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First Aid training handbook David Olley

A.E.D. Abdominal Injury Amputation Anaphylaxis Angina Asthma Basic Life Support Bleeding Burns Chain of Survival Chest Injury Choking Compression only C.P.R. Cross Infection Crush Injury Diabetes Dislocations Eye Injury Febrile convulsions First Aid Kit Foreign Bodies Fracture Head Injury Heart Attack Heat Exhaustion Heat Stroke Hypothermia Internal Bleeding Introduction Meningitis Pelvic Fracture Poisons Recovery Position Seizure Shock Sickle cell disease Skeleton Slipped Disc Soft Tissue Injury Spinal Injury Stroke Unconsciousness Wounds Wound dressing

15 42 41 64 35 29 12 37 53 12 27 24 15 15 2 42 63 50 67 60 71 40 44 61 32 56 56 57 39 3 65 48 69 10 60 35 34 44 52 51 47 59 9 38 38

This handbook is ideal for use in support of a properly structured first aid course. It will also prove invaluable as ongoing reference for someone who has completed the course.


first aid training handbook


The nervous system

Accident records




Cross infection




First aid kit


Febrile convulsions


Initial response


Head injury


Primary survey








Secondary survey


Unresponsive casualty Š2013 Safety Publishing Ltd. All rights reserved. No part of this publication may be reproduced in any form or by any means without the written permission of Safety Publishing Ltd



Burn by depth


Agonal breathing


Burn by size


AVPU scale


Burn to the airway


Basic life support


Burn to the Eye


Chest compressions


Corrosive burns




Electrical burns


CPR children


Heat Exhaustion


Face masks/shields


Heat stroke


Recovery position




Rescue breathing


Treatment of burn


Sudden cardiac arrest


Muscul0-skeletal injury Back pain


Airway obstruction


Complicated fracture




Closed fracture


Chest injury










Fractured skull




Fractured spine


Fractured pelvis


Circulatory system

483 Green Lanes London N13 4BS

Burn by type


Respiratory system

Safety Publishing Ltd

Burn injury

Abdominal injury


Fractured rib




Fractured collarbone




Fractured arm


Blood loss


Fractured leg




Greenstick fracture


Circulatory system


Open fracture






Foreign body


Slipped disc


Heart attack




Internal bleeding


Sprains and strains


Minor wounds


Nosebleed Scalp wound Shock Splinters Wounds Wound dressing

41 43 35 40 38 38

Other conditions Anaphylaxis


Bites and stings




Eye injury







Cross Infection Cross infection occurs when bacteria or viruses that cause infection are passed from one person to another. In a First Aid situation this may be from the casualty to the first aider or first aider to the casualty, so it is a good idea to minimise any risk. Although the risk of catching disease from a patient is low, it is something that anyone who is likely to offer first aid should be aware of.

Blood born pathogens Pathogens are microorganisms 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. Having the correct information can allay irrational fears about exposure to HIV and HBV. On the other hand, treating these potential infections too lightly may lead you to ignore appropriate protective measures. It is important to understand what the potential problems might be and what measures you can take to protect yourself from exposure.

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 bloodborne 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 performing rescue breathing 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 dustpan.

▪ Handle all waste as if it contains sharps or infectious material. ▪ After removing PPE wash hands and other affected areas with soap and warm water. ▪ Place all potentially infectious materials and contaminated items in closable containers or bags, clearly marked as infected waste or biohazard.

If you think you have been exposed ▪ ▪ ▪ ▪

Flush the area with warm 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.

First Aid First aid is the initial or first help given to someone who is injured or taken suddenly ill, usually at the scene and at the time. Anyone at the scene can give first aid but obviously the more you know, the better the help that you can give. A handbook such as this can help but it is much better to attend a proper first aid course.

The Aims of first aid The main aims of first aid are to keep our casualties alive, treat their injuries to stop them from getting worse and to hand them over to the medical authorities in the best possible condition in the circumstances. The best way to achieve this is to follow the three basic principles of first aid:

▪ Preserve life. ▪ Prevent worsening ▪ Promote recovery

Requirements and responsibilities A first aider needs to have a great deal of common sense and to be cool and calm in any emergency, as well as having a caring personality. Not everybody will be suitable. The ability to remain calm in an emergency comes from confidence and confidence starts with training and practice. What you will learn on your first aid course will be sufficient to carry out your duties and possibly even to save life but the course is only the beginning of the learning process.

You need: ▪ to protect yourself, the casualty and others at the scene from potential danger. ▪ to arrange for appropriate assistance. ▪ to identify where appropriate the injury or illness affecting the casualty. ▪ to decide on priorities and to offer the casualty the appropriate treatment for their condition. ▪ to allow your casualties to retain their dignity and modesty and to respect their privacy.

▪ to arrange for the transfer of the casualty to the appropriate medical authority or to their home. ▪ to remain with the casualty until they are handed over to the care of others. ▪ to inform subsequent carers of your observations and treatment.

Accident records All accidents and incidents that occur in the workplace should be reported and recorded. A book for this purpose can be bought from most stationers or first aid equipment suppliers. The records and the way they are kept should comply with the Data Protection Act 1998 The record may be completed by anyone but should include: ▪ the date, time and location of the incident ▪ the personal details of the injured party ▪ details of the injury or illness and what first aid treatment was given

▪ what happened to the casualty after treatment (went home, hospital etc.) ▪ the name and signature of the person completing the record

Accident reporting - RIDDOR Reporting of Injuries, Disease or Dangerous Occurrences Regulations 1995 If you are an employer, self-employed or in control of premises then it is a legal obligation to report any serious incident or near miss, as well as injuries and some illness other than minor and particularly if they result in more than seven days off work. A full schedule of reportable incidents can be found here: All reporting can now be done on line here: Fatal and major injuries ONLY may be reported by telephone on 0845 300 9923



Initial Response The first aider should not be expected to deal with complex casualties or incidents, but to provide an initial response where first aid is required. In some circumstances such as minor wounds or injuries the first aid given may be the only treatment that the casualty receives. Where injuries or illnesses are more serious first aid may be followed by treatment from ambulance paramedics, doctors or hospital staff.

Assess the situation ▪ Identify potential hazards to the health and safety of yourself, the casualty and others. ▪ Where appropriate, attempt to minimise these hazards. ▪ Assess the casualty’s vital signs and physical condition in accordance with established first aid procedures.

Apply basic first aid techniques ▪ Apply first aid management in accordance with established first aid procedures. ▪ Conduct a primary survey to establish the presence of life-threatening conditions. ▪ Respond to results of primary survey and give basic life-support as appropriate. ▪ Control blood loss, look for and treat shock. ▪ Conduct secondary survey to establish the presence or otherwise of further illness or injury. ▪ Treat injuries as appropriate according to established first aid procedures.

▪ Reassure and make the casualty comfortable as appropriate. ▪ Request medical assistance at the appropriate time with 999/12 call ▪ Accurately convey details of the casualty’s condition and treatment given to the emergency services or relieving personnel ▪ Assist where appropriate in the preparation of accident investigation reports.

Summoning help 999 or 112 are the free 24-hour numbers to call for emergency help. When you get through the operator will ask you if you need police fire or ambulance services. If you ask for an ambulance they will then take details of why you need help. The initial questions are to prioritise just how urgent the problem is. In particular they will ask you if the person you’re calling about is unconscious, has breathing difficulties or 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. ▪ Only pass on information you know to be true, guesses or assumptions may mean you are given inaccurate advice. ▪ Give as much information about your location as possible to help the ambulance crew find you. ▪ Don’t hang up until the ambulance controller tells you to. ▪ In an emergency the controller is trained to talk you through procedures or to remind you to do checks that you may not have thought of. This can be reassuring at a very tense time. These days most people carry a mobile telephone and it is likely that the emergency call would be made from this. If this is the case then dialling 112 instead of 999 may have some advantages. ▪ Over 70 countries including all of Europe use 112 as an emergency number. ▪ If your mobile doesn’t have a signal, when you dial 112 it will automatically search for and use any other mobile service which does have a signal. ▪ If your P.A.Y.G. Mobile is out of credit it will still call 112. ▪ With most modern mobiles if you have to call from someone else’s phone which is locked, it will still call 112 even without the password. ▪ 112 will work just as well as 999 from a land line telephone.

Emergency Response Summary In any emergency it helps to have a clear plan of action. This helps you to prioritise your actions and to ensure that things are not missed. The plan will need to cover the following steps:

Make the area safe if possible Do not take risks


DANGER To yourself,the Casualty or others No


Find and treat other injuries Start with serious bleeding Look for and treat shock Call for medical attention

BREATHING NORMALLY? Check for no more Yes than 10 seconds

Conduct a secondary survey Recovery position Treat other injuries Call for medical attention

RESPONSE? Shout and shake No

Shout “HELP” But don’t leave the casualty

AIRWAY Open with head tilt - chin lift


CALL AN AMBULANCE Before doing anything else

Start CPR Continue at 30:2

Priorities for first aid treatment The priorities for first aid treatment can be remembered by the initials D.R.A.B.C.

Danger: Are you, the casualty or others in danger? Response: Is the casualty responsive? Airway: can they breathe? Breathing: are they breathing normally? Circulation: are they bleeding or in shock?



Casualty Assessment You need to find and treat conditions that are immediately life-threatening. This is the primary survey. What you are looking for is: ▪ Can they breathe? (Airway) ▪ Are they breathing normally? (Breathing) ▪ Are they bleeding or in shock? (Circulation) You need to deal with each condition in order to resolve the problem before moving on to the next condition. Once you have established that they are not suffering from a life threatening condition then you can find out what else might be wrong with them. This is the secondary survey.

Primary survey This is a rapid initial assessment to find and treat conditions that are immediately life-threatening. If you find a conscious casualty, who looks and acts normally and is speaking to you in a normal fashion it is likely that this element of the survey will be completed quite quickly. However, if the casualty is unresponsive or their condition suggests a much more serious problem then you will probably have to spend some time before you can move on to the next stage of assessment. It is easiest if you follow the ABC assessment

A – airway B – breathing C – circulation

A Airway

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

B Breathing

Are they breathing normally? If they are unconscious and not breathing normally first call 999/112 for help, then start resuscitation. If they are unconscious and breathing normally examine them for other injuries and place them carefully into the Recovery Position If they are conscious but have breathing problems such as Asthma treat this condition before moving to the next step.

C Circulation

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

Secondary survey 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 will be checked methodically for any clues as to their current condition. Ideally these checks should take place with the casualty in the position found, at least until you have ascertained that it is safe to move them. Whenever possible make a note of your findings. This may be important to subsequent carers. There are three elements to the secondary survey: ▪ History/mechanism of injury (MOI) ▪ Symptoms ▪ Signs

History/mechanism of injury This refers to what happened or how it happened and will give important information or clues as to what may be wrong. History should include what happened (history of the event) and also any previous history of similar events or illnesses. The information may be given by the casualty or by witnesses at the scene. There may also be physical clues at the scene. Where possible ask the casualty about previous episodes and try to find out if they are currently taking any medication, if they have any allergies and when they last had anything to eat or drink. If the casualty is unable to pass on this information it might be found on medical warning lockets or bracelets, particularly if it concerns a chronic illness.

Casualty Assessment Symptoms Symptoms are the feelings that the casualty experiences due to the accident, injury or illness. The most common symptom described by the casualty following an injury is probably pain. Remember that pain is a good indicator that there is a problem but it may be a poor indicator of the severity of the problem. Some minor injuries may be very painful whilst more major injury may cause little or no pain.

Ask the casualty about the nature of the pain, is it sharp, dull, burning or crushing? Is it constant or does it come and go? Does anything make it feel better or does anything make it feel worse? Other feelings the casualty may describe could include feeling hot or cold, dizziness or sickness and thirst. Listen to the casualty and always remember, they know how they feel better than you do.

Signs A sign is something that you find for yourself using your own senses. It may be something that you see, feel, hear or smell. Signs may include swelling, bruising, deformity or blood on the skin or clothing. A smell of alcohol on the breath may explain a change in level of consciousness but always be aware that this could be masking a serious medical condition. Skin colour or appearance may be significant, the casualty who is seriously ill tends to look seriously ill. It is important to look for signs in a methodical manner to avoid missing things. Physical evidence that may be found could include such things as medical alert lockets or bracelets, adrenaline auto injectors for anaphylaxis, insulin injecting equipment or possibly insulin pump, asthma inhalers or other medications carried by the casualty for their own use.

Examining the casualty It is important that you look closely and methodically at the casualty so as to find any indications as to what may be wrong with them. Remember, even the casualty may be unaware of the extent of their injury. It is important that this examination should not just consist solely of pressing on the casualty to see if they have a painful response, as is frequently done. We should not be causing the casualty pain. It is often suggested that first aiders should feel or palpate areas such as the neck, spine or abdomen looking for abnormalities. This approach can be potentially misleading and dangerous for the following reason: Most first aiders will never have examined enough normal bodies to know what is abnormal and therefore could never discount the possibility of injury based on their examination, it would not be safe to do so. Therefore if anything about the history, mechanism of injury, signs or symptoms suggest the possibility of a particular injury or illness then we have to assume that to be the case until somebody better qualified can discount it. First aiders should also remember that their actions may be misunderstood so it is important not to start removing clothing or feeling underneath clothing unless there is a very good reason for doing so. Assess their breathing. ▪ Is it fast or slow? Is it deep or shallow? ▪ Does it seem easy or laboured? ▪ Is it quiet or is it noisy? ▪ Are they coughing? If so are they coughing anything up, particularly blood? If you have been trained to do so check their pulse. Assess the speed or rate in beats per minute and note whether it is heavy or weak. Look at the casualties face. ▪ 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. ▪ If the casualty is wearing dentures and they are well fitted then leave them in place but if they have become dislodged or loose in the mouth they should be removed. ▪ Look at the colour of the skin, in particular look for a blue or grey appearance of the lips or earlobes (cyanosis) which might indicate a shortage of oxygen. ▪ Look for obvious signs of blood or swelling around the head or in the hair. Do not press on any injuries to see if it hurts, it almost certainly will. ▪ Check the pupils of the eyes to see if they are of equal size.



Casualty Assessment Level of response At some point you will have to establish the casualties level of response so that you can tell if it is changing. Once you have established the level then you need to monitor for deterioration and pass this information to subsequent carers. Check the neck ▪ Loosen any tight clothing around the neck. ▪ Ask them to keep their head and neck still. ▪ Look for and remove any ligature. ▪ Look for bruises or abrasions that might suggest strangulation. ▪ Look for bruising and swelling around the neck. ▪ Ask the casualty if they have any pain in the neck. ▪ Ask the casualty if they have any strange sensations in their arms and legs Do not be tempted to press on the spine, if the history of the incident suggests spinal injury then assume it. Look at the chest ▪ Look for signs of obvious injury such as blood on the clothing. ▪ Ask the casualty to take a deep breath and watch their face for signs of discomfort. ▪ Does the chest move equally on both sides. ▪ Listen for any unusual sounds particularly a sucking sound on breathing in or a bubbling sound on breathing out. ▪ Look at the collarbones for evidence of bruising, swelling or deformity. Check the abdomen ▪ Ask the casualty if they have any abdominal pain. ▪ Is the pain in any particular area of the abdomen? ▪ Do they feel sick or have they vomited? ▪ Do not be tempted to press on the abdomen to see if it is painful to touch. Check their arms ▪ Ask them if they have any pain in their arms. ▪ Ask the casualty 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 visible blood, swelling or deformity. ▪ Ask the casualty if they have any strange sensations such as pins and needles or burning sensations in the arms and hands. ▪ Check the casualty’s grip by getting them to squeeze your fingers. ▪ Check both sides at the same time to compare. Check the legs ▪ Ask them if they have any pain in the legs. ▪ Ask them if they can move their legs normally. ▪ Compare one leg with the other. Do they look the same size and shape? Are they pointing in the right 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. If it is cold to touch or grey/blue in appearance it could indicate injury or circulatory problem. Check beneath them ▪ Slide your hands gently underneath their torso as far as it is comfortable to reach. ▪ Start either side of the chest below the armpit and slide down towards the waist. ▪ Check for blood or dampness that might indicate injury. ▪ Do not press on the casualty and in particular do not press on the casualty’s spine. Check clothing and pockets ▪ Look for any information that might explain the condition. ▪ Are they carrying any medication? ▪ Look for Medic alert or SOS Talisman lockets or bracelets. ▪ Remove sharp or bulky items from pockets where they may cause a problem if the casualty is rolled or moved.

The Unconscious Casualty 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. As the casualty loses consciousness their muscles lose their stiffness or tone and relax. As the muscles of the tongue relax the tongue becomes floppy and may fall across the back of the throat. If it does not form a complete blockage the casualty’s breathing may become noisy, with loud snoring. If the blockage is complete the casualty will stop breathing altogether. The base of the tongue is attached to the jaw so by tilting the head gently backward and lifting the jaw the tongue can easily be lifted from the back of the throat. Opening the airway in such a way is a life-saving manoeuvre. As the casualty’s level of consciousness deteriorates their reflexes and muscle tone become weaker and an obstructed airway becomes more likely. Their level of consciousness can be estimated using the AVPU scale.

A Alert

▪ Fully Conscious and Aware ▪ Eyes open spontaneously

▪ Reacting normally to events ▪ Reflexes are normal

V Verbal

▪ Appears sleepy with eyes closed ▪ Eyes open to speech or sound ▪ Speech may be slurred

▪ May make uncoordinated movements ▪ Reflexes are intact

P Pain

▪ Appears deeply asleep with eyes closed ▪ Does not open eyes to speech

▪ Little or no muscular coordination ▪ Functioning reflexes

U Unresponsive

▪ Appears deeply asleep with eyes closed ▪ Does not open eyes

▪ Does not respond to any stimulus ▪ Reflexes absent

The unconscious casualty – causes Direct injury to the brain such as: ▪ head injury ▪ haemorrhage ▪ stroke ▪ brain abscess

Indirect injury to the brain such as: ▪ infections ▪ drugs, including alcohol ▪ extremes of temperature ▪ heart attack ▪ diabetes ▪ shock ▪ asphyxia

The unconscious casualty– treatment ▪ ▪ ▪ ▪ ▪ ▪

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 the casualty carefully into the recovery position to maintain and protect the airway. Send for medical help. Continue to observe and monitor.


10 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. This allows the tongue to fall forward and allows the drainage of blood and saliva or stomach contents from the mouth, by gravity. This in turn reduces the risk of the corrosive stomach contents entering and damaging the airway and lungs due to the absence of the swallow and cough reflex.

Before moving the casualty ▪ ▪ ▪ ▪

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.

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

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

Pull gently on the knee to roll them toward you.

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

Adjust the head to keep the airway open.

The recovery position– two person If spinal injuries are suspected tilt the head back just enough to allow breathing.

Rescuer one stabilises the head and neck

Rescuer two controls shoulders and hips.


On command the casualty is rolled, avoiding twisting or bending

Sudden Cardiac Arrest Sudden cardiac arrest (SCA) occurs when the heart suddenly and unexpectedly stops beating. This results in a lack of blood supply and therefore oxygen, to the brain and other organs. Left untreated it will lead to death in a very few minutes. There may be many reasons why a heart could suddenly stop beating, for example following trauma such as head injury or spinal injury or as a result of blood loss. It may also result from heart disease such as heart attack. Regardless of cause our approach would be the same.

How the heart is controlled The heart works as a pump by regularly contracting and relaxing at a rate of around 60 to 80 times a minute. The speed and rhythm of the contractions are controlled by a group of pacemaker cells in the heart wall. These cells send out an electrical signal along nerve pathways in the heart walls and stimulate the heart muscle to contract. The rate will depend upon several factors such as fear and excitement or exercise and will respond to demand. The hearts electrical system regulates the mechanical system, and in a healthy heart the result is a rhythmic and coordinated beating of the heart. Problems with the heart’s electrical system can result in abnormal heart rhythms or arrhythmias. There are many different types of arrhythmias. Some may cause the heart to beat too fast, some too slow and some may cause the heart to stop beating altogether. SCA occurs when the heart stops beating. The most common type of arrhythmia that causes SCA is ventricular fibrillation, or VF. In VF, the signal to the ventricles or pumping chambers of the heart becomes disorganised, resulting in the pumping chambers starting to quiver very rapidly and irregularly. When this happens, there is very little output from the heart to the other organs of the body and death will follow within a few minutes. VF causes more sudden cardiac arrests than any other arrhythmia, and without the correct treatment 95% of sufferers will die. Sudden cardiac arrest can affect anyone at any time and although it is more common with age and in people who have heart problems, many sufferers have no known risk factors or previous history.

A- Sino atrial node B.- Atrio-ventricular node


B Electrical conduction in the heart

SCA and heart attack Although both conditions are connected with the heart they are different problems. SCA is an electrical problem and heart attack is a blood supply problem. Sometimes a heart attack can trigger a sudden cardiac arrest.

Treatment for SCA The only treatment proven to restore a normal heart rhythm is to administer an electric shock to the casualty’s heart. This is called defibrillation and can be life-saving in sudden cardiac arrest. 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 does not have ventricular fibrillation. This means that AEDs can be used safely by non-medical people to save lives in sudden cardiac arrest.

Automatic External defibrillator


12 Basic Life Support 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 access to the rescue services or to someone with a defibrillator. Early CPR To buy time until the arrival of the defibrillator. CPR alone is unlikely to reverse SCA Early defibrillation Chances of survival decrease by around 10% per minute. Early defibrillation has to be the target. Early ACLS Advanced cardiac life support is essential to maintain life following cardiac arrest. Good post resuscitation care Medications or surgery to treat the underlying condition and maintain life.

Emergency response D Danger

Check for danger to yourself, the casualty or others.

R Response

Check for response. Shout and shake

A Airway

Can they breathe? Check and open the airway

B Breathing

Are they breathing normally? Check for no more than 10 seconds.

C Circulation

Are they bleeding or in shock? Control blood loss.

Basic life support – adult sequence Approach with CARE Make sure that there is no danger to yourself, the casualty or bystanders.

Check RESPONSE ▪ ▪ ▪ ▪

Check initially in the position that you find them. Speak loudly and clearly to them. Use their name or ask them to open their eyes. If they don’t respond shake them gently by the shoulder.

If they respond: ▪ Leave them in the position that you found them. ▪ Check to find out what might be wrong. ▪ Observe and reassess regularly. If they do not respond: ▪ Shout loudly for help.

Basic Life Support Shout HELP ▪ If someone is nearby, ask them to wait as you may need their assistance. ▪ If you are alone, shout for help loudly to try to attract attention, but do not leave the casualty.

Open the AIRWAY ▪ Undo anything tight round the neck. ▪ Remove their glasses if worn. ▪ Place one hand on the forehead and two fingers on the other hand under the bony part of the jaw. ▪ Gently rotate the head backward and lift the jaw (head tilt / chin lift) ▪ This lifts the tongue and straightens the airway.

Check for NORMAL BREATHING ▪ ▪ ▪ ▪ ▪

Place your ear over the nose and mouth, looking down towards the feet. Check for no more than 10 seconds. Look – for movement. Listen – for breathing. Feel – for breath on the cheek.

AGONAL breathing Immediately following a cardiac arrest is not uncommon for the casualty to be taking what appear to be short irregular gasps for breath. The should not be mistaken for normal breathing and resuscitation should be started without delay. Sometimes, during a ongoing resuscitation attempt, the casualty may exhibit this type of gasping and again this is not normal breathing so it is important not to discontinue resuscitation.

If 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 soon as it is practical to do so. Dial 999/112 for medical assistance. Continue to monitor their condition.

If they ARE NOT breathing normally ▪ Call 999/112 or raise the alarm before you do anything else. If you are alone: ▪ Call 999/112 for an ambulance on your mobile phone (only leave them if absolutely necessary) ▪ Get an AED immediately if one is available. If you have someone with you: ▪ Send them to call 999/112 for an ambulance. ▪ Tell them to fetch AED, if available, whilst you start resuscitation.


14 Basic Life Support Basic life support – adult sequence (continued) 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 them or to expose their chest, unless they are wearing very heavy outer clothing. (Illustrations show chest exposed 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, your 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 them 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. Your performance is liable to deteriorate as you get tired. For this reason it is recommended that if another rescuer is available and can perform chest compressions you should change over every two minutes.

Deliver 30 chest compressions Deliver RESCUE BREATHS After 30 chest compressions give two rescue breaths

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.

Release the nose and keeping the airway open let them breathe out. Reseal your lips give another rescue breath. Give two breaths in total.

The 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 more than two breaths before returning to chest compressions. ▪ If problems persist, go to compression only resuscitation. ▪ ▪ ▪ ▪ ▪ ▪

Basic Life Support 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 by a breathing problem. ▪ If you are unable or unwilling to give rescue breaths, start compression only resuscitation immediately. ▪ Give chest compressions to a depth of 5 - 6 cm at a rate of 100 - 120 compressions a 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 at the lowest point to ensure drainage. remove debris from the mouth with your fingers. place them on to their back and resume cpr as soon as possible.

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. ▪ Someone else takes over from you. ▪ You are alone and too exhausted to continue.

Two-person resuscitation If there is another rescuer present who can perform CPR then the rescuers should take turns, changing every 1 to 2 minutes. This will help to prevent deterioration in performance due to fatigue.

When the A.E.D. arrives An AED can be used safely by almost anyone, so its use is not restricted to trained rescuers. However training is useful 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 will all have similar layouts and properties. The essence of AED design and use is simplicity and 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 leads to the AED if necessary.


16 Basic Life Support When the A.E.D. arrives (continued) 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 collar bone, next to the breastbone. The other pad should be placed below the left armpit, on the side of the chest wall, over the lower ribcage. It is not important which way round the pads are placed.

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.

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. ▪ 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 two minutes or until prompted to stop. ▪ Continue to follow voice prompts.

Basic Life Support When the A.E.D. arrives (continued) Shock indicated ▪ Ensure that everybody is clear of the casualty. ▪ Press the shock button as directed. ▪ After the shock is delivered continue CPR for two minutes, or until directed to stop. ▪ Allow the AED to analyse. ▪ Continue to follow voice prompts.

13 BLS and AED flowchart Unresponsive? Shout “HELP” Open airway Check breathing Not breathing normally?

Call 999 Send or go for an AED

Start CPR at 30:2 Until AED attached

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


18 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 even 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 the 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 10cm 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 inflammable 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, to limit any possible damage to the heart. In most cases the pads are designed to be placed centrally on the chest and upper back,directly opposite one another, although some may be placed in the conventional “adult” position. 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. All children should receive at least one minute of effective CPR before attempts are made to defibrillate as per paediatric life support guidelines.

AED storage ▪ The AED should be stored in a secure but 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 also allow easy checking of the unit’s 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.

Hygiene Hygiene and personal protection Administering basic life support offers little threat to the rescuer. There is a perceived threat from blood-borne viruses such as HIV or hepatitis, but realistically this is a blood problem. They will not be transmitted giving or receiving rescue breathing. However, many people are reluctant to offer rescue breathing because of this perceived risk because of contamination of the casualty’s face with vomit or blood. If this is the case they may be more comfortable using some form a barrier between themselves and the casualty. To be effective these barriers should contain some form of one-way valve. They come in two main forms: ▪ Face shields ▪ Facemasks

Face shields Face shields consist of a polythene or plastic sheet with a reinforced hole that fits over the casualties nose and mouth. The hole may be protected with non-woven material or may contain a simple one-way valve. The sheet is laid across the face of the casualty and the rescuer blows through the hole. The advantage of this equipment is that it is inexpensive, easy-to-use and compact, so that it can easily be carried with the rescuer ready for use

Facemasks Facemasks are larger and more substantial, often coming in a case. Most masks will have a one-way valve. Some may have an attachment for oxygen tubing. They require slightly more training and practice to be used effectively, but give a greater feeling of security to the rescuer. They fit over the nose and mouth of the casualty and the rescuer blows through the valve until the chest rises.

Keeping the airway open with head tilt and chin lift, the facemask is placed over the casualty’s nose and mouth.

The rescuer then blows through the one-way valve. The casualty’s expired air is deflected from the rescuer by the valve.

The mask may be held in place more easily using both hands in an “over the top” position with the rescuer at the head of the casualty.


20 Basic Life Support-Infants and Children Resuscitation of children Most sudden cardiac arrests that occur outside of hospitals happen to adults and come from heart problems. Because there is oxygen dissolved in the blood at the time of the cardiac arrest, greater emphasis is placed on circulating the blood by delivering 30 chest compressions first. However, children are less likely to suffer from heart problems and more likely to suffer an arrest following a breathing problem. In this case it is likely that they will be little oxygen in the blood at the time of the arrest and so it may be beneficial to give rescue breaths before starting chest compressions. 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 the differences however then the following changes may be beneficial.

CPR unresponsive child

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 five rescue breaths before giving 30 chest compressions.

Give chest compressions at a rate of 120 compressions per minute using one or two hands. If you are on your own perform CPR at 30:2 for one minute before going for help. Aim to compress the chest to one third of its depth.

If the baby is not breathing normally give five rescue breaths. Seal your lips around the baby’s nose and mouth and blow until the chest rises.

Give 30 chest compressions at 120 compressions a minute using two fingers only on the breastbone. Aim to compress the chest to one third of its depth. Perform CPR at 30:2 for one minute before going for help.

CPR unresponsive infant

Open the airway with one finger beneath the jaw and the other hand on the head. Do not over extend the neck. The finished position should be with the babies eyes looking straight upward.

C.P.R. 21

20 CPR summary Unresponsive?

Shout for Help

Open Airway


Call 999/112

Deliver 30 Chest Compressions

Give two Rescue Breaths

Continue CPR at 30:2 until arrival of AED or qualified help

Not breathing normally?

Child / Drowning

Give 5 Rescue Breaths

Give 30 Chest Compressions

Do CPR at 30:2 for one minute

Dial 999 / 112 or raise the alarm

Do CPR at 30:2 until help arrives

Speed is of the essence ▪ ▪ ▪ ▪

Ensure a RAPID response. Raise the alarm QUICKLY. Maintain the SPEED of compressions. Practice QUICK changeovers.

Sudden cardiac arrest is the ultimate MEDICAL EMERGENCY and your response should be well practised and rehearsed so that you can meet the challenge.

22 The Respiratory System. The respiratory system Nose





Tongue Larynx Trachea Rib Sternum Lung




Breathing Breathing is controlled by a collection of nerve cells in the brain called the respiratory centre. These respond to changes in the level of carbon dioxide dissolved in the blood, as the level rises it triggers a breath. The act of breathing is controlled by muscles, particularly the intercostal muscles between the ribs, and the diaphragm, a large dome shaped sheet of muscle which separates the chest cavity from the abdominal cavity. When muscles are stimulated by the nervous system they contract. The contraction of the intercostal muscles has the effect of pulling the ribs upward and outward whilst the dome shaped diaphragm flattens out and pulls downward like a piston inside a cylinder. The combined effect of this is to make the volume of the chest cavity larger, creating lower air pressure inside the chest than in surrounding air. This sucks air in by the nose and mouth, down the windpipe or trachea and into the lungs. In the lungs oxygen passes into red blood cells which are in the tiny capillaries surrounding the air sacs or alveoli. At the same time carbon dioxide is given off from the blood and passes into the lungs to be expelled as waste. We call this process gas exchange.

Oxygen and respiration Oxygen is a gas that forms around 21% of the air that we breathe. It is essential to life, being used by every cell in the body to help convert fuel into energy (metabolism) Our bodies store very little oxygen, just a few minutes worth, so as we need a consistent supply we need to continuously replace it by respiration. There are four stages in the respiration process: Ventilation: from the surrounding air into the air sacs of the lungs Pulmonary Gas Exchange: transfer of oxygen from the air sacs into the blood stream and carbon dioxide from the blood into the lungs, to be breathed out. Gas Transport: from the pulmonary capillaries, through the circulation to the peripheral capillaries. Peripheral Gas Exchange: from the tissue capillaries into the cells.

Hypoxia 23 Respiration The ventilation and gas transport stages depend on mechanical pumps to work, whilst the gas exchange steps rely on passive diffusion. When the air that we breathe contains adequate levels of oxygen and all of the elements of respiration are working properly our bodies will be supplied with all of the oxygen we need, but should one part of the process fail our bodies become short of oxygen, a condition known as Hypoxia. Hypoxia literally means a shortage of oxygen in the body. Hypoxaemia means a shortage of oxygen in the blood.

Causes of hypoxia Environmental Could be due to a lack of oxygen in the ambient air, due to altitude or other causes. Impaired Ventilation Normal ventilation depends upon the mechanical effect of the contracting diaphragm and inter-costal muscles to alter the volume of the chest cavity, thus creating a difference in pressure and drawing air in, to be trapped in the lungs. Factors that could interfere with this might include damage to the chest wall or an obstruction to the airway preventing air from reaching the air sacs. Impaired Gas Exchange For efficient gas exchange in the lungs there needs to be a balance between air containing adequate amounts of oxygen entering the lungs (ventilation) and the flow of blood through the pulmonary capillaries (perfusion). Factors which may interfere with gas exchange include altered blood flow from poor cardiac output (heart disease, shock or pulmonary embolism) or a lack of oxygen carrying ability from reduced haemoglobin (anaemia) or carbon monoxide poisoning. There may be collapse of the air sacs (pneumonia, pulmonary oedema or other medical conditions) or chronic conditions (COPD).

Recognition of hypoxia Hypoxia may be difficult to see in the early stages, as signs and symptoms may be absent or may vary from individual to individual. Signs ▪ ▪ ▪ ▪

Rapid breathing Cyanosis Lethargy Poor judgement

Symptoms ▪ ▪ ▪ ▪ ▪ ▪ ▪

Dizziness Headache Breathlessness Fatigue Nausea Visual impairment Euphoria

A more accurate way of recognising and confirming hypoxia, or at least hypoxaemia, is through the use of a device called a Pulse Oximeter.

Treatment of hypoxia The initial treatment of hypoxia should be to identify, treat and where possible, reverse the cause. Other treatments may include enriching the individual’s inspired air with extra oxygen from an external source. This is Oxygen Therapy Although oxygen therapy is not a routine part of First Aid, where it is available it may, in some circumstances, be extremely helpful or even life saving.

24 The Obstructed Airway.



Back blows

The problem often occurs whilst eating. They will often stand up and clutch their neck. They may look anxious or distressed. They will often attempt to leave. They may be attempting to cough.

Encourage them to cough. If the obstruction is not complete this will clear the airway. If they are coughing do not slap them on the back, this may encourage the object to drop further into the throat

Give up to 5 back blows. Bend them forward supporting them on the shoulder. Give up to 5 blows with the heel of the hand between the shoulder blades. Check effectiveness after each blow.

Abdominal thrusts

Abdominal thrusts

Abdominal thrusts

Stand behind them and reach with your arms around the upper abdomen, between the belly button and the point of the breastbone.

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

Pull sharply backward and upward, bending from the elbows at an angle of about 45° to the horizontal. Repeat up to 5 times. Check effectiveness after each thrust

If the casualty is unconscious or becomes unconscious: ▪ ▪ ▪ ▪

Lower them carefully to the ground. Make sure an ambulance is called. Immediately start CPR with 30 chest compressions. Continue CPR until they breathing normally.

Check after each back blow or abdominal thrust. The aim is to clear the airway not necessarily to deliver all five. Due to the risk of internal injury, casualties who have received treatment for obstructed airway should be referred to a doctor, particularly if they have required abdominal thrusts. They should also see a doctor if they still have a feeling of discomfort or of something stuck in the throat.

The Obstructed Airway-Child and Infant 25 The majority of choking events occur whilst the child is eating or playing, often when a carer is present. If these events are witnessed, treatment is usually carried out quickly whilst the child is still conscious. When a child chokes the immediate response is coughing. This is likely to be the most effective and safest way of removing the obstruction. If coughing is not effective however, or the foreign body completely obstructs the airway, treatment needs to be immediate.

Awareness You might suspect choking on a foreign body if: ▪ the child develops very sudden breathing problems. ▪ there are no other signs of illness or other obvious explanation. ▪ the child was playing with small objects or eating immediately prior to the event.

General signs of choking Effective cough ▪ ▪ ▪ ▪

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

Ineffective cough ▪ ▪ ▪ ▪ ▪

Silent or quite cough. Unable to speak or cry. Unable to breathe. Decreasing level of consciousness. Blue colouration (cyanosis)

Treatment – child ▪ 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 along one arm, 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 not 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. If the baby is unconscious ▪ Place them on a firm flat surface. Call or send for help if possible, but do not leave the baby. ▪ Open the mouth and look for any obvious foreign objects and remove them if possible. ▪ Attempt to give five rescue breaths. Assess the effectiveness of each breath. If the breath does not make the chest rises reposition the head before attempting the next breath. If the chest does not rise: ▪ Immediately start chest compressions combined with rescue breathing at a rate of 30 compressions followed by two breaths. ▪ When opening the airway to give rescue breaths, check the mouth for obstructions and remove them if possible. ▪ Continue until the baby is breathing normally or help arrives.

26 The Obstructed Airway. The obstructed airway/choking summary

Signs of Choking?

Prevent them from leaving


Effective Cough?


Severe Obstruction


Mild Obstruction

Give up to 5 Back Blows

Dial 999 /112 for Ambulance

Obstruction not relieved?

Start Chest Compressions

Give up to 5 Abdominal Thrusts

Continue CPR at 30:2 until the obstruction is relieved and casualty is breathing normally

Alternate 5 Back Blows and 5 Abdominal Thrusts

Encourage Cough

Continue to monitor for deterioration to ineffective cough or relief of obstruction

Penetrating Chest Injury 27 The inside wall of the chest and the surface of the lungs 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.

Decreased air entry

Pleura Pneumothorax Air is drawn in

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.

Penetrating 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

Penetrating chest injury– treatment

Dial 999/112 for an ambulance. Place the casualty in a sitting or half sitting position leaning towards the injured side.

Seal the wound with the palm of your hand or anything that will make an airtight seal.

Cover the wound with plastic or other airtight material. The plastic should be at least 2” wider than the wound all-round. Tape the plastic on three sides, leaving the bottom edge open to allow drainage of air and blood.

28 Chest Injury Closed chest injury Air can also enter the space between the two layers of the pleura by escaping from the surface of the lung, a closed pneumothorax. This may follow an injury, possibly a fractured rib puncturing a lung, or may happen for no obvious reason – a spontaneous pneumothorax. If the air trapped in the pleural space cannot escape then as more air is drawn in the pressure may increase. This could lead to pressure over the good lung and even the heart and may interfere with the function of these organs. This could very rapidly become life-threatening and would require immediate medical attention.

Air entry

Closed chest injury– recognition Following injury: ▪ History of blow to the chest or crushing injury. ▪ Discolouration or bruising at the site of injury. ▪ Pain and tenderness at the site of injury. ▪ Shortness of breath. ▪ Difficulty breathing, possibly getting worse. ▪ Pain on breathing or coughing. ▪ Pale, may be cyanosis. ▪ May cough up blood

No history of injury: ▪ Sudden breathlessness for no obvious reason. ▪ Dry, unproductive cough. ▪ Pain in the chest, back or arms. ▪ Shortness of breath. ▪ Difficulty breathing, possibly getting worse. ▪ Pale, may be cyanosed.

Closed chest injury– treatment ▪ ▪ ▪ ▪

Place in a well supported half sitting position, leaning slightly towards the injured side. Reassure. Continue to monitor breathing. Call 999/112 for an ambulance as a matter of urgency.

Blunt trauma chest injury The chest may be injured by direct force such as a blow to the chest or by crushing injuries. This may result in fractured ribs. If several ribs are broken a segment of the chest wall may become detached from the other ribs. This is known as a flail chest injury. As the casualty attempts to breathe in the detached segment is pulled inward, due to the vacuum in the chest cavity. As the casualty breaths out it is pushed back out (paradoxical breathing). This will result in reduced air entry into the lungs.

Blunt chest injury– recognition ▪ ▪ ▪ ▪ ▪ ▪

History of violent injury to the chest wall. Bruising or discolouration at the injury site. On breathing in the injured chest wall is sucked inward. On breathing out the chest wall moves outward. Breathing difficulty/short of breath. Pale, may be cyanosed.

Blunt chest injury– treatment ▪ ▪ ▪ ▪ ▪ ▪

Place in a well supported half sitting position, leaning slightly towards the injured side. Help to stabilise the chest wall by placing the arm on the affected side in a sling. Reassure. Continue to monitor breathing. Be prepared to give rescue breathing. Call 999/112 an ambulance.

Asthma 29 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. This leads to difficulty 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 which is quite characteristic. 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 their spasm. This will be in a blue inhaler.

Acute asthma attack They are having an acute attack if any of the following happens: ▪ Their reliever isn’t helping or the effect isn’t lasting over four hours. ▪ Their symptoms are getting worse (cough, breathlessness, wheeze or tight chest) ▪ They are too breathless or it’s difficult to speak, eat or sleep. ▪ Their breathing may get faster. ▪ They may feel that they can’t get their breath in properly.

Asthmatic bronchiole

Normal bronchiole

An acute asthma attack is a medical emergency. If you have any doubt about the patient’s condition you should call 999/112 for an ambulance.

Acute asthma attack– recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Possible known history of the condition. Difficulty in breathing. Chest feels tight. May feel as if there is a heavy weight on the chest. Coughing. Noisy, wheezing breathing. Difficulty in walking or talking. Breathing may get faster. Cyanosis (blue lips/complexion) Anxiety and distress.

Acute asthma attack– treatment ▪ ▪ ▪ ▪ ▪ ▪ ▪

▪ ▪ ▪

Place them at rest in a sitting position. Leaning forward on to a table or chair back can be helpful. Reassure. Encourage them to breathe slowly and deeply. Encourage them, or help them, to use their blue reliever inhaler. They should take one or two puffs immediately. If they do not start to feel better they should take two puffs of their reliever inhaler (one puff at a time) every two minutes They can take up to 10 puffs. If they do not feel better after taking their inhaler as above or if you are worried at any time, call 999/112. If an ambulance does not arrive within 10 minutes and they are still feeling unwell, they should resume using their inhaler, two puffs every two minutes, up to 10 puffs in total.

30 Respiratory problems Croup refers to a group of conditions which involve inflammation of the upper airway and lead to a harsh “barking” cough. Croup is usually caused by a viral infection but may be caused by bacteria or even an allergic reaction. It most commonly affects children between three months and five years old and tends to be most severe in those under three years old. It is most common in the autumn and winter. Most cases of viral croup are fairly mild but it can become serious or even life-threatening. Children who were born prematurely or with narrowed airways and those with respiratory disease such as asthma are most likely to be affected.

Croup - recognition The condition often starts like a cold with a stuffy or runny nose and a slightly raised temperature. As the condition develops, the child’s voice may become hoarse and they may start to cough with the characteristic sharp barking sound. The condition becomes dangerous when the upper airway becomes swollen to the point where it is difficult for the child to breathe.

Signs of severe croup ▪ Distressed or rapid breathing ▪ Excessive movement of the belly when breathing ▪ The skin between the ribs being sucked inward when breathing in ▪ Noisy rasping breathing (stridor)

▪ Pale grey or blueish tinge, particularly around the mouth ▪ Difficulty in swallowing or drooling ▪ Inactivity / looks ill ▪ Condition appears to be getting worse

Croup - treatment ▪ Treatment is generally to relieve the symptoms. ▪ Breathing in moist air is often recommended but is unlikely to be of any benefit. ▪ If the child’s condition appears to be worsening they will require hospitalisation although most cases remain fairly mild. ▪ Sit the child in a comfortable position to aid breathing and reassure.

Hyperventilation Hyperventilation is usually associated with a condition of acute anxiety and is often part of a panic attack. It is commonly found in those who suffer panic attacks or it may follow a period of emotional upset. The increase in breathing leads to depletion of carbon dioxide from the blood which can cause chemical changes in the blood. These changes may cause symptoms in the patient, such as unnaturally rapid breathing, dizziness or feeling sick, fear and apprehension and trembling.

Hyperventilation– recognition ▪ ▪ ▪ ▪

Rapid breathing rate. Increased pulse rate. Fear and apprehension. Dizziness or faintness.

▪ ▪ ▪ ▪

Sweating. Dry mouth/thirst. Tingling in the hands and fingers. Cramp.

Hyperventilation– treatment Hyperventilation responds best to calm reassurance. Try to remove the casualty from an upsetting environment and if possible take them somewhere quiet and away from other people. Offer calm reasoned reassurance. Be firm but kind. Do not suggest that they re-breathe their expired air from a paper bag. This has been shown to be ineffective and potentially dangerous. As the patient’s rapid breathing subsides their symptoms will improve. Suggest that they may want to speak to their doctor to get advice on preventing and controlling future panic attacks.

The Circulatory System 31 The circulation

Pulmonary capillaries Pulmonary artery Pulmonary vein Aorta Right atrium Left atrium Left ventricle Right ventricle Oxygenated blood De-oxygenated blood

Peripheral capillaries

The circulation The circulation is the transport system of the body. It is responsible for transporting nutrients and oxygen to the cells and for carrying waste product away from them. It is also part of the body’s defence against infection. The elements of the circulatory system are: The heart (pump) The arteries, veins and capillaries (pipework) The blood (the fluid being pumped) The heart The heart is a muscular pump about the size of your fist. It is found in the middle of the chest behind the breastbone and between the lungs. By squeezing and relaxing around 80 - 100 times a minute, the pumping action produces pressure within the system (blood pressure) and this pressure is responsible for circulating the blood. Blood vessels There are three types of blood vessels: Arteries which supply high pressure oxygenated blood from the heart to the body, Veins which return low-pressure deoxygenated blood back from the body to the heart. Capillaries which are the fine mesh which feeds nutrients and oxygen to the individual cells. The blood The blood is the transport medium which is circulated around the body within the circulatory system. It carries a mixture of blood cells; red cells which carry oxygen, white cells which fight infection and platelets which help in blood clot formation. The average adult will have around 5 to 6 L of blood. The liquid element or plasma will be renewed and replaced from liquids taken by the casualty by mouth. The blood cells are manufactured in the marrow of the long bones. The marrow can switch manufacture to red or white cells on demand.

32 Heart Attack A heart attack occurs when a blood clot forms in a coronary artery, blocking it and depriving part of the heart muscle of blood and therefore oxygen. That part of the heart muscle which is deprived of oxygen may subsequently be damaged or die (myocardial infarction or M. I.) The severity of the heart attack will depend upon the position of the blood clot and therefore how much heart muscle is affected. It may range from mild chest pain to sudden death. Some people who suffer heart attack may exhibit no signs or symptoms at all.

Venae Cavae


Circulation blocked Coronary artery Atheroma

Area affected by lack of blood supply

Blood clot formed in 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. ▪ Pain may start at any time with no obvious cause. ▪ Pain does not improve with rest. ▪ Casualty may look pale or grey. ▪ There may be 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. ▪ Sudden collapse. Potential area of chest pain in heart attack

Heart attack - treatment The primary aim is to reduce the load on the heart by placing the casualty at rest and then to urgently call 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 pillows or folded blankets. ▪ If the chest pain does not subside after a few minutes assume a heart attack. ▪ Reassure the casualty continuously. ▪ Anxiety and fear will increase the heart rate and increase the load on the heart and should be avoided. ▪ Dial 999/112 for an ambulance. ▪ Inform ambulance control that you suspect a heart attack. ▪ If the casualty has a previous history of chest pain and has angina medication such as tablets or spray then assist them to take them. ▪ Monitor the casualty’s level of consciousness and breathing and if you have been trained to do so check their pulse frequently. ▪ Record your findings. ▪ Try to stay calm and matter of fact yourself. ▪ Be prepared to offer life support as appropriate.

Angina 33 Angina is a condition caused by narrowing or spasm of the coronary arteries, the pipes that deliver freshly oxygenated blood to the heart muscle. This leads to less blood and therefore less oxygen reaching the heart muscle. There may be sufficient blood to feed the muscle when the heart is beating normally, but when the heartbeat increases due to exertion or excitement the demand for blood increases with it, leading to demand outstripping supply. This can lead to a cramp like pain in the chest, often brought on by exercise and which goes away with the rest.

Venae cavae


Blood flow restricted by atheroma

Coronary artery


Angina - 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. ▪ Pain will often start with exercise or excitement. ▪ Pain will usually improve with rest. ▪ Pain will usually improve with GTN medication. ▪ Casualty may look pale grey. ▪ Pulse may be rapid, weak and irregular. ▪ They may be sweating. ▪ They may complain of shortness of breath. ▪ They may feel dizzy or weak.

Angina - treatment The primary aim is to reduce the load on the heart by placing the casualty at rest . ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Place the casualty at rest. Make them as comfortable as possible to ease the strain on the heart. If the chest pain does not subside after a few minutes assume a heart attack. Reassure the casualty continuously. Anxiety and fear will increase the heart rate and increase the load on the heart and should be avoided. If the casualty has a previous history of chest pain and has angina medication such as tablets or spray then assist them to take them. Monitor the casualties level of consciousness and breathing and if you have been trained to do so, check their pulse frequently. Record your findings. Try to stay calm and matter of fact yourself. Be prepared to offer life support as appropriate.

▪ If their condition does not improve with rest call 999/112 for an ambulance urgently.

Chest pain Chest pain is a symptom which must always be taken seriously. It may be caused by a minor problem such as indigestion or by a major and potentially dangerous problem such as heart attack. From a first aid perspective it is always safer to assume the worst and hope for the best. Remember, it is much better to over treat indigestion than to under treat heart attack. Heart related chest pain may result from angina or heart attack. Other causes of acute chest pain may include pulmonary embolism, pneumothorax, injury to the chest wall and some types of acute chest infection such as pneumonia or pleurisy.

34 Sickle-cell Disease Sickle-cell disease is a condition inherited from the parents. It would have been diagnosed at a very early age. Child carers need to be aware if there is a child with sickle cell disease in their care, and will need to discuss the child’s condition and care with the parents. Sickle-cell is a condition which affects mostly people of African, Caribbean, Middle Eastern or Asian descent. In sickle-cell the chemical that carries oxygen in the red blood cells is formed wrongly and these blood cells, in some instances, can become rigid and unbending and take on a curved or sickle shape. This shape is difficult to pass through the small blood vessels and so the cells may clump up and form a blockage. This leads to a lack of blood supply to the affected part of the body, which is likely to cause serious pain and could lead to organ damage and death of tissue. This is known as a sickle cell crisis and can be extremely serious. The condition is usually diagnosed originally in childhood but will continue into adult life.

Normal red Blood cell

Sickle cell

Sickle cells clumping

Red blood cell

Causes of sickle cell crisis Different things may trigger a crisis in different sufferers but some known triggers may include: ▪ Dehydration. ▪ Over-excitement. ▪ Extremes of temperature – too hot or too cold. ▪ Cold weather. ▪ Cold drinks. ▪ Bumps and bruises. ▪ Infections.

Sickle cell crisis– recognition ▪ The most common symptom is pain. ▪ This may be very severe and may occur most commonly in hands, arms, legs lower back and sometimes in the joints. ▪ Headaches, tummy aches and pains in the chest may also be seen.

Sickle cell crisis– treatment The best thing is to try to avoid a crisis happening, so if there is a particular known trigger in an individual, take steps to avoid exposing them to it. ▪ Make sure that they have plenty of drinks, even if they say they are not thirsty ▪ Remember that they may have to go to the toilet more often as well. ▪ Keep them warm and dry. ▪ Make sure that they do not become overtired. ▪ Be alert for signs of an infection. ▪ Be aware that they may suddenly become unwell.

An acute sickle cell crisis is a medical emergency. Dial 999/112 for an ambulance

Shock 35 Shock occurs when the circulation is unable to supply sufficient oxygen to the tissues. Blood is responsible for transport within the body, it transports oxygen and fuel to the cells and takes waste products away from them. If we have an inefficient circulation or insufficient blood then it will not be able to perform these vital tasks and the cells will be damaged and could die. This can lead to organ failure and the death of the casualty. We call this condition shock.

Causes of shock Fluid or blood loss This can 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 minor cases of shock it may be enough 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. Shock that originates from a heart problem is called cardiogenic 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. Allergic shock Sometimes shock may result from a severe allergic reaction (see anaphylaxis)

Recognition of shock ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Appropriate history (cause) Pale cold clammy skin. Cyanosis. Rapid weak pulse. Rapid shallow breathing. Cold and shivery. Thirst or dry mouth. Confused and disorientated. Worsening level of consciousness. Dizziness, nausea and vomiting.

Treatment of shock

▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Treat the cause where possible Reassure. 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. Nothing by mouth (until seen by Dr) Moisten their lips if they complain of thirst. No smoking. Do not give alcohol. Do get urgent medical attention.

36 Fainting 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 a 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. Fainting could occur when a bodily function or activity places a sudden strain on the nervous system. Possible causes could include: ▪ Coughing ▪ Sneezing ▪ Swallowing

▪ Laughing. ▪ Eating. ▪ Exercising

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. More seriously some heart conditions such as abnormal heart rhythms or heart attack could cause a sudden drop in blood pressure leading to a faint.

Fainting –recognition Some people will not experience any warning systems 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. ▪ visual disturbances. ▪ sudden clammy sweating. ▪ ringing in the years. ▪ nausea. ▪ unsteadiness and loss of strength. ▪ fast, deep breathing. ▪ unconsciousness. ▪ feeling lightheaded.

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.

Bleeding and Blood Loss 37 Blood loss refers to blood lost from the circulatory system. It may be lost from the body – external bleeding, or it may be lost from the circulation but retained inside the body – internal bleeding.

Effects of blood loss Blood volume varies with the size of the individual, but the normal blood volume of an adult is around 5 to 6 L or 10 to 12 pints. A loss of around 10% of this total is unlikely to cause any problem. In fact this is the amount usually donated by blood donors. A 20 to 30% blood loss would produce significant symptoms including a serious drop in blood pressure and the onset of shock. Blood loss of 30% or more could be immediately life-threatening and 40% of circulating volume is almost sure to be fatal unless replacement is carried out quickly.

Bleeding by type Arterial bleeding: ▪ Produces bright red blood at high pressure. ▪ Often spurting from the wound in time with the heartbeat. ▪ Blood loss is often rapid and substantial. Venous bleeding: ▪ Blood tends to be darker red or purple due to lack of oxygen. ▪ The blood tends to trickle or gush from the wound with no spurting. ▪ Blood loss may be substantial, dependent upon the size and site of the injury. Capillary bleeding: ▪ Usually results in slow oozing blood flow containing a mixture of venous and arterial blood. ▪ The most common type of blood loss from small injuries.

Bleeding– recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

The casualty may exhibit some or all of the following signs and symptoms: Obvious bleeding wound. Pale cold clammy skin. Rapid weak pulse. Rapid shallow breathing. Mental confusion/disorientation. Dizziness/faintness. Dry mouth/thirst. Cyanosis.

Control of bleeding Bleeding is controlled because blood congeals and forms blood clots. It is the blood clot which blocks the hole and stops the bleeding. The first aid treatment of bleeding is designed to encourage this to happen by slowing down the flow of blood. This involves the use of: ▪ Direct pressure. ▪ Elevation.

Direct pressure and elevation ▪ Apply pressure directly over the bleeding point using your fingers or a pad. ▪ Pressure should be maintained for more than 10 minutes to allow a blood clot to form. ▪ Elevate the bleeding point above the level of the casualties heart if their injuries permit. ▪ Maintain direct pressure and elevation until bleeding is controlled or until a dressing and bandage become available.

38 Wounds 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 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.

Incised wound

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.


Lacerated wound

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. Puncture wound

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 split open at the point of contact.

Abrasion Abrasions, often called grazes, are injuries that affect the surface of the skin. They are often caused by sliding falls or moving machinery. Although blood loss is usually limited they are very often dirty injuries as debris is dragged into the wound.

Contused wound


Applying 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.

Internal Bleeding 39 Wound dressing ▪ If blood soaks through the dressing, apply another one on top of the first. ▪ If blood soaks through the second dressing, remove both and re-apply making sure that pressure is directly over the bleeding point. ▪ 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 bandage it means that the blood supply is adequate. ▪ Check the blood supply to the extremities with the fingernail test. The nail bed is normally pink due to the capillaries full of blood which lie beneath the nail. ▪ Squeeze the nail firmly between finger and thumb. ▪ This squeezes 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, so 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 and 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 bleeding. ▪ Pain and tenderness over the affected area. ▪ Bruising or discolouration over the affected area.

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.

40 Specific Injury 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, 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 pressure 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. This is a job best performed by the emergency services.


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

Grasp the end of the splinter firmly with clean forceps.

Pull the splinter straight out at the same angle that it went in. Squeeze gently to produce a small drop of blood.

If the splinter does not come out easily, if it is longer than you thought or if it is over a joint, do not attempt to remove it. Advise the casualty to seek medical attention and to make sure that their tetanus protection is up-to-date.

Minor cuts ▪ 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 and if it show signs of becoming infected, i.e. swelling, pain, redness or discharge, then they will need to seek medical advice.

Grazes A graze is usually caused by a sliding fall onto a rough or dirty surface, or by using hand tools such as files or electrical grinders. They are often contaminated by dirt and grit. The graze should be washed thoroughly under a running tap to remove dirt contamination. It is often less painful to allow the casualty to do it themselves.

Specific Injury 41 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 the casualty 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 minutes to allow for blood clot formation. ▪ If this is not successful 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.

Bruises 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. ▪ Treatment is to elevate the injury if appropriate and apply an ice pack. ▪ This will help to reduce blood flow to the injury and results in reduced swelling and bruising. ▪ It is important to look at how the injury was caused and to be alert for more serious internal bleeding. ▪ Sometimes, bruising from deeper injuries may not become visible for hours or even days following the injury. ▪ If you suspect the possibility of internal injury then you must seek medical advice urgently

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 or trauma. ▪ 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. ▪ The 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 and sent to hospital with the casualty, avoiding direct contact with the ice. ▪ Control bleeding with direct pressure and elevation. ▪ Apply a dressing and firm bandage. ▪ Anticipate and treat shock. ▪ Transfer the casualty to hospital.

42 Specific Injury 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 toxins 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 minutes do not attempt to release them. Send urgently for medical assistance, reassure and monitor their condition until it arrives.

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 onto the surface of the abdomen.

Abdominal injury– treatment ▪ ▪ ▪ ▪ ▪ ▪ ▪

Position the casualty so the wound does not gape. This may be half sitting with the knees raised. Carefully inspect the wound. If abdominal contents have not escaped, apply a wound pad and firm bandage. If abdominal contents have escaped, do not handle or attempt to replace them. Cover them lightly with clean, soft and non-fluffy material. Get urgent medical attention.

Scalp Wound Scalp wounds are a relatively common injury, as the skin and underlying tissues are easily compressed against the skull laying just underneath, causing them to burst open. Because of the very rich blood supply to this area of the body, blood loss from a scalp wound may be greater than you would expect. The casualty’s real problem though may not be the visible wound, but what lies underneath it. If a casualty has been hit on the head hard enough to cause the wound they may well have a much more serious underlying fracture of the skull.

Scalp wound 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 were 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 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, if the casualty is unconscious , maintenance of the airway takes priority.


44 Injuries to Bones, Joints and Soft Tissue The skeleton The muscular skeletal system consists of individual bones, supported by ligaments, tendons muscles and cartilage. The skeleton has six functions:

Skull Mandible Cervical Vertebrae Clavicle Scapular

shape and support – the skeleton forms a framework that supports us.

Sternum Humerus

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.

Lumbar Vertebrae

Ulna Pelvis Sacrum Coccyx Femur Patella Fibula Tibia Metatarsals



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 conveniently placed into one of four groups: ▪ Closed fracture. ▪ Open fracture. ▪ Complicated fracture. ▪ Greenstick fracture

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

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 will probably wait until the arrival of the ambulance or other trained help, along with more advanced immobilisation equipment.

Injuries to Bones, Joints and Soft Tissue 45 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.

Complicated fracture of the pelvis

Greenstick fracture ▪ Because children’s bones are softer and more pliable than adults, they tend to bend rather than break. ▪ Sometimes part of the bone breaks. This incomplete fracture is known as a greenstick fracture because it breaks like a green branch or twig.

Fracture recognition ▪ ▪ ▪ ▪ ▪

Swelling. Bruising (later). Deformity. Shortening of the limb. Crepitus.

▪ ▪ ▪ ▪

Signs of shock. Sound of bone breaking. The feeling of bone breaking. Pain and tenderness at the fracture site.

Fracture – treatment Broken bones take 6 to 8 weeks to heal and nothing that first aiders do is do is going to make any difference to that. The injury occurred before we got there and we cannot heal it. Realistically, there is nothing we can do for the fracture. The aim of first aid for fractures is to minimise the damage that the fracture causes to the surrounding tissue and to deal with the effects of the fracture. In most cases, the only treatment required is to assist the casualty in keeping the fracture in a comfortable position and to call the emergency services. It is not usually necessary to start applying splints or other devices to fractured limbs. ▪ ▪ ▪ ▪ ▪

Deal with any more urgent problems first. Do not move the casualty unless absolutely necessary. Immobilise the fracture prior to movement. Be prepared to treat shock. Get medical attention.

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 a boiled 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.

46 Injuries to Bones, Joints and Soft Tissue Fractured skull– recognition ▪ ▪ ▪ ▪ ▪ ▪

History of a blow to the head or a 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. Give 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


Intervetebral disc

Spinal Nerve


Spinal Cord

Lumbar Spinal Nerve

Spinous Process

Sacrum Coccyx

Spinal Injury 47 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 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 neck or back, 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.

Vertabral fracture

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. ▪ Priaprism.

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 either come 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. Life over limb Do not wait until the unconscious casualty has started to vomit. ▪ Dial 999/112 for an ambulance. ▪ Keep the conscious casualty in the position found. ▪ Try to stabilise their neck and spine using rolled up blankets or clothing or of course your hands. ▪ Reassure the casualty continuously, tell them to keep still and not to attempt to move.

▪ Place the unconscious casualty carefully into the recovery position. ▪ Stabilise the neck first. ▪ Immobilise by supporting head trunk and legs. ▪ Roll the casualty like a solid log. ▪ Avoid twisting or bending.

48 Fractures Pelvic fracture The pelvis is a large heavy girdle of bone and it takes considerable force to fracture it. Injury is often caused by crushing or severe direct force. In either case, there are likely to be other injuries and shock from internal bleeding should always be anticipated. Many pelvic fractures will occur at the thinnest and weakest point, which is in the front and for this reason, it is common for the jagged bone ends to damage the bladder or associated structures. Fracture

Recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪

History of violent force or crushing injury. Pain and tenderness at the site. Inability to weight bear. Bruising or discolouration over lower abdomen. Signs and symptoms of shock Frequency (feeling of wishing to pass urine frequently) Passing small amounts of bloodstained urine.

Treatment ▪ ▪ ▪ ▪

Immobilise the casualty in a position of comfort. Treat the shock Try to persuade the casualty not to pass urine too frequently. Dial 999/112 for an ambulance.

Rib fracture Fracture of the rib is generally a fairly minor injury which requires little treatment, but it may be complicated by damage to the lung and so may affect breathing.

Recognition ▪ ▪ ▪ ▪

History of injury. Pain at the site, made worse by movement. Sharp pain on breathing or coughing. Breathing may be getting worse.



Treatment ▪ Place in a half sitting position leaning towards the injured side. ▪ Place the arm on the affected side in a sling or tuck it into the casualties clothing. ▪ If breathing deteriorates dial 999/112 for an ambulance. ▪ Otherwise, take casualty to hospital for a check x-ray to confirm injury and treatment.

Rib fracture

Damage to bladder

Fractures 49 Collarbone fracture The collarbones are the arched bones between the top of the breast bone and the shoulder. Most fractures occur as a result of indirect force following a fall onto the outstretched arm or onto the point of the shoulder.

Recognition ▪ ▪ ▪ ▪

History of injury. Swelling and deformity at site. Pain and tenderness. Casualty supporting the arm on the affected side with the affected shoulder elevated and head inclined to the affected side.

Treatment ▪ ▪ ▪ ▪

Place the casualty at rest. Apply an elevation sling if appropriate, or let the casualty support their arm if they happy to do so. Pad between arm and torso. Take or send the casualty to hospital.

Upper limb fracture Although 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 the casualty to support their own arm if they are happy doing so. Immobilise with the appropriate sling if required. Elevate where possible. Check circulation and sensation below fracture site. Refer to medical help.

50 Fractures Leg fracture

Front view

Side view

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. Front of lower leg often an open fracture. Signs and symptoms of shock.

Treatment Treat any obvious wound or bleeding. Check circulation and sensation below the fracture site. Elevate where possible. Do not move 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 the casualty to hospital. ▪ ▪ ▪ ▪ ▪ ▪

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 a 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.

Fractured fibula

Fractured tibia

Fractured lower leg

Soft Tissue Injury 51 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.

Ligament Muscle

Soft tissue injuries are either: ▪ Strains ▪ Sprains Tendon Bone

Strain A strain occurs when a muscle or tendon has been overloaded or stretched, resulting in the tearing of some of the fibres.

Recognition ▪ Immediate and severe pain. ▪ Muscle spasm over the affected area.

Treatment ▪ Rest until the spasm subsides. ▪ Apply ice packs over the affected area several times daily. ▪ If pain does not improve advise to see GP.

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 a joint. Immediate pain. Swelling. Discolouration.

Treatment ▪ ▪ ▪ ▪

Sit the casualty down and elevate the injury. Apply an ice pack if one is available. Apply a firm support or elastic bandage. Mobilise as the pain allows.

R.I.C.E ▪ ▪ ▪ ▪

Rest Ice Compress Elevate

52 Back Problems 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. ▪ lifting and carrying. ▪ poor posture. ▪ reaching, twisting and lifting. ▪ repetitive handling tasks. ▪ slips or trips. Although back pain isn’t 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. ▪ both of your legs feel weak or you are unsteady on them. ▪ you become incontinent.

Slipped disc

Pressure on the spinal nerve

In this condition properly called a 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 often to cause pain, which may travel along the pathway of the nerve affected.

Prolapsed disc

Recognition ▪ 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.

Treatment ▪ If the pain is severe, the casualty will want to rest ▪ The casualty 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 casualties should see their GP. ▪ Simple painkillers such as aspirin or paracetamol may help but sometimes anti-inflammatory drugs may be more effective. ▪ Although prolapses are more common in the lower back, they may also occur in the neck.

Sciatic nerve Sciatica

Burn Injury 53 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.

Burns by type Thermal burns: caused by the exposure of tissue to heat, often subdivided into two categories; dry heat and moist heat (scald) 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 There are several factors to consider when assessing the severity of a burn. ▪ Depth of the burn. ▪ Extent of the burn. ▪ Site of the burn.

▪ The casualty’s health. ▪ The casualty’s age. ▪ The cause of the burn.

Burn by depth Burns can be described as: ▪ Superficial ▪ Partial thickness. ▪ Deep Superficial burns: affect only the surface layers of the skin. They heal quickly with no scarring. Partial thickness burns: go into but not through the skin. They may cause blistering and obvious fluid loss and are very painful. Shock is often a problem. Deep burns: 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 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.

54 Burn Injury Deep 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 the amount and type of fluid replacement required in their treatment. 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. 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.

1% BSA

General burn treatment ▪ 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 minutes. ▪ Cover the burn with a clean non-fluffy dressing. Plastic or cling-film is ideal. ▪ Avoid touching, coughing on or contaminating the burn. ▪ Do not burst blisters. ▪ Do not apply any creams, ointments or fats to the injury.

Corrosive 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 tissues. 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. ▪ Be aware that contaminated water from the site may cause burns to other areas of the casualty or to the rescuer, so care must be taken in positioning the casualty to make sure that this does not happen.

Burn Injury 55 Electrical burn 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, possibly on the foot. ▪ There may be other injuries if, for example, the victim was thrown across the room. Although electrical burns can appear to be very 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.

Burn to the airway 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. It may also be caused by swallowing very hot liquids or corrosives.

Recognition - hot gas or smoke ▪ ▪ ▪ ▪ ▪

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 mucous. Difficulty in breathing. Sign or symptoms of poisoning.

Recognition - hot liquids ▪ Often affects children. ▪ History of drinking hot drink.

▪ Maybe burns elsewhere on the body from dropped drinking vessel. ▪ Immediate pain with screaming and crying.

Treatment ▪ ▪ ▪ ▪

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

Recognition - corrosives ▪ Physical evidence / container at the scene. ▪ Often happens to children. ▪ May be a suicide attempt and the casualty may be disturbed.

Treatment - corrosives ▪ Do NOT make the casualty vomit as the corrosive can burn on the way up. ▪ Give mouthwashes to remove the chemical. ▪ Give frequent small drinks of bland liquids to dilute the material. ▪ Seek urgent medical attention.

▪ There is usually intense pain. ▪ There may be swelling or staining around the mouth.

56 Effects of Temperature 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 the casualty to a cool environment. ▪ Lay them down and elevate their legs. ▪ Give them copious cool drinks (isotonic sports drinks are preferred) ▪ Keep the casualty at rest and monitor vital signs. ▪ Arrange for medical attention.

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. Use a fan Lay down and elevate the feet

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.

Use cold compresses

Treatment ▪ Remove the casualty to a 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 vital signs and be prepared to give life support if required.

Give drinks if conscious

If the casualty stops sweating it is a critical emergency. Call 999/112 immediately

Hypothermia 57 Hypothermia


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.

38 37 36

36.5-37.5°C Normal adult



Mild hypothermia


Moderate hypothermia


Deep hypothermia


Critical hypothermia

34 33 32 31 30

Recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Shivering Cold pale skin. Slow pulse. Apathy Disorientation, Slurred speech. Staggering gait. Dropping level of consciousness.

Treatment Young casualty/moderate hypothermia Remove the casualty to shelter. Remove wet clothing, if appropriate. If available, place the casualty into a warm bath or shower (40° C).* Do not leave a re-warming casualty alone. When the casualty feels normal and has 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. ▪ Arrange for medical attention.

▪ ▪ ▪ ▪ ▪

*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,

Elderly Casualty (be aware that hypothermia may be disguising other serious medical conditions) ▪ ▪ ▪ ▪ ▪ ▪

Place the casualty in bed in a warm (not hot) room. Insulate the casualty with layers of blankets or duvet. Allow the casualty to re-warm slowly. Monitor their level of consciousness and vital signs. Be prepared to offer life support as required. Handle the casualty gently and keep movement to a minimum.

58 The Nervous System The nervous system The function of the nervous system is to gather information, store information and send out directions to the body. It can conveniently be thought of in two main parts: The central nervous system. The peripheral nerves.

From side

From back Brain

The Central nervous system The central nervous system comprises of the brain and spinal cord. The brain is like a computer which receives information from the body, stores or processes it and sends directions to the body. The spinal-cord is the cable that carries information and out of the brain. Brain and spinal cord tissue are not repaired or replaced if they are damaged.

Peripheral nervous system

Spinal cord

Central nervous system

The peripheral nerves other nerves outside the central nervous system. There are 12 pairs of cranial nerves which originate directly in the brain and 31 pairs of spinal nerves which branch from the spinal cord at the level of each vertebrae. They comprise of bundles of nerve fibres which can carry both in coming signals (sensory nerves, or nerves of feeling) and outgoing directions (motor nerves, or nerves of movement.

Autonomic nervous system Some of the cranial nerves and some spinal nerves operate together and form the autonomic nervous system. They are concerned with the function and performance of some bodily organs such as heart rate and breathing. Many of the functions are outside the conscious control of the person and work automatically.

Peripheral nerves

Stroke 59 Stroke is a condition in which the blood supply to part of the brain is interrupted leading to localised brain injury with death of brain cells.

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 F.A.S.T. test ▪ ▪ ▪ ▪

F Face A Arms S Speak T Time

Ask them to smile. Does their face look lopsided? Is the eye or mouth drooping on one side? Ask them to raise both of their arms above their head Can they raise them equally? Can they speak clearly? Can they understand what you say?

Time to call 999/112 for an ambulance

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 ▪ ▪ ▪ ▪ ▪

Reassure. Lay them down with the head slightly raised. Place them in the recovery position if they are or if they become, unconscious. Call urgently for medical attention. Continue to monitor their condition until the arrival of the ambulance.

Mini stroke or T IA (transient ischaemic attack) ▪ Some people may exhibit the signs of a stroke which then goes away, leaving them unaffected. This should not be ignored. ▪ Get medical help for them as soon as possible as this may lead to a major stroke and should always be investigated.

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

Tonic/clonic seizure–recognition ▪ The casualty’s body goes suddenly stiff. ▪ They lose consciousness. ▪ They fall to the floor.

▪ Their body may jerk or convulse. ▪ They may be blue around the mouth. ▪ They may foam at the mouth.


A Assess C Cushion T Time I Identify O Over N Never

Assess the situation – are they in danger of injuring themselves? Remove any nearby objects that could cause injury. Cushion the head (with a pillow or clothing) to protect them from head injury. Check the time – if the seizure lasts longer than five minutes you should call an ambulance. Look for a medical bracelet or ID card – it may give you information about the person’s seizures and what to do. Once the seizure is over, put them on their side (in the recovery position) Stay with them and reassure them as they come round. Never try to restrain the person, put something in their mouth or try to give them food or drink.

Call an ambulance if: ▪ You know it is their first seizure. ▪ The seizure lasts for more than five minutes.

▪ One seizure appears to follow another without the person regaining consciousness in-between. ▪ The person is injured. ▪ You believe they need urgent medical attention.

Febrile seizures Febrile convulsions are seizures that happen to children who have a fever (a temperature above 38° C) They may be very frightening for the parents but are generally not dangerous. They can occur at any time during the fever, when the temperature is rising, or dropping from a previously high level. 80% of febrile seizures are simple seizures, the remaining 20% are known as complex febrile seizures.

Febrile seizures–recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪

The child’s body may become stiff. Their arms and legs may begin to twitch. They will lose consciousness. They may become incontinent. They may vomit. They may foam at the mouth. Their eyes may roll back.

▪ The seizure usually lasts for less than five minutes. ▪ Following the seizure the child may be sleepy for up to an hour afterwards. ▪ Complex febrile seizures tend to last longer than 15 minutes and the symptoms may affect only one area of the child’s body.

Febrile seizures–treatment ▪ Protect the child from harm during the seizure. ▪ Place them carefully on their side to protect the airway. ▪ Call your GP or NHS direct (dial 111)for advice. ▪ Be prepared to take the child to the nearest hospital if they have no previous history of seizures.

▪ Look out for signs of dehydration. ▪ Dial 999 immediately for an ambulance if your child shows any of the symptoms below: ▪ The seizure lasts longer than five minutes and shows no sign of stopping. ▪ The child has breathing difficulties.

Head Injury 61 The problem with any head injury is not necessarily the injury that you can see but the potential damage to the brain that may be permanent and also the subsequent loss of consciousness. It should also be remembered that anyone with a head injury also has a potential neck injury and should be treated as if this were the case.

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 sudden loss of consciousness which is usually of fairly short duration. A concussion is a generally mild brain injury that normally results 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 a height. Possible scalp wound or swelling. Sudden, but short term, loss of consciousness. Headache.

▪ ▪ ▪ ▪

Rapid weak pulse. Pale cold skin. Sweating Nausea / vomiting.

Concussion– treatment ▪ ▪ ▪ ▪ ▪

Assess their level of consciousness, if they are unconscious check ABC. Place the unconscious casualty into the recovery position. Continue to monitor their vital signs. Call 999/112 for an ambulance if their condition deteriorates. Advise them to seek medical attention if there is any change in their condition after recovery. Blood clot

Compression injury 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. The brain is contained within the rigid box of the skull which does not allow for expansion. Any swelling within this rigid box will cause the pressure within the box to rise. When the pressure within the skull begins to get close to the pressure of the blood supplying the brain (BP) the level of blood and therefore oxygen reaching the brain tissue will be reduced. Other causes of raised pressure inside the skull could be: ▪ Generalised swelling caused by some medical conditions or following injury. ▪ Fluid buildup following a stroke. ▪ Poor venous blood return in heart failure, or due to constriction around the neck.


Compression injury– recognition ▪ ▪ ▪ ▪

History of a blow to the head or a fall from a height. Possible scalp wound or swelling. Pain in the head getting worse. Possibly blood or cerebrospinal fluid (CSF) appearing at the nose, ears or collecting around the eyes. (Black eyes with no evidence of damage to the face)

▪ One or both pupils in the eyes dilating, with sluggish or reduced response to light. ▪ Flushed complexion with warm dry skin. ▪ Dropping level of consciousness. ▪ Slowing irregular breathing. ▪ Seizures ▪ Slowing pulse

Compression injury– treatment ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Assess the level of consciousness, if they are unconscious check their ABC. Give life support as appropriate. Dial 999/112 for an ambulance. If they are conscious, place in a half sitting position with their head and shoulders elevated. Support and immobilise the neck. If they are unconscious and breathing, place them in the recovery position. Keep the bleeding ear downward to encourage drainage. Continue to monitor their condition.

Unequal pupils

62 Head Injury Ongoing treatment Any casualty who has been unconscious should be assessed by a medical professional. The problem is that a head injured casualty may seem perfectly well immediately after the event but their condition may deteriorate over time and could become life-threatening.

The casualty who is recovering from a head injury should be advised to seek urgent medical attention if they develop any of the following signs or symptoms. ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

A headache, possibly getting worse. Increasing drowsiness. Mental confusion. Loss of memory. Limb weakness. Problems with balance. Dizziness. Seizure. Visual disturbances / double vision. Breathing difficulties. Blood, clear fluid or a mixture of both leaking from ears or nose. Black eyes with no evidence of damage to the face.

Diabetes 63 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 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* *In later stages

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.

Diabetes in children If a child has been diagnosed they will almost always be treated with insulin given by injection. The amount will be carefully worked out by their doctor or hospital team. Most small children will need frequent doses of fast acting insulin, older children may use a continuous insulin pump. The important thing in treating diabetes is to keep the sugar level in the blood stable, not too high or too low. If the levels are too high the child may experience the symptoms above, but if the levels drop too low it can have a much more sudden effect that can become rapidly life-threatening if not treated. This is called hypoglycaemia or hypo for short. It happens when the child has insulin but doesn’t eat enough sugar to balance the effect. It can also happen if the child burns up a lot of sugar with exercise.

Hypoglycaemia–recognition ▪ History of diabetes. ▪ Receiving insulin or other hypoglycaemic drug. ▪ 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 6 to 8 teaspoons in a glass of water, sugary sweets, non-diet sweet drinks or whatever is to hand as quickly as possible. If unconscious ▪ place them in the recovery position. ▪ refer to medical help urgently, with history if available.

▪ If recovery is not swift, repeat. ▪ Refer to medical help if appropriate, or if no rapid response.

64 Anaphylaxis 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. The reaction affects the whole body and may start within minutes of exposure or may be delayed by several hours.

Anaphylaxis– recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Swelling/puffiness of the face. General flushing of the skin. Swelling of the mouth and tongue. Difficulty in swallowing or talking. Alteration of the heart rate. Widespread blotchy skin rash (hives) 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 the casualty is carrying an auto injector of adrenaline (Epi-pen or Jext injector) and is able to use it, then help them to do so. ▪ If you have been trained to use the auto injector then use it to inject the casualty* ▪ If the casualty has problems breathing, place and a half sitting position. ▪ If they show signs of shock, then lay them down. *Although the use of an auto injector is usually restricted to those who have received appropriate training, in a potentially life-saving situation anyone may use one by following the instructions.

Using a Jext injector

Grasp the injector with your thumb closest to the yellow cap.

Pull off the yellow cap with your other hand.

Place the black injector tip against the outer thigh, holding the injector at right angles.

Push the black tip firmly into the thigh until you hear a click confirming that the injection has started, then keep it pushed in. Hold the injector firmly in place against the thigh for 10 seconds.

Massage the injection area for 10 seconds. Seek immediate medical help

Meningitis 65 Meningitis is an infectious disease which affects the meninges;the coverings of the brain and spinal cord. There are several different causes of meningitis, but the two most common organisms are viruses and bacteria. Viral meningitis Meningitis caused by virus infection is usually a fairly mild disease but it can make people feel very ill. Thousands of cases may occur each year, mostly affecting babies and children. Although most people will make a full recovery, some may be left with serious after effects. Bacterial meningitis Bacterial meningitis can rapidly become life-threatening and requires urgent medical attention. Although most people who suffer from bacterial meningitis will recover, many can be left with serious after-effects and one in 10 may die. The main types of bacterial meningitis in the UK are Meningococcal and Pneumococcal. Neonatal meningitis Occurs in babies under one month old. As with all other cases of meningitis it is serious and requires medical attention. Many people still believe that meningitis only affects babies and young children. This is not the case, it can affect anyone, of any age, at any time. Meningitis can start in minutes and kill within hours. Early recognition and medical treatment can be life-saving.

Meningitis first aid There is very little that first aid can do to help meningitis. By far the most important thing is recognising it early and getting medical attention as soon as possible. The problem is that it can be difficult to recognise in the early stages. It starts in a similar way to colds or flu but the casualtyâ&#x20AC;&#x2122;s condition can deteriorate very rapidly. The best advice is to be suspicious and follow your instincts. If you suspect meningitis do not wait to see if other signs and symptoms occur, get medical attention immediately. Tell the doctor/hospital/ambulance controller that you suspect meningitis and be prepared to stand your ground and demand attention. The signs and symptoms of meningitis can appear in any order and some may not appear at all so do not wait until you see all of the following signs and symptoms. Trust your instincts.

Meningitisâ&#x20AC;&#x201C; signs & symptoms in babies and toddlers Babies and the very young are at the highest risk for meningitis and meningococcal septicaemia. Know the signs and symptoms and trust your instincts.

Unusual cry, moaning.

Fever with cold hands and feet

Pale blotchy skin. Spots/rash, see glass test.

Refusing food and vomiting.

Fretful, dislike of being handled.

Tense bulging fontanelle

Drowsy, floppy, unresponsive

Neck stiffness, dislike of bright lights.

Rapid breathing or grunting.

Convulsions or seizures.

66 Meningitis Meningitis– signs & symptoms in children & teenagers Teenagers and young adults at the second highest risk group for meningitis and meningococcal septicaemia.

Severe muscle pain

Fever with cold hands and feet

Pale blotchy skin. Spots/rash, see glass test.

Refusing food and vomiting.

Severe headache.

Drowsy, difficult to wake.

Stiff neck.

Confusion and irritability.

Dislike of bright lights.

Convulsions or seizures

Meningitis– signs & symptoms in adults Meningitis can strike at any time, regardless of health, gender, age, race or class. People over 55 are at higher risk of meningitis as their immune systems weaken with age. Adults can still suffer the same after-effects from meningitis as children, such as brain damage, hearing and sight loss and where septicaemia has occurred, loss of limbs and scarring. The signs of meningitis meningococcal septicaemia in adults are generally the same as in teenagers and young adults.

The glass test One of the signs of meningococcal septicaemia is a rash which may appear quite suddenly and cover some or all of the body surface. If someone is ill or getting worse do not wait for the rash to appear. It may appear late or not at all. A particular property of the meningitis rash is that the spots do not fade under pressure. A fever with spots or a rash that does not fade under pressure is a medical emergency. Take an ordinary clear glass or plastic tumbler. Place it on the skin next to the spots/rash. Roll it onto the spots/rash, applying firm pressure. Note that the normal skin under the glass goes white as the blood is pushed out of the capillaries. ▪ If the spots fade when the glass is rolled over them, the rash may not be serious, but keep checking, it can develop into a rash that does not fade. ▪ If the spots/rash doesn’t fade, it is a non-blanching rash and needs urgent medical attention. ▪ ▪ ▪ ▪

Remember, don’t wait for a rash, it won’t always appear or may appear late. Trust your instincts.

Eye Injury 67 It is probably true that in most cases of eye injury the victim will seek assistance from a doctor or other qualified person. There may be occasions however, when medical help is not immediately available or the casualty’s condition is such that it demands immediate attention. In these cases, first aid would be appropriate.

Blunt trauma ▪ History of the blow to the eye from a ball or fist. ▪ Bruising and swelling to upper and lower eyelids. ▪ Pain in the affected area. ▪ Inability to open the eye. ▪ Apply a cold compress. ▪ Refer to medical attention.

Corneal abrasion ▪ History of something sharp entering the eye. ▪ Severe pain. ▪ Blurred vision. ▪ Copious watering. ▪ Apply an eye pad. ▪ Take them to hospital.

Loose foreign body ▪ History of dust or grit blowing into the eye. ▪ Small particles seen lying on the surface of the eye. ▪ Sit them down. ▪ Attempt to wash the dust out with water. ▪ Use the damp corner of a handkerchief to lift the dust out. ▪ Do not attempt to remove anything which is stuck to the surface of the eye.

Wounds to the eye ▪ History of injury. ▪ Visible wound. ▪ Intense pain. ▪ Reassure the casualty. ▪ Try to prevent them from touching the eye. ▪ Attempt to close the eye, but do not force. ▪ Apply a light cover.

Embedded foreign body ▪ History of material entering the eye. ▪ Visible foreign body. ▪ Intense pain. ▪ Reassure and try to prevent them from touching the eye. ▪ Do not attempt to remove the object. ▪ Pad carefully and cover the unaffected eye. ▪ Send or take to hospital.

High velocity impact ▪ Feels something strike the front of the eye. ▪ Little or nothing visible. ▪ There may or may not be much pain. ▪ Assume the object has entered the eye. ▪ Apply a light eye pad.. ▪ Arrange transport to hospital.

68 Burns to the Eye Burns to the eye may occur in one of three ways: ○ Heat (thermal burns) ○ Radiation. ○ Corrosive chemicals.

Thermal burns to the Eye Recognition ▪ History of exposure to heat source ▪ Dry scratchy eye or eyes.

▪ Pink or reddened skin to the face.

Treatment ▪ Cool affected eyes with clean cool water. ▪ Get the casualty to hold a loose cover over the eye or apply an eye patch from the first aid kit.

▪ Seek medical attention.

Corrosive burns to the Eye Recognition ▪ History of exposure to corrosive chemicals. ▪ Severe pain in the affected eyes. ▪ Redness and swelling around the eyes.

▪ Copious watering of the eye. ▪ The casualty may have their hands to their face, or may be rubbing the eye.

Treatment ▪ Sit the casualty down and prevent them from rubbing their eyes. ▪ Irrigate the eye with running water using a glass or cup. Use sterile eye wash bottles, if available.

▪ Irrigate for at least 10 minutes or until all trace of chemical is removed. ▪ Be careful that contaminated water does not affect the good eye. ▪ Arrange to take or send the casualty to hospital.

Radiation burns to the Eye Radiation burns to the eye are almost always caused by ultraviolet radiation in the form of sunlight or more probably a welder’s arc, often referred to as arc eye or welders flash. The casualty is often unaware of the exposure, feeling nothing at the time but effects will be felt some hours later, often waking the casualty in the early hours of the following morning.

Recognition ▪ ▪ ▪ ▪

History of exposure to U.V. Light. Often standing close to or assisting a welder. Onset several hours after exposure. Both eyes affected.

▪ ▪ ▪ ▪

Burning, gritty sensation in the eyes. Intense pain in the eyes. Made worse by exposure to light. Profuse watering.

Treatment ▪ Cold compresses can help. ▪ Apply light eye patches to eyes, wear dark glasses or stay in a darkened room.

▪ Seek medical attention with history. ▪ Radiation burns usually resolve themselves within 24 - 48 hours.

Eye irrigation This is the preferred method of dealing with loose foreign bodies and chemical contamination. The casualty should be sat down and should lean toward the affected side so that the affected eye is at the lowest point. Water should be allowed to run across the surface of the eye from the nose side outward and to drain away to safety, making sure that contaminated water does not enter the good eye. In cases of chemical contamination this irrigation should continue for at least 10 minutes. After irrigation the eye should be carefully dried before taking the casualty to hospital.

Poisoning 69 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. ▪ Absorption through the skin or membranes

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. ▪ Chemicals in the workplace are subject to the COSHH (Control Of Substances Hazardous To Health) regulations and they will have all of the required information on data sheets, and on container labels.

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

Inhaled poison 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 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. In this case these personnel should be summoned urgently.

Swallowed 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 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 by 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 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. The best treatment for overdose or accidental poisoning by mouth is the general treatment for poisoning. ▪ Support and maintain ABC. ▪ Get to medical help with as much information as possible.

70 Bites and Stings A sting occurs when venom is injected through a hollow tube into the skin or underlying tissue. A bite does not inject venom but may still cause an allergic reaction. Most insect bites and stings in the UK are likely to cause discomfort rather than danger but being stung or bitten is possibly painful and may be distressing.

Recognition The most common stinging insects in the UK are the bee, wasp or hornet and the sting will often cause an immediate and possibly intense burning pain at the site, followed very quickly by swelling and redness around the sting. This will usually ease after a few hours. The biggest threat from such a sting would be a severe allergic reaction, or anaphylaxis (see page 33) A less serious allergic response may lead to localised swelling. This child had a wasp sting to the index finger that lead to swelling of the hand. The swelling and redness may spread to be several centimetres across or may even involve a whole arm or leg. It will usually go away over a few days. It is not dangerous unless it affects the airway but in severe cases it may cause blister formation or infection if the skin breaks down. A wasp will not usually leave its sting behind and may sting more than once but a bee’s sting is barbed and will remain in the skin, with its venom sac attached. It is important not to press on this as it will push more venom into the wound.

Wasp sting

Wasp sting

Treatment ▪ If the casualty has been stung by a bee and the sting is still in the skin it should be removed as soon as possible. Delay could lead to more venom being pushed into the tissues, ▪ It is important not to try to grip or squeeze the sting as this may squeeze more poison from the sac. ▪ The best method is to scrape the sting out using something like the edge of a card, the back of a knife or your fingernail. ▪ If you see any signs of a general allergic reaction then get medical help urgently. Phone 999 for an ambulance. Be alert for swelling in or around the mouth and lips. ▪ If the casualty has been stung multiple times they require the same urgent medical attention. ▪ Apply a cold compress to the site. Ice or frozen peas wrapped in a cloth or a cold wet flannel. Repeat as required. ▪ If there is a localised allergic reaction with swelling, redness and itching then they may benefit from an anti histamine either by mouth of as a cream or ointment. ▪ If there is a small local reaction (most commonly) then after the cold compress the itching and swelling will go away over time.

Allergic response

Bee sting

Tick bites Ticks are transferred to the skin from leaves or grass and cling onto the skin with their jaws. As they feed on blood their bodies swell, often taking on a grey appearance. Tick bites tend to be painless. Ticks may carry a germ that could go on to cause Lyme’s disease which can be very serious. For this reason anyone who has suffered a tick bite should receive medical attention. Early signs of Lyme’s disease is a rash developing at the site of the bite a few days later, along with a raised temperature up to a month after the bite. Ticks should be removed with a pair of fine tweezers. This is probably best done by someone with experience as it is easy for the tick to break, leaving the head part embedded. This invariably leads to a localised infection at the site.

Poison sac Removing a bee sting

Tick removal

First Aid Kits Contents of first aid kits - BS-8599 Contents First Aid Guidance Leaflet Contents List Medium Dressing (12cm x 12cm) (Sterile) Large Dressing (18cm x 18cm) (Sterile) Triangular Bandage (Single Use) ((90cm x 127cm) Safety Pins (Assorted) (minimum length 2.5cm) Eye Pad Dressing with Bandage (Sterile) Washproof Assorted Plasters Moist Cleaning Wipes Microporous Tape (2.5cm x 5m or 3m for Travel Kit) Nitrile Gloves (1 Pair) Finger Dressing with Adhesive Fixing (3.5cm) Mouth to Mouth Resuscitation Device with Valve Foil Blanket (130cm x 210cm) Eye Wash (250ml) Burn Relief Dressing (10cm x 10cm) Universal Shears (Suitable for cutting clothing) Conforming Bandage (7.5cm x 4m)

Small 1 1 4 1 2 6 2 40 20 1 6 2 1 1 0 1 1 1

Medium 1 1 6 2 3 12 3 60 30 1 9 3 1 2 0 2 1 2

Large 1 1 8 2 4 24 4 100 40 1 12 4 2 3 0 2 1 2

Travel 1 1 1 1 1 2 0 10 4 1 1 0 1 1 1 1 1 1

Size of first aid kits Employers are required to make a risk assessment to decide what their hazard levels are and how many employees are involved in the area to be covered. Below is a useful guide to help match this risk assessment to an appropriate kit size. Where there are special circumstances, such as remoteness from emergency medical services, shift-work or sites with several separate buildings, there might need to be more First Aid kits than set out in the table. Hazard Level

Number of Employees

Size of FA kit

Low Hazard

Less than 25

Small size kit

Low hazard

25 - 100

Medium size kit

Low hazard

More than 100

1 large size kit / 100 employees

High hazard

Less than 5

Small size kit

High hazard

5 - 25

Medium size kit

High hazard

More than 25

1 large size kit / 25 employees

Low Hazard - Offices, shops, libraries etc. High Hazard - Light Engineering and Assembly work, Food Processing, Warehousing, Extensive work with dangerous machinery or instruments, construction, chemical manufacture etc


72 Notes


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