessment 1. Expose, Examine – You can’t treat what you don’t find – Remove clothing from critical patients 2. Vitals signs are not necessary to determine whether patient is critical Regardless of your findingsIf the patient looks sick, he is sick 3. Initial Resuscitation:  Aggressively correct hypoxia, hypovolemia  Immobilize C-spine  Maintain airway  Oxygenate

III-History, Physical Exam – You will get to this with MOST trauma patients – Perform only after: – Initial assessment is completed, and – All life-threats are corrected – Include – Rapid head-to-toe assessment if Significant mechanism of injury or multiple injuries – Focused assessment of injury site if NO significant mechanism of injury, isolated trauma only – Baseline vital signs – SAMPLE history Head to Toe Exam  Organized, systematic  Superior to Inferior  Proximal to Distal  Extremity assessment must include: » Pulse » Skin color, temperature » Capillary refill » Motor, sensory function

Baseline Vital Signs 1. Pulse » Rate: Rapid or Slow » Rhythm: Regular or Irregular » Quality Weak (Thready) ,Full or Bounding 2. Respirations » Rate :Inadequate or <10 or >24 » Rhythm :Regular or Irregular » Quality :Shallow-Full-Deep-Labored 3. Blood Pressure » Hypotensive? » Hypertensive? » Narrow pulse pressure? » Wide pulse pressure 4. Pupils » Dilated? » Unequal? » Reaction to light 5. Skin » Color » Temperature » Moisture » Turgor » Capillary refill

SAMPLE History – Signs, Symptoms – Allergies – Medications – Do you take any medications? – What are they? – Past, Pertinent Medical History – Have you had any recent illnesses? – Have you been receiving medical care for any conditions? – Last oral intake – Last food or drink – Events leading up to incident

Chapter 3

Shock & Bleeding

Shock

First Aid

SHOCK Inadequate perfusion (blood flow) leading to inadequate oxygen delivery to tissues. Physiology  Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose)  No oxygen= no energy  No energy= no life Cardiovascular System  Transports oxygen, fuel to cells  Removes carbon dioxide, waste products for elimination from body What is needed to maintain perfusion? 1. Pump Heart 2. Pipes Blood Vessels 3. Fluid Blood How can perfusion fail? 1. Pump Failure 2. Pipe Failure 3. Loss of Volume

Types of Shock and Their Causes 1) Hypovolemic Shock (the most common) – Loss of volume (blood , plasma and fluids) – Causes • Blood loss: trauma and haemorrhge • Plasma loss: burns • Water loss: Vomiting, diarrhea, sweating, increased urine loss 2) Cardiogenic Shock – Due to Pump failure – Heart’s output depends on • How often it beats (heart rate) • How hard it beats (contractility) – Rate or contractility problems cause pump failure – Causes • Acute myocardial infarction • Very low heart rates (bradycardias) • Very high heart rates (tachycardias) 3) Neurogenic Shock 1. Spinal cord injured

2. Vessels below injury dilate and Loss of peripheral resistance 4) Psychogenic Shock – Simple fainting (syncope) – Caused by stress, pain, fright – Heart rate slows, vessels dilate – Brain becomes hypoperfused – Loss of consciousness occurs 5) Septic Shock – Results from body’s response to bacteria in bloodstream – Vessels dilate, become ―leaky 6) Anaphylactic Shock – Results from severe allergic reaction – Body responds to allergen by releasing histamine – Histamine causes vessels to dilate and become ―leaky‖ Signs and Symptoms of shock » Restlessness, anxiety » Decreasing level of consciousness » Rapid, shallow respirations » Nausea, vomiting » Thirst

» Diminished urine output » Hypovolemia will cause – Weak, rapid pulse – Pale, cool, clammy skin » Cardiogenic shock may cause: – Weak, rapid pulse or weak, slow pulse – Pale, cool, clammy skin » Neurogenic shock will cause: – Weak, slow pulse – Dry, flushed skin » Sepsis and anaphylaxis will cause: – Weak, rapid pulse – Dry, flushed skin – Patients with anaphylaxis will: • Develop hives (urticaria) • Itch • Develop wheezing and difficulty breathing (bronchospasm) What chemical released from the body during an allergic reaction accounts for these effects? Shock is NOT the same thing as a low blood pressure! A falling blood pressure is a LATE sign of shock!

Treatment 1.

Secure, maintain airway

2. Apply high concentration oxygen 3. Assist ventilations as needed 4. Keep patient supine 5. Control obvious bleeding 6. Stabilize fractures 7. Prevent loss of body heat 8. Elevate lower extremities 8 to 12 inches in hypovolemic shock 9. Do NOT elevate the lower extremities in cardiogenic shock 10.Administer nothing by mouth, even if the patient complains of thirst

Bleeding

First Aid Bleeding

Types – External – Internal • Traumatic • Non-Traumatic Significance: If uncontrolled, can cause shock and death Identification of External Bleeding 1. Arterial Bleeding • Bright red-Spurting 2. Venous Bleed • Dark red-Steady flow 3. Capillary Bleed • Dark red-Oozing Control of External Bleeding 1. Direct Pressure(Fig.3-1) • gloved hand • dressing/bandage 2. Elevation

3. Arterial pressure points 4. Splinting • Air splint • Pneumatic antishock garment 5. Tourniquets • Final resort when all else fails • Used for amputations • write ―TK‖ and time of application on forehead of patient • Notify other personnel Epistaxis – Bleeding per nose – It is a Common problem – Causes 1. Fractured skull 2. Facial injuries 3. Sinusitis, other URIs 4. High BP 5. Clotting disorders 6. Digital insertion (nose picking) – Management

1. Sit up, lean forward 2. Pinch nostrils together 3. Keep in sitting position 4. Keep quiet 5. Apply ice over nose 6. 15 min adequate – Epistaxis can result in life-threatening blood loss Internal Bleeding – causes: • Trauma • Clotting disorders • Rupture of blood vessels • Fractures (injury to nearby vessels) Can result in rapid progression to hypovolemic shock and death – Signs and Symptoms • Pain, tenderness, swelling, discoloration at injury site • Bleeding from any body orifice • Vomiting bright red blood or coffee ground material • Dark, tarry stools (melena) • Tender, rigid, or distended abdomen

• Signs and symptoms of hypovolemia without obvious external bleeding – Management • Open airway • High concentration oxygen • Assist ventilations • Control external bleeding • Stabilize fractures • Transport rapidly to appropriate facility

Chapter 4

Soft Tissue Injuries

Soft tissue Injuries

First Aid Soft Tissue Injuries

Skin Anatomy and Physiology: see before Soft Tissue Injuries • Closed • Open Closed Injury • Associated with blunt trauma • Skin remains intact • Damage occurs below surface • Types – Contusions – Hematomas Contusion – Produced when blunt force damages dermal structures – Blood, fluid leak into damage area causing swelling, pain – Presence of blood causes skin discoloration called ecchymosis (bruise) Hematoma – ―Blood lump‖. Causes mass of blood to collect in the injured area – Larger blood vessel damaged

Abrasion

First Aid

Closed Injury Management 1. Rest 2. Ice 3. Compression 4. Elevate 5. Splint When in doubt assume underlying fractures are present Open Injury – Skin broken – Protective function lost – External bleeding, infection become problems Open Injury Types 1. Abrasions 2. Lacerations 3. Punctures 4. Avulsions 5. Amputations Abrasion • Loss of portions of epidermis, upper dermis by rubbing or scraping force. • Usually associated with capillary oozing, leaking of fluid • ―Road rash‖ is an example

Laceration, Puncture, Avulsion

First Aid

Laceration (Fig.4-1)

• Cut by sharp object • Typically longer than it is deep • May be associated with severe blood loss, damage to underlying tissues • Types – Linear – Stellate Punctures • Result from stabbing force • Wound is deeper than it is long • Difficult to assess injury extent • Object producing puncture may remain impaled in wound Avulsions (Fig.4-2) • Piece of skin torn loose as a flap or completely torn from body • Result from accidents with machinery and motor vehicles • Replace flap into normal position before bandaging • Treat completely avulsed tissue like amputated part

Amputation

First Aid Amputations (Fig.4-3)

• Disruption of continuity of extremity or other body part • Part should be wrapped in sterile gauze, placed in plastic bag, transported on top of cold pack • Do NOT pack part directly in ice • Do NOT let part freeze Open Wound Management 1. Manage ABCs first 2. Control bleeding 3. Prevent further contamination, but do not worry about trying to clean wound 4. Immobilize injured part 5. Mange hypoperfusion if present Special Considerations Implanted Objects • Do NOT remove • Stabilize in place • Exception – Object in cheek(Remove, dress inside and outside mouth)

Evisceration, Neck wounds, Chest wound

First Aid

Eviscerations • Internal organs exposed through wound • Cover organs with large moistened dressing, then with aluminum foil or dry multi-trauma dressing • Do NOT use individual 4 x 4’s • Do NOT attempt to replace organs Neck Wounds • Risk of severe bleeding from large vessels • Risk of air entering vein and moving through heart to lungs • Cover with occlusive dressing • Do NOT occlude airway or blood flow to brain • Suspect presence of spinal injury Open Chest Wound • May prevent adequate ventilation • Cover with occlusive dressing • Monitor patient for signs of air becoming trapped under pressure in chest (tension pneumothorax)

Chapter 5

Musculoskeletal Injuries

Musculoskeletal Injuries, Fracture

First Aid

Musculoskeletal System o Bones o Muscles o Cartilages o Tendons o Ligaments See anatomy Extremity Trauma A. Fracture: Break in bone’s continuity Causes w Direct force w Indirect force w Twisting forces (torsion) w Diseases of bones (pathological fractures) • Osteoporosis • Tumors Open vs. Closed Fractures w Closed = skin over fracture site intact w Open = break in skin over fracture site • Bone ends do not have to be exposed • Small opening in skin communicating with fracture site = open fracture • Open fractures more serious due to external blood loss, possible infection

One of the most important things we do is to prevent closed fractures from becoming open ones Fracture Types (Fig,5-1) w Transverse: fracture is at 90o angle to shaft w Oblique: fracture is at an angle other than 90o to shaft w Spiral: fracture coils through shaft of bone like a spring w Impacted: bone ends driven into each other w Comminuted: bone broken into > 3 pieces w Greenstick w Shaft of bone not completely broken w Compressed on one side, splintered outward on other What group of patients does this type of fracture occur in? (Children and old age)

Fig.(5-1):Types of Fractures

Fracture Signs w Deformity w Tenderness • Usually point tenderness • Overlies fracture site w Inability to use limb • Reliable sign of significant injury if present • Reverse is not true w Swelling, ecchymosis w Exposed fragments w Crepitus • Grating of bone ends • May be heard or felt • Do NOT actively seek

Dislocation,Sprains,Strains

First Aid

B-Dislocation: Displacement of bones from normal positions at joint Signs of dislocation w Deformity w Swelling, ecchymosis about joint w Pain/tenderness in joint w Loss of motion usually perceived as ―locked‖ joint C-Sprains w Partial, temporary dislocations w Result in tearing of ligaments w Bone ends NOT displaced from normal positions Signs w Tenderness w Swelling, ecchymosis w Inability to use extremity w No deformity w Degree of joint dislocation at time of injury cannot be determined during exam w Extensive damage to neural or vascular structures may have occurred D-Strains w Muscle pull‖ w Injury to musculotendenous unit w Pain on active motion w Pain not present on passive motion

Assessment, Management of musculoskeletal injuries

First Aid

Assessment of musculoskeletal injuries w Perform initial (primary) assessment w Locate, treat life-threats w Assess for injuries of head, chest, abdomen, pelvis w Assess distal neurovascular function w With exception of pelvic, possibly femur fractures, orthopedic injuries are NOT life-threatening. w Do NOT let spectacular orthopedic injury distract you from ABCs w It’s the unobvious things that kill patients!

w Evaluation must ALWAYS be done of distal neurovascular function: – Pulse – Skin color – Capillary refill – Sensation – Movement Management of musculoskeletal injuries w Splinting • Prevents further movement at injury site • Limits tissue damage, bleeding • Eases pain When in doubt SPLINT

w It may be difficult to differentiate fractures, dislocations and sprains Principles of Splinting 1) Do NOT move patients before splinting unless patient is in danger 2) Remove clothes to allow inspection of limb 3) Note, record distal neurovascular function before, after splinting 4) Cover wounds with dry, sterile compression dressings 5) Fractures: splint joint above, below fracture 6) Dislocations: splint bone above, below joint 7) Minimize movement 8) Support injury until splinting completed 9) Pad splint to avoid local pressure 10)

Angulated fractures w Realign before splinting w If resistance, pain encountered stop, immobilize as is

11)

Dislocations w Splint as is unless circulation compromised w Attempt to reposition once to restore pulse w If resistance, pain encountered stop, immobilize as it is

Chapter 6

Burns

Burns

First Aid BURNS

– Skin: Largest body organ – More than just a passive covering Skin Functions 1. Sensation 2. Protection 3. Temperature regulation 4. Fluid retention Two layers ( Fig.6-1) 1) Epidermis: Outer layer 2) Dermis: Elastic connective tissue, Contains specialized structures: a) Nerve endings b) Blood vessels c) Sweat glands d) Sebaceous (oil) glands e) Hair follicles

Fig.(6-1)

Types of Burn Injury • Thermal burns: flame, contact with hot objects. • Scald burns: hot fluids. • Chemical burns: necrotizing substances (acids, alkali). • Electrical burns: intense heat from an electrical current • Smoke & inhalation injury: inhaling hot air or noxious chemicals • Cold thermal injury: frostbite. Pathophysiology Burn is the Third leading cause of trauma deaths – Loss of fluids – Inability to maintain body temperature – Infection Critical Factors: classification of burn depends on 1) Depth 2) Extent Burn Depth (Fig.6-2) 1) First Degree (Superficial) • Involves only epidermis • Red • Painful • Tender

• Blanches under pressure • Possible swelling, no blisters • Heal in about 7 days 2) Second Degree (Partial Thickness) (Fig.6-3)

•

• Extends through epidermis into dermis • Salmon pink • Moist, shiny • Painful • Blisters may be present • Heal in ~7 to 21 days • Burns that blister are second degree,But all second degree burns don’t bliste

3) Third Degree (Full Thickness) (Fig.6-3)

• Through epidermis, dermis into underlying structures • Thick, dry • Pearly gray or charred black • May bleed from vessel damage • Painless • Require grafting l

Often cannot be accurately determined in acute stage

l

Infection may convert to higher degree

l

When in doubt, over-estimate

Complications of Burns(Common Complications) �Infection and Septicemia (can occur at any time during convalescence) �Renal Failure �Pneumonia �Diabetes (Stress Diabetes) �Curling's Ulcer (A stress ulcer specific to burns) �Adrenocortical insufficiency

Burn Extent: Rule of Nines A. Adult Rule of Nines(Fig.6-4)

Fig(.6-4):Adult rule of Nine

B. Pediatric Rule of Nines(Fig.6-5)

For each year over 1 year of age, subtract 1% from head, add equally to legs Rule of Palm Patient’s palm equals 1% of his body surface area Burn Severity Based on • Depth • Extent • Location • Cause • Patient Age

• Associated Factors Critical Burns 1. 3rd Degree >10% BSA(body surface area) 2. 2nd Degree > 25% BSA (20% pediatric) 3. Face, Feet, Hands, Perineum 4. Airway/Respiratory Involvement 5. Associated Trauma 6. Associated Medical Disease 7. Electrical Burns 8. Deep Chemical Burns Moderate Burns 1. 3rd Degree 2 to 10% 2. 2nd Degree 15 to 25% (10 to 20% pediatric) Minor Burns 1. 3rd Degree <2% 2. 2nd Degree <15% (<10% pediatric) Associated Factors that affect severity of burns a) Patient Age • < 5 years old • > 55 years old b) Burn Location • Circumferential burns of chest, extremities

Management of Burns

First Aid

MANAGEMENT OF BURNS 3 Phases – Emergent (resuscitative) – Acute – Rehabilitative Pre-hospital Care • Remove from area! Stop the burn! • If thermal burn is large--FOCUS on the ABC’s A=airwayCheck for patency, soot around nares, or signed nasal hair B=breathingCheck for adequacy of ventilation –O2 supply C=circulationCheck for presence and regularity of pulses • Burn too large--don’t immerse in water due to extensive heat loss • Never pack in ice • Patient should be wrapped in dry clean material to decrease contamination of wound and increase warmth Emergent Phase (Resuscitative Phase) • Lasts from onset to 5 or more days but usually lasts 24-48 hours

• begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins • Greatest initial threat is hypovolemic shock to a major burn patient! • Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn) Fluid Therapy The fluid leak, which is caused by increased capillary permeability, continues for 24 to48 hrs. post burn. • 1 or 2 large bore IV lines • Fluid replacement based on: – size/depth of burn – age of pt. – individualized considerations. • there are formula’s for replacement: – Parkland formula – Brooke formula – Modified Brooke – Evans formula

Parkland Formula Total 24 hours need =4 cc x % BSA x Kg – 1 / 2 over the first eight hours – 1 / 2 over the next sixteen hours Lactate Ringers is the fluid of choice Assessment of adequacy of fluid replacement • Urine output is most commonly used parameter • UOP= 30-50 ml/hr in an adult Wound Care After the initial resuscitation • Remove smoldering clothing • Do not remove adherent clothing • Provide comfort and pain control • Dry linen dressings, not gauze • Do not cool wound, can advance the degree of burn Emergency Department �Warmed saline on gauze, dry sterile towels until complete assessment performed. After complete assessment: 1. Clean with warm saline. 2. Debride loose dead tissue with sterile forceps. 3. Apply topical antibiotic cream or ointment.

4. Cover and wrap with sterile gauze. General Principles of Cleaning 5. Use clean technique and sterile instruments. 6. Debride any loose dead tissue with each dressing change. 7. Remove any remaining ointment or cream with each dressing change. 8. Open blisters if: a. Prevent movement of joint. b. Very large. c. Fluid in blister is not clear. General Principles of Dressing 1. Ensure gauze does not stick to wound. 2. Apply adequate cream or ointment. 3. Use protective layer to prevent adherence. 4. Adjacent burn surfaces should not touch. 5. Example: individually wrap fingers. 6. Adequate gauze to absorb drainage. 7. Gauze is for comfort, protection, warmth, and to keep area clean.

Topical Antimicrobials: Silver sulfadiazine (Flamazine, silvadene) – Good gram positive coverage and good yeast coverage. – Poor gram negative coverage. – Disadvantage: incomplete eschar penetration Splinting – Useful for hand burns and feet burns. – Keep hands in position of function Management of specific areas Face: – Polysporin bid or tid. – Occasionally, wet saline soaks bid. Eyes: – tetracycline or chloromycetin ointment. Surgical procedures • Escharotomy •

Fasciotomy

• Dressing / hydrotherapy • Debridement • grafting • Splinting

Chapter 7

Head Injuries

Head Injuries,Scalp Laceration

First Aid

Head injuries Nervous System Components • Central Nervous System – Brain(Cerebrum,Cerebellum,Brainstem) – Spinal Cord • Peripheral Nervous System – Motor nerves – Sensory nerve Injuries to Scalp and Skull • Scalp Lacerations • Skull Fracture Scalp Lacerations • Bleeding usually NOT severe enough to produce hypovolemic shock • If shock present, think about other injuries • Exceptions – Laceration that involves a large artery – Scalp injuries in children

Skull Fracture, Brain Concussion

First Aid

Skull Fractures • Injury to rigid box around brain • Indicates significant force • What happened to brain and neck? Types of Skull Fracture • Linear(fissure) – Most common – Crack in skull – Detected only on x-ray • Comminuted Multiple cracks radiate from impact point • Depressed – Bone fragments pressed inward – Places pressure on brain

Injuries to Brain Brain Concussion • Temporary disturbance in brain function • Probably due to brain being ―rattled‖ inside the skull by a blow to the head

Cerebral Contusion, Epidural Haematoma

First Aid

• Usually confused or unconscious • Retrograde amnesia--―What happened?‖ Cerebral Contusion • Means Bruising and swelling • Results from brain hitting skull’s inside • Since brain is in closed box, pressure increases as brain swells, blood flow to brain decreases Signs and Symptoms of Cerebral Contusion – Loss of consciousness – Paralysis (one-sided or total) – Unequal pupils – Vomiting Epidural Hematoma • Usually associated with skull fracture in temporal area • Fracture damages artery on skull’s inside • Blood collects in epidural space between skull and dura mater • Since skull is closed box, intracranial pressure rises Signs and Symptoms – Loss of consciousness followed by return of consciousness (lucid interval)

– Headache – Deterioration of consciousness – Dilated pupil on side of injury – Weakness, paralysis on side of body opposite injury – Seizures Subdural Hematoma • Usually results from tearing of large veins between dura mater and arachnoid • Blood accumulates more slowly than in epidural hematoma Signs and Symptoms • Deterioration of consciousness • Dilated pupil on side of injury • Weakness, paralysis on side of body opposite injury • Seizures Cerebral Laceration • Tearing of brain tissue • Can result from penetrating or blunt injury • Can cause: – Massive destruction of brain tissue – Bleeding into cranial cavity with increased intracranial pressure

Assessment of Head Injuries

First Aid

Assessment of Head Injury • Early detection of increased intracranial pressure is critical • If pressure inside skull exceeds average blood pressure, blood flow to brain stops • Level of consciousness is BEST indicator of patient’s condition • AVPU system • Glasgow scale AVPU System • Alert • Responds to Verbal Stimulus • Responds to Painful Stimulus • Unresponsive Glasgow Scale • Eye Opening – Spontaneous = 4 – To Voice = 3 – To Pain = 2 – None = 1 • Verbal Response – Oriented = 5

– Confused = 4 – Inappropriate Words = 3 – Incomprehensible Sounds = 1 – None = 1 • Motor Response – Follows Commands = 6 – Localizes Pain = 5 – Withdraws = 4 – Flexion = 3 – Extension = 2 – None = 1 • Maximum Score = 15 • Minimum Score = 3 Management of Head Injury • ABCs with C-spine control • C-collar, long board • Do NOT apply pressure to open or depressed skull fractures • Do NOT attempt to stop flow of blood or CSF from nose, ears • Do NOT remove penetrating objects

References

Basic Emergency Care

References 1. Limmer D., O'keefe M., Grant H. et Emergency Care,9th edition; Printice Newjersy.USA. 2. Hebb M.O. (1998): The Gist of Emergency edition,published by www.erbook.com. 3. Chapleau W.and Alexander M.(2008): nd Medical Technician Exam,2 edition; Barron's Series. 4. Adult Basic Life support; American Heart Retrieved on 13-6-2007. www.americanheart.org. 5. www.procpr.org.

al.

(2001): Hall-Inc.,

Medicine.3rd Emergency educational Association.