First Aid

4
CHAPTER 1

THE ROLE OF OBSERVATION IN FIRST AID

CYNERGEX GROUP has specifically designed its first aid training courses to give students the
confidence to respond to medical emergencies by providing them with good skills and background
knowledge in relevant techniques. Our courses concentrate on teaching students how to identify a
problem, measure its impact and utilise a range of techniques and equipment to deal with it. Our
emphasis also ensures that the techniques we train students to use are part of an integrated approach
which allows the emergency medical services to pick up the treatment and progress it as seamlessly
as possible.

A significant part of effective first aid is measurement. Without measurement, we cannot assess a
casualtys condition and we have no idea of how sick they are or whether what we are doing to treat
them is working to improve their situation or not. Measurement in first aid is about measuring and
recording the pulse rate, rhythm and strength; recording the respiratory rate, rhythm and strength;
recording the blood pressure (where available); recording the level of the casualtys consciousness;
and recording their skin condition.

HISTORY

In addition to the above measurements, it is vital that we have a clear understanding of what is
happening or has happened to the casualty. The story of the incident is the history we collect and it is
essential that it is accurate.

HISTORY

The history of an incident is the story of the incident and the casualtys role in it. History is one
of the most useful tools available to first-aiders, ambulance and medical staff as they attempt
to determine the specific problems faced by a specific casualty. The unconscious or confused
casualty left in a hospital casualty department is a complete mystery to the medical staff
unless they gain insight through a good history. A good history is of great benefit whether the
casualtys problem is a medical condition or an injury.

HISTORY OF AN ILLNESS

With medical conditions the history of the casualty, and even their family, is of great use in
identifying the possible cause of a casualtys illness. For example, the casualty who develops
crushing, central chest pain which radiates to the left neck and arm may be suffering the first
signs of an acute myocardial infarction (AMI) (a very serious heart attack). If the casualty is
able to tell you that they have had episodes of breathlessness and chest tightness over the
last few weeks, then it adds strongly to the evidence that the casualty is having an AMI. If the
casualty also details a family history that includes a father dying of a heart attack, an uncle
having had heart problems and a brother also having had a heart attack, then the evidence is
overwhelmingly in favour of this casualty having an AMI.

HISTORY OF AN ACCIDENT

In a car accident the history is also of great importance in estimating the way in which the
casualty was injured and thus the injuries that the casualty may have suffered. In accidents, a
good history allows medical staff to quickly focus their attention on areas with a high
probability of injury and this gets the casualty into the operating room faster.

For example, a car runs off the road at around 11:30pm in light rain at a Y intersection and
travels towards an electricity pole approximately 50 metres from the edge of the roadway in a
direct line with the bottom end of the Y. The car was travelling along the stem or bottom part
of the Y and has left the road stopping short of the pole by about 5 metres.
5
Fig 1.

At first glance, the scene seems simple enough. The car has left the road and stopped just
short of the pole. There is little likelihood that anyone has sustained an injury. However, the
history and the physical evidence tell an interesting story.

On arrival at the scene, the first thing you noticed is that there were no skid marks on the
surface of the road and that the tyre marks on the soft edges and the wet soil leading up to the
tree show tread marks all along their length. This indicates that the driver did not apply the
brakes during the accident (under braking the marks would be smooth, that is true skid
marks). You also note that the wheel ruts are dead straight, indicating that the driver made no
effort to turn the steering wheel. You also note wet mud freshly sprayed over the rear of the
car indicating that the driver was driving the car under power. This tells you that the casualty
was probably conscious throughout.

On arriving at the drivers side door you noticed the driver is sitting up and looking forward at
the pole. Following your knock on the window the driver, the only occupant, winds down his
window and talks to you confirming that he was conscious when he ran off the road.

The indications we have is that the vehicle ran off a wet road in the dark and that the driver did
not attempt to steer away from a pole towards which the car was travelling. We also know
that he did not attempt to brake and that he actually applied power to the car. This indicates a
deliberate attempt to drive the car into the pole and indeed this was the case as the driver in
this case later admitted. The history told a story that indicated no physical injury but a
possibility of a person in distress. That is why the ambulance crew in this case persevered
with questioning the driver until he admitted the truth. This allowed them to ensure that the
police at the scene did not leave him alone and that they arranged further help for him.

In addition to reporting a closely observed history the next set of observations that the first-
aider can establish is that of Clinical State. The clinical state of the casualty can also be
defined as being the measurement of how sick, or likely to die, the casualty is. Indeed, once
the first-aider learns to rely on the clinical state most of the doubt is removed from the decision
making process.

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OBSERVATION AND MEASUREMENT

THE HEALTHY CASUALTY

For a healthy adult the measurements listed in the box below are normal.

EMERGENCY OBSERVATIONS

These four observations tell you that the heart is pumping blood filled with oxygen, food and water
through the blood vessels to the cells of the body and removing carbon dioxide and waste products
from them. In an emergency the following four observations have real importance:

Where a casualty has two or more of the above signs get help immediately by calling an
ambulance. Do not wait for the casualty to get worse.

The Sick casualty - A person who is seriously ill or injured will suffer poor perfusion because the body
cannot supply enough oxygen, water and food to the bodys cells and cannot remove carbon dioxide
and waste products quickly. Poor perfusion exists where a casualty has two or more of the following
observations:
OBSERVATIONS FOR A HEALTHY CASUALTY

Normal Conscious State -Alert, aware of time and place
Normal Skin -Pink, warm and dry
Normal Pulse -60 to 80 beats per minute
-Pushes about 70mls of blood per beat
-Regular rhythm
Normal Respiratory Rate -12-16 per minute (at rest)
-Normal breath = 500ml
-Expired air contains:
-17% Oxygen
-78% Nitrogen
-4.04% Carbon Dioxide
-1% Inert gasses
-Temperature 37
0
C
-water
Normal Blood Pressure -120mmhg over 80mmhg
Normal Temperature - 37-37.6
0
C.
Urine Output -1 to 1.5litres in 24 hours. No sugar
THE HEALTHY PERSON WITH GOOD PERFUSION

1. Conscious state: person is alert and aware of time and place
2. Skin condition: pink skin in mouth and dry, warm skin on rest of body
3. Pulse: 60 to 80 beats per minute and a regular rhythm
4. Respirations: 12 to 20 per minute
5. Blood Pressure: 120mm Hg above 80mm Hg
POOR PERFUSION (SHOCK)

1. Conscious state: altered, usually depressed
2. Skin condition: pale, cold and wet or clammy
3. Pulse: more than 100 beats per minute or less than 50 per minute
4. Respirations: more than 24 per minute or less than 10 per minute
5. Blood Pressure: 120mm Hg above 80mm Hg
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TAKING THE PULSE

There are two pulses that the first aider needs to take: the carotid pulse, for sick casualties, and the
radial pulse, for when the casualty is unwell but not at immediate risk of serious illness or death.

MEASURING RESPIRATION

In primary patient assessment observe that the patient has an adequate respiratory rate and depth by
visual observations. Respirations should be regular and inaudible.
Count respirations for one minute by observing the rise and fall of chest.
Assess whether the accessory muscles are being used, as the overuse of accessory muscles could
indicate respiratory distress.
Listen for abnormal/noisy breath sounds e.g. gurgling, sighing, and wheezing.

MEASURING CONSCIOUSNESS

RAPID ASSESSMENT

Initial assessment of a casualtys conscious state is based upon their awareness of their surroundings.
Thus, a casualty who responds to your presence, is able to tell you where they are and when they are
(aware of time and place), and is able to speak clearly is conscious.

DETAILED ASSESSMENT

In order to more accurately track changes in a casualtys conscious state a scale, called the Glasgow
Coma Scale (GCS), is used. The GCS enables us to objectively chart a casualtys level of
consciousness at a given point in time using a standardised measure. The elements of the GCS are
the ability of the casualty to open their eyes, to speak and to use their muscles.

The GCS requires no equipment other than a watch and a pen/pencil and paper.

It is important that you record the best response to the test, even if the casualty cannot immediately
reproduce it.

Fig.1-2: Taking the radial pulse
The radial pulse is located in the wrist at the
base of the thumb running up along the radius.
Fig.1-1: Taking the carotid pulse
The carotid pulse is found on either side of the neck
nestled in between the sterno-mastoid muscle and
the windpipe (trachea).

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GLASGOW COMA SCALE

EYE OPENING

Spontaneous 4
To Speech 3
To Pain 2
Nil 1

BEST VERBAL RESPONSE

Orientated 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1

BEST MOTOR RESPONSE

Obeys 6
Localises 5
Withdraws 4
Abnormal Flexion 3
Extensor Response 2
Nil 1

The importance of the GCS is that over time the carer can track changes (decline or improvement) in
the casualtys condition. The sooner you establish accurate recording of the GCS the closer to an
injury or event you can move treatment. The charts below provide an example of what some
conditions look like.

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MEASURING BLOOD PRESSURE

Blood Pressure is the pressure exerted by the blood on the walls of a blood vessel. The most usual
blood vessel for the measurement of the blood pressure is the Brachial artery in the casualtys master
arm (the one they write with).

Blood pressure is measured against a column of Mercury (chemical symbol is Hg) as it takes a
significant amount of pressure to lift the mercury a millimetre. Therefore blood pressure is written as
120 mm Hg (the pressure is sufficient to lift a column of Mercury 120mm) over 80mm Hg for the lower
pressure.

Blood pressure is split into two parts, the systolic (or upper number) which usually measures 120mm
Hg and the diastolic (the lower number), measuring around 80mm Hg. These numbers are found by
applying a blood pressure cuff attached to a calibrated gauge and then inflating it until the pulse
disappears in the brachial artery. Once the pulse disappears the cuff is inflated a little more (around
20mm Hg) and the stethoscope is applied to where the pulse was felt. The valve on the pump is
opened slowly and the pressure released from the cuff until the first beat is heard. This often follows a
point where the needle of the dial begins to jump. The point at which the pulse is heard again (say
120mm Hg) is the systolic pressure.

Continue to release pressure from the cuff and listen for either where the pulse disappears or the
sound changes notably (usually a swish, swish sound). This is the point at which the diastolic
pressure is noted (say 80mm Hg).

10
CHAPTER 2

APPROACH TO THE INCIDENT

Reassuring the casualty is very important in first aid and the best reassurance for both casualty and
bystanders is a confident first aider taking decisive action. In order to treat a casualty you must first
manage the incident and the most important skills in first aid are those that allow you to quickly:

1. identify the causes of the incident,
2. identify potential dangers to yourself, bystanders and the casualty,
3. obtain a good History to assist in the provisional diagnosis, and
4. provide effective leadership and manage the scene until help arrives

Effectively managing an incident is very demanding, no matter how experienced we are. It is
important that the first aider develops a systematic approach to all incidents. A systematic approach
allows you to quickly identify and deal with problems, and, more importantly, it gives you the
confidence to take control of an incident. The systematic approach to an incident covers the areas of
danger, provisional diagnosis and triage, and life saving treatment.

DANGER

All emergency incidents are chaotic and there are many dangers. However, all these dangers come
from the environment, the casualty and the bystanders.

Take your time. Be alert and wary. Approach the incident by identifying potential dangers, then
neutralise or remove them, or move yourself, bystanders and the casualty clear of the danger.

Your job is to reduce chaos and not add to it by allowing others, including yourself, to become victims.
In some situations such as high voltage electrocution or poisonous atmospheres, you may be
powerless to help a casualty. If this is the case you must wait and let the experts handle the rescue of
the casualty.

Always Protect Yourself First - If you are injured you cannot help anyone else. The emergency
services will have an extra casualty, and you may find yourself uninsured and off work.

Protect the Bystanders next - Your next priority is to protect bystanders. If necessary, move
bystanders well back from the incident, but remember they will provide valuable help in managing the
incident so make full use of them. However, if you give a bystander a task you must ensure that:

1. they understand exactly what you want done,
2. they can safely carry out the task.

Protect the casualty Last: If you are to effectively deal with a casualty you must have a safe and
ordered environment so minimise danger for the casualty by removing it or, if absolutely necessary,
moving the casualty.

TRIAGE
Where there is more than one casualty you must decide which casualty is to be treated first. To make
this decision you have to look at all the casualties and prioritise them. This process is called triage,
which is a word derived from the French word for three. It is used in medicine to describe the three
levels of seriousness of a casualtys condition:

1. life threatening
2. serious injury
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3. minor injury
If you are first to arrive at a multi-patient scene you will contribute greatly to the treatment of casualties
if you are able to direct ambulance staff to those most in need of immediate care. Concentrating on a
single seriously injured casualty may allow the unnecessary death of another casualty. By triaging all
of the casualties at a scene you will be able to:

1. give accurate information to the emergency services,
2. know which casualties should be seen first, and
3. direct the emergency services personnel to the areas of most concern

Therefore:

1. look at all of the injured and triage them,
2. use bystanders and the lightly injured to care for all the injured, and
3. ensure you direct arriving ambulance personnel to the most badly injured

Only after you have organised the incident can you begin to treat individual casualties.

THE PROVISIONAL DIAGNOSIS

To treat the individual casualty you have to decide what is wrong with them. The process of coming to
such a decision is called making a provisional diagnosis. Remember that it is more important to be
guided by the casualtys perfusion status; if they are sick - get help immediately. The provisional
diagnosis is obtained by considering a casualtys History, Signs, and Symptoms.

History - The History is the story of the accident or the incident and is a very dependable element in
finding out what is wrong with a casualty. It is essential that you take the time to look at the evidence
at an incident and collect information by talking to people including eyewitnesses, bystanders and
casualties. Their stories and the physical evidence provide you with valuable clues to the casualtys
condition. As you approach the incident:

LOOK:
1. at the Incident: A sign of a severe accident can be a casualtys belongings,
especially their shoes being spread over a large area
2. at the direct cause of the injuries: inspect the object which caused the injury or
damage. The greater the damage to it, the more serious the injury to the casualty
3. at the casualty: How old is the casualty? The young or elderly often suffer more
serious injury at lower speeds

Fig. 3-1: The accident scene contains much information

4. Talk to bystanders, eye-witnesses and the casualty
5. Note and Record the time, what you saw and what you were told

When you collect a History try not to make it an interrogation. Take care not to intimidate or
antagonise and be especially careful not to put words into their mouths.
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PATTERN OF INJURY

A useful guide to the possible injuries a casualty may suffer at an accident is the pattern of injuries.
The term Pattern of Injuries describes the most common types of injury caused to a human body by
the forces involved in a particular type of accident. Common patterns of injury are:

1. three or more points of injury following falls,
2. fracturing of the collar-bone following a fall on an out-stretched hand,
3. head injuries following falls from moving vehicles,
4. the association of airway burns with burns to the body,
5. pedestrians struck by cars have a pattern of injuries depending on their age, size, how
the car hits them and the speed of impact. Adults most commonly get hit by vehicles on
their sides because they instinctively turn side-on to danger. Children turn to face
danger. Thus adults are usually injured on one side whilst children suffer injuries to
both sides. Adults also suffer more lower limb injuries than children due to their
respective heights

PATIENTS AT SERIOUS RISK
1

Suspect serious injury where there is:

1. a combined speed over 60KPH,
2. major deformity of the vehicle/airbag deployment,
3. a death in one of the vehicles involved,
4. a casualty is ejected or falls from a vehicle,
5. a cyclist/pedestrian hit is by vehicle travelling over 30KPH,
6. a fall of 3 metres or more, especially for adults,
7. injury to more than one body region,
8. burns of more than 20% of an adults body or 10% for a child

or where the casualty complains of:

1. central chest pain,
2. acute respiratory distress, or
3. loss of consciousness

SIGNS

Signs are those things on or about the casualty that you can see, hear, touch, smell or taste for
yourself. They are identified by using a systematic examination. Remember the most important set of
Signs in first aid are those which tell you the casualtys perfusion status.

SYMPTOMS

Symptoms are the feelings and sensations (pain, nausea, visual disturbances, dizziness, tingling) that
only the casualty can feel. Only the casualty can tell you about their Symptoms. This means that,
unlike History or Signs, Symptoms cannot be substantiated from other sources.

Before we look at life saving it is perhaps worth considering death and first aid.

1
Ambulance Service of New South Wales, Ambulance Protocols, Protocol 4, 2004.
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DEATH AND THE FIRST AIDER

Death is a natural and normal part of our lives. When you are called upon to provide first aid to a
casualty it is important that you appreciate that, even with the best first aid and medical treatment,
they may still die. Such an outcome is very seldom the fault of the first aider. It is usually the
inevitable result of the serious injury or illness the casualty has suffered.

APPROACH TO AN INCIDENT AND EXAMINING A CASUALTY

CAREFULLY APPROACH SCENE AND CASUALTY

1. Check area for danger:
-look at the scene
-look at the direct cause of Injury
-look at the casualty
2. Take history:
-ask questions:
-of bystanders
-of eye-witnesses
-of casualty
-check for medical history card, pendant, etc.
3. Move into casualtys body space, near the head
4. Watch casualtys eyes and begin assessment of casualtys conscious state
-i.e. opens eyes spontaneously
5. Introduce self
-tell casualty to open eyes
-if no response crouch down and repeat order
-then tap cheek, flick eyelash and watch response
-if no response observed casualty is unconscious

Fig. 3-2: Try to wake casualty by tapping cheek

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CHECK AIRWAY

- Position self at casualtys head and watch reactions
1. Extend casualtys head:
-place hand nearest top of casualtys head on their forehead
-push casualtys head firmly but gently back
-keep head in that position
2. Jaw lift:
-take hold of casualtys chin between thumb and forefinger
-and open mouth
3. Look into mouth:
-check for injury to teeth and gums
-check for missing teeth
-foreign objects
4. Smell for:
-blood and vomit

Fig. 3-3: Clearing the airway using head extension and jaw lift

CHECK BREATHING

1. note skin colour
2. place ear near casualtys lips, look, feel and listen for breathing
3. place hand on casualtys lower chest and feel for chest movement
4. listen for air movement in casualtys airway

Fig. 3-4: Check for breathing

CHECK FOR SIGNS OF LIFE

1. Check for Signs of Life:
-conscious or unconscious
-responsive or unresponsive
-breathing normally or not breathing normally
-check skin condition/muscle tone

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CONTROLLING A SEVERE HAEMORRHAGE

1. Approach to the Incident
2. Observe serious bleeding
3. Locate site of haemorrhage
-cut or remove clothing
4. Apply immediate direct pressure
-immediately grasp wound and apply direct pressure
-if arterial bleeding place your thumb or finger directly on site of spurt

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CHAPTER 3

BASIC ANATOMY AND PHYSIOLOGY

SURFACE ANATOMY

Surface anatomy is the identification of landmarks on the surface of the skin which allows us to
compare our knowledge of our own surface anatomy with that of an injured person.

Fig 1-3: Male and female adults in the anatomical position

The best way to learn about surface anatomy is to look at and examine your own body. What you
learn from this will help you find injuries on others.

THE SKELETON

Fig 1-4: The skeleton

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The skeleton is made up of bone, which is living tissue that requires a blood supply. The larger bones
in the body, such as the pelvis and the femurs, have a greater blood supply because the blood is
made in their marrow.

THE NERVOUS SYSTEM

The nervous system is divided into three parts:

1. The Central Nervous System of the brain, cranial nerves and spinal cord;

Brain
Spinal Cord

Fig. 1-5: The Central Nervous System

2. The Peripheral Nervous System, which is comprised of motor (voluntary) nerves and
sensory nerves. For example, the brain uses motor (voluntary) nerves to transmit commands
to the muscles so when you wish to pick up a glass the motor nerves tell the muscles of the
hand, arm, shoulder and chest to move.

Fig.1-6: Peripheral Nervous System including Motor (Voluntary) Nerve and Sensory Nerves

3. The Autonomic (involuntary) Nervous System controls activity in the body without involving
the conscious mind. Most of the functioning of the body is controlled by the autonomic or
involuntary nervous system.

Fig 1-7: Autonomic Nervous System

To Spine Sensory Nerve

Motor Nerve
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THE RESPIRATORY SYSTEM

The respiratory system consists of the airway, lungs and the ribs and muscles of respiration.

THE AIRWAY
Nasal Cavity
Mouth
Nasopharynx
Larynx
Trachae
Bronchi
Lungs

Fig 1-8: The airway

The airway extends from the lips and nostrils, through the nasal and oral cavities to the naso-pharynx
and pharynx, through the larynx, tracheae, bronchi and down to the surface of the air sacs in the
lungs. The airway can be blocked at any point along its length. The most common causes of such
blockage are our own position, vomit, food, saliva, and blood.

THE LUNGS

The air sacs (alveoli) in the lungs are structures one cell thick. They are thin so as oxygen and other
gasses can easily pass into and out of the blood stream.
O2
Co2

Fig 1-9: Air sac (Alveolus) with walls one cell thick

The lungs themselves are therefore made up of the tubes of the airway and the millions of alveoli that
enable oxygen to move into the blood stream.

Fig 1-10: The lungs and chest cavity
18
The lungs are contained within the chest and are protected by the chest wall and a layer of tough
tissue called the pleurae.

THE CIRCULATORY SYSTEM

The circulatory system comprises the blood, heart, arteries, veins and capillaries. The function of the
circulatory system is to transport oxygen, food, CO
2,
and waste products to and from the cells of the
body.

THE HEART

The heart is a muscular organ that pumps blood to the body and the lungs. It consists of four
chambers, two collecting chambers (atria) and the pumping chambers (ventricles).

Right Ventricle
Left ventricle
Left Atrium
Right Atrium
Aorta
Superior Vena Cava
Inferior Vena Cava
Pulmonary Arteries
The Heart

Fig. 1-11: The heart showing the flow of blood from the atria to the ventricles

THE BLOOD VESSELS

Fig. 1-12: Cross section of an artery and vein showing the difference in thickness.

Both arteries and veins have three layers of tissue and in both the layers are a tough outer coat, a
middle muscle layer and a smooth lining. The difference between the two is that the muscle layer is
much thicker in the artery than in the vein. The artery requires a thick muscular wall so that it can
assist in pumping blood around the body. The vein is soft so that blood can be squeezed along it by
other muscles.

The capillary is similar to the air sacs in the lungs in that its walls are only one cell thick. This is
because, like the air sacs oxygen and CO2, water and food have to pass through its walls to get to the
cells of the body and to the outside.
O2
Co2

Fig. 1-15: Cross section of a capillary.
19

Fig. 1-13: The major blood vessels of the body.

THE ABDOMEN

The abdomen contains the spleen, stomach, intestines, liver and pancreas, kidneys, bladder, female
reproductive system and the blood vessels which supply them and the legs.

Fig. 1-14: The organs of the abdomen.
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THE SKIN

The skin comprises a number of layers and structures which protect the body from temperature
change, damage, fluid loss and infection. What we see as skin is in fact the outermost layer which is
dead.

Fig. 1-15: Layers of the Skin

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CHAPTER 4

TRANSMISSIBLE DISEASE

Today there is a great deal of concern about transmissible diseases, especially Acquired Immuno-
deficiency Syndrome (AIDS) due to Human Immuno-deficiency Virus (HIV). However, HIV-AIDS is
only one disease and whilst dangerous, it is not the most dangerous or only infectious disease that the
first aider has to consider. There are a range of other diseases which are more common and more
easily caught and are therefore more dangerous than AIDS. For example, Hepatitis B (which is wide
spread in some communities and is about 240 times more infectious than HIV-AIDS), influenza, colds,
childhood diseases, sexually transmitted diseases, herpes, TB, bacterial infections and infestations
such as scabies, ringworm etc. In order to protect ourselves we must treat all casualties as being
potentially infectious and the procedure for dealing with a potentially infectious casualty is called
Universal Precautions.

UNIVERSAL PRECAUTIONS INFECTION CONTROL PROCEDURE

1. Wash hands prior to beginning work,
2. Wash hands after going to the toilet,
3. Wash hands before eating,
4. Clean hands after touching each casualty
5. Wear gloves and use universal precautions kit
6. Wash hands even after you have used gloves.
7. Wash skin clean of any blood or body fluids immediately
8. Separate out contaminated clothing and bleach for 30 min, and wash.
9. Wash work surfaces with bleach solution.
10. Ensure that any waste products are disposed of in a biohazard system.

Fig.2-1: Put on gloves

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CHAPTER 5

LIFE SAVING TREATMENTS

At any stage of the approach to the incident or during the examination you may detect an injury or
serious condition. The conditions you detect will fall into three groups:

1. those which threaten life which you can treat,
2. those which threaten life which you cannot do anything about, and
3. those which will not immediately threaten life

There are five areas of life saving activity,

1. Clearing the airway,
2. Conducting Assisted Ventilation,
3. Conducting Cardio-Pulmonary resuscitation,
4. Controlling Severe Haemorrhage, and
5. Managing the unconscious casualty

CLEARING THE AIRWAY

In dealing with any casualty it is vital that you deal with the airway first. The danger from airway
obstruction is very real in all casualties who have a reduced level of consciousness. Most airway
blockages are caused by the casualtys own position, saliva, mucus, tongue, tissues, blood, vomit,
teeth, food and foreign bodies.

CHECK AIRWAY

-extend head backward
-open mouth and look in
-smell for vomit or blood
-check dentures are fixed and if so leave in place
-listen for noisy breathing

Fig. 3-6: Clear airway with fingers

PROCEDURE FOR CLEARING THE AIRWAY

1. Either turn casualty onto side (Stable Side Position) or
Turn casualtys head to the side
carefully use index and big fingers to scoop matter from mouth and
Drain fluids
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CHOKING

Choking is due to the blockage of the casualtys airway with a foreign object or substance. Choking
falls into two categories; partial and complete obstruction.

PROVISIONAL DIAGNOSIS OF PARTIAL OBSTRUCTION

HISTORY
a. Adult casualty has often been talking, eating and drinking alcohol
b. child casualty has often been seen playing with small objects
c. Elderly and infirm person
d. Story of sudden violent struggling by casualty

SIGNS
a. Poor perfusion and respiratory distress
b. Convulsive and violent efforts to breath
c. Distended neck and facial veins
d. Clutching at throat
e. Noisy breathing

SYMPTOMS
a. Patient is distressed

TREATMENT FOR PARTIAL OBSTRUCTION

2. Call ambulance immediately
3. Calm casualty down and get them to rest
4. Get casualty to control breathing
5. Continue to reassure casualty
6. Keep casualty still and do not attempt to clear obstruction

COMPLETE OBSTRUCTION

The History will tell you if a casualty has suffered a complete obstruction of their airway. Very few
people, except the very frail or elderly, choke without a struggle. A major indicator of complete
obstruction is that the casualty will not make any sound because the airway is completely blocked.
Fortunately complete obstruction is rare.

PROVISIONAL DIAGNOSIS OF COMPLETE OBSTRUCTION

HISTORY
a. Adult casualty has often been talking, eating and drinking alcohol
b. Child casualty has often been seen playing with small objects
c. Elderly and infirm person
d. Story of sudden violent struggling by casualty

SIGNS
a. Poor perfusion and respiratory distress
b. Convulsive and violent efforts to breath
c. Distended neck and facial veins
d. Clutching at throat
e. Respiratory arrest

SYMPTOMS
a. None

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TREATMENT OF COMPLETE OBSTRUCTION

3. Open airway
-extend head backward
-open mouth and look in and check for blood, vomit and foreign objects
-attempt to remove obstruction with fingers without pushing object further down
-if unsuccessful give four sharp blows to centre of casualtys back
-check for respiration,

Fig. 3-7: Slow sharp chest thrusts

4. If Airway still obstructed:
-place casualty supine
-place both hands middle of breast bone
-same position as CPR
-compress chest sharply four times
-check for breathing
-If unsuccessful repeat
5. If obstruction is ejected, check for breathing:
6. If casualty begins breathing place on side and watch for vomiting,
7. Take and record a full set of observations.

Fig. 3-8: Clearing an infants airway

25
ASSISTED VENTILATION IN CPR

Assisted Ventilation is designed to provide a supply of oxygen to the casualty who is unconscious and
doesnt show normal breathing.

PERFORMING ASSISTED VENTILATION

1. Approach to the incident
2. Approach to the casualty
3. Obtain assistance
4. Check and clear airway
5. Check respiration - If no normal breathing
6. Begin assisted ventilations
-keep casualtys head extended
-pinch nose closed using the forefinger and thumb of hand on
forehead
-take a slightly bigger than normal breath
7. Inflate casualtys lungs
-seal casualtys mouth by completely covering with your own
-blow air into casualtys lungs
-watch and feel for the rising of casualtys chest
8. Following two (2) quick and effective breaths commence chest compressions

Fig. 3-9: Inflate casualtys lungs

INFLATE CASUALTYS LUNGS USING MOUTH TO NOSE RESUSCITATION
(USEFUL WHERE CASUALTY IS IN WATER OR HAS JAW INJURIES)

-cover casualtys nostrils with your mouth and seal tightly
-seal casualtys lips with thumb
-watch for the rising of chest

INFLATE CASUALTYS LUNGS USING MOUTH TO STOMA RESUSCITATION

-head tilt by using chin lift
-if possible cover stoma with face shield or similar
-seal casualtys stoma by completely covering with your own mouth
-watch for the rising of chest

26

Fig. 3-10: mouth to mouth and nose on a baby

ASSISTED VENTILATIONS ON BABY

1. For a baby use mouth to mouth and nose
-use only your cheeks
-seal casualtys mouth and nose
-keep babys head in the neutral position
-puff in air (like blowing out a match) and watch for the rise of the chest

CHEST COMPRESSIONS

Chest compressions are performed following the start of Assisted Ventilations. CPR is the combined
use of assisted ventilations and External Cardiac Compression (ECC) to maintain the casualty until
the arrival of more advanced medical treatment such as electrical defibrillation or drug therapy. It is
very rare for CPR to restart the heart of a casualty.

PERFORMING CARDIO-PULMONARY RESUSCITATION

2. Approach to the casualty
3. Call ambulance
4. Check Airway/Breathing
5. Check Skin Colour and Muscle Tone
6. Give 2 quick and effective ventilations
7. Locate Position for Hands for adult
-locate centre of chest
-usually between the nipples
-place the heel of hand in the centre of the chest
-place the other hand on top and lock
-extend arms till elbows locked straight
-position shoulders directly above hands
8. Compress Sternum
-press sharply but firmly
-depress sternum 1/3
rd
the chest depth
-keep fingers clear of chest wall
9. Rate and Rhythm of CPR by One Rescuer
-give 30 compressions
-must produce carotid pulse

27

Fig. 3-11: Locate position for hands

Fig. 3-12: Single operator CPR

-rate of Compression at 100 per minute
-complete approx. 4 cycles of 2 inflations/30 compressions per minute

Fig. 3-13: Two people CPR

10. Rate and Rhythm of CPR by Two Rescuers
-Give 2 quick and effective ventilations
-chest must rise
-rate of Compression at 100 per minute
-complete approx. 4 cycles of 2 inflations/30 compressions per minute
-do not stop
-only stop if too tired or relieved

28
CHILDREN AND BABIES

CPR FOR CHILD AGED 1 TO 8 YEARS

-Give 2 quick and effective modified ventilations
-chest must rise
-place the heel of hand in the centre of the chest
-place the other hand on top and lock
-extend arms till elbows locked straight
-position shoulders directly above hands
Compress Sternum
rd
the chest depth
-keep fingers clear of chest wall

Fig.3-14: ECC on child

PERFORM CPR ON BABY UNDER ONE YEAR OLD

-Give 2 quick and effective puffs
-chest must rise
-place two fingers of hand at that point
-keep fingers straight vertical
rd
the chest depth

Fig.3-15: ECC on a baby

29
CONTROL OF EXTERNAL HAEMORRHAGE

Severe haemorrhage can occur from arteries or from veins and involves large amounts of blood
flowing or spurting from the body. Where you come across severe bleeding it is vital that you take
immediate action to control it. For example if you observe uncontrolled arterial bleeding you should
not check the airway, breathing and signs of life until you have stopped the flow of blood because you
would not see arterial bleeding unless the heart was functioning.

Despite the high drama of serious haemorrhage (a little blood goes a long way) it is easy to control
using the three simple steps of direst pressure, elevation and rest.

CONTROLLING A SEVERE HAEMORRHAGE

2. Observe serious bleeding
3. Locate site of haemorrhage
-cut or remove clothing
4. Apply immediate direct pressure
-immediately grasp wound and apply direct pressure
-if arterial bleeding place your thumb or finger directly on site of spurt

Fig. 3-16: Direct pressure to bleeding Fig. 3-17: Elevate bleeding part

5 Elevate injured part if possible
6. Rest and reassure casualty
-if possible immediately get casualty to rest or lie down
-loosen tight clothing, tie, belt etc.
-reassure casualty
7. Dress wound
-place dressing pad directly on wound
-cover entire wound
-pressure on pad
-small hard object placed directly over site of arterial bleed
-second pad applied if required
-firm bandage applied covering entire dressing pad
8. Check, maintain and immobilise
-ensure part is elevated
-check bandage and dressing for blood seeping through
-if blood seeping through leave original dressing in place
-add new dressing on top of original
9. Recheck dressing for blood seeping through
-remove bandage and top dressing
-apply new dressing
-place hard object on dressing directly over site of bleeding
-bandage firmly
10. Call Ambulance
11. Recheck bleeding is controlled
-if bleeding is severe and uncontrolled apply constrictive bandage

30
CONSTRICTIVE BANDAGE

As a last resort, in rare circumstances, where direct pressure, elevation and rest does not stop
bleeding it may be necessary to use a constrictive bandage. Constrictive bandages are very
uncomfortable for the casualty and can cause severe distress.

APPLICATION OF A CONSTRICTIVE BANDAGE

1. Cut/remove all clothing from around upper limb
-ensure that the constrictive bandage can be easily seen
2. Select firm bandage such as a wide bandage
-ensure material is not too elastic
-ensure bandage is not too narrow
3. Apply bandage evenly and firmly to limb and tighten until bleeding stops
4. Ensure bleeding is stopped and secure bandage
-write time of application in pen on casualtys skin

1300hrs

Fig. 3-18: Application of constrictive bandage

5. Remove bandage after 30 minutes
-watch carefully for resumption of bleeding
-if bleeding is controlled leave bandage off
-if bleeding recurs proceed with entire procedure again

INTERNAL BLEEDING

Internal bleeding into the chest or abdomen is a common injury which presents a major threat to life.
The priority is to get the casualty to a surgical hospital as soon as possible.

PROVISIONAL DIAGNOSIS OF INTERNAL BLEEDING

HISTORY
a. Patient suffering accident
b. History of illness such as cancer or bleeding ulcers

SIGNS
a. Poor perfusion
b. Guarding of abdomen
c. Obvious injury or frank blood excreted from body, coughed, vomited
or passed in urine or bowel motion

SYMPTOMS
a. Pain and tenderness
31

TREATMENT OF INTERNAL BLEEDING

1. Examine and continuously assess casualtys perfusion status
2. Immediately call ambulance
3. Elevate casualtys legs above head
4. Give nothing to eat or drink

32
CHAPTER 6

HEAD INJURY AND UNCONSCIOUSNESS

BRAIN INJURY

Injury to the brain is one of the more serious outcomes that occur due to injury or illness. The first
aider plays a major role in limiting damage that has already occurred and in preventing damage by
identifying the danger of a potential brain injury.

PROVISIONAL DIAGNOSIS OF BRAIN INJURY

HISTORY
a. Story of blow to the head or unconsciousness

SIGNS
a. Altered state of consciousness (Glasgow Coma Scale)
b. bleeding and cerebro-spinal fluid from ears and/or nose
c. blood under the sclera (white area) of the eye and bruising around eyes
d. obvious head injury
e. loss of movement on one side of the body (Hemiplegia)
f. loss of power on one side of the body (Hemiparesis)

SYMPTOMS
a. headache
b. nausea
c. confusion
d. speech disturbance
e. loss of balance
f. visual disturbance including a dislike of bright light

Because of the danger of compression it is very important that you are able to accurately identify
potential brain injury and monitor changes in a casualtys level of consciousness. The method of
measuring conscious level is the Glasgow Coma Scale.

INJURIES TO THE BRAIN

There are three types of injury inflicted upon the brain

Concussion -Concussion occurs where the brain is subjected to violent `shaking
usually as a result of a blow or deceleration. This rapid motion results in the
opening up of little gaps between the nerve cells that make up the brain.

Contusion -This is bruising and tearing of the brain and is caused when the brain is
bounced around inside the skull or damaged by a foreign body.

Compression - Compression is caused by bleeding inside the skull due to the
rupture of a blood vessel due to injury or a physical weakness. The danger with
compression is that it may not be noticed until after the casualty begins to suffer
permanent brain damage. As a result all casualties who have been knocked out
must see a doctor
33
ASSESSING THE LEVEL OF CONSCIOUSNESS USING THE GLASGOW COMA
SCALE

There are three features to the Glasgow Coma Scale; eye opening, verbal response and motor
response
1
.

GLASGOW COMA SCALE
EYE OPENING

Spontaneous 4
To Speech 3
To Pain 2
Nil 1

BEST VERBAL RESPONSE

Orientated 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1

BEST MOTOR RESPONSE

Obeys 6
Localises 5
Withdraws 4
Abnormal Flexion 3
Extensor Response 2
Nil 1

Calculation: (E + M + V) = casualtys level of consciousness at a given time. A fully conscious
casualty would have a score of 15 and a deeply unconscious a score of 3.

1. Jennings B., Teasdale. G., Management of Head Injuries, F.A. Davis Company, Philadelphia.
APPLYING THE GLASGOW COMA SCALE TO A CHILD

Best Verbal Response

Appropriate words, social smile or fixes and follows objects with eyes 5
Cries but is consolable 4
Persistently Irritable 3
Restless and agitated 2
Nil 1

Eye Opening - casualties opening their eyes spontaneously are normal, opening
when addressed or opening when pain is inflicted indicates a reduced conscious
state.

Best Verbal Response - The responses in this area are classified as normal,
orientated conversation; confused conversation; one-way conversation where the
casualty is not responding to your questions or comments but is holding a different
conversation; grunts groans or other sounds; or no response at all.

Best Motor Response - As the upper limbs show the best range of responses and
are easier to see, they should be used for assessing best motor response.
34

TREATMENT OF HEAD INJURY

1. Danger, Response, Airway, Breathing, Compressions and defibrillation
2. Treat for Spinal Injury
4. Dress wounds
5. Glasgow Coma Scale and Observations including Circulation

HEAD INJURY INVOLVING SKULL AND SCALP

Head injury describes all injuries inflicted to the head. These injuries may be caused by:

direct force applied to the head by a blow, bullet wound or other penetrating
injury; or,
indirect force such as a person who falls from a height and lands upon their feet
causing the base of the skull to fracture

INJURIES TO THE SPINE

Fig. 4-1: Skeleton of the head and neck

The spine and back may be injured in many ways. The most common injuries are those caused by
damage to the muscles and the discs between the vertebrae. These injuries occur as a result of
dangerous lifting practices and are extremely painful, costly and, unfortunately, very common. Other
injuries include stable and unstable fractures and dislocations of the spine. With stable injuries there
is little danger of the bone damaging the spinal cord, but with unstable injuries damage to the spinal
cord can be easily caused by movement.

Spinal injuries not only result in paralysis but can cause many problems such as poor perfusion and
uncontrolled loss of heat from the body. As well as the spinal injury there may be other injuries,
particularly severe head injury. Remember that all unconscious casualties with severe head injury
have a spinal injury till proven otherwise in hospital.

There are three types of fractures involving the bones of the head.

1. Open - This involves the broken bone and brain being exposed to the air.
2. Closed -Closed fractures of the skull and face referring to breaks in the bones.
3. Complicated -Complicated fractures involve damage to the brain or its protective
coverings and blood vessels.
35

PROVISIONAL DIAGNOSIS OF SPINAL INJURY

HISTORY
a. severe head injury
b. patient, if conscious, often reports hearing a snapping noise

SIGNS
a. obvious head injury
b. poor perfusion
c. no movement following the accident
d. inability to differentiate between the sharp and blunt end of a pin

SYMPTOMS
a. pain in the region of the spine
b. loss of sensation/numbness/tingling in body, arms or legs
c. loss of movement
d. loss of power

TREATMENT OF SUSPECTED SPINAL INJURY

2. Call ambulance
3 Check A,B,C
4. Keep casualtys head and neck straight
-do not move casualty unless necessary
-keep head, neck and torso aligned
-never allow flexion or twisting of neck
5. Control bleeding and dress wounds
6. Cover casualty, maintain and constantly monitor body temperature
7. Complete full examination and take observations

36
Fig. 4-2: Distribution of Spinal Nerves

INJURIES TO THE FACE, JAW AND SENSORY ORGANS

Injuries to the face are common and dramatic but rarely life threatening. Most facial injuries consist of
lacerations which are treated like any other bleeding using direct pressure, elevation and rest.
However, severe facial injuries pose a very real threat to the casualtys life through airway blockage
and brain and spinal injury.

NOSE INJURIES

Fractured Nose -Fractures of the nose are painful and disfiguring but not life threatening unless there
is associated uncontrolled bleeding.

Foreign Body in Nose - If it can not be blown out or swallowed send to medical practitioner.

Nose Bleed -Most nose bleeds (epistaxis) are dramatic but not life threatening unless it follows severe
facial injury or the casualty is unconscious or elderly.

TREATMENT OF NOSE BLEED

1. Rest casualty and sit them forward
2. Pinch nose below bone for 10 minutes
3. Get casualty to breath through mouth
4. Loosen all tight clothing
5. Have casualty Spit blood from throat into bowl
6. Apply ice packs to throat, neck and forehead
7. If bleeding lasts longer than 20 minutes seek medical aid

Severe facial injuries are usually accompanied by severe head and neck injuries as
well. In one US study 55% of severe facial fractures were found to have an
associated closed head injury and 10% were found to have associated cervical spinal
injuries.
TECHNIQUE FOR MAPPING SPINAL INJURY

When a casualty suffers an actual injury to the spinal cord the ability to feel
sensations such as pain, pressure or temperature will be lessened or lost. Thus
where the casualty is conscious a spinal injury can be identified by testing the
casualtys ability to differentiate between pain and pressure.

The procedure is simple and consists of using an open safety pin to map the level of
sensory nerve activity. The procedure begins by establishing the casualtys ability to
differentiate between the sharp and blunt ends of the pin on their forehead
(sensation in the skin of the forehead is transmitted via the Ophthalmic Nerve
directly to the brain and is not affected by spinal cord injury).

Once the casualty is able to differentiate between the sharp point and blunt end of
the pin on their forehead you then ask the casualty to identify which part of the pin is
being used to touch along their body. This is continued until the casualtys body is
fully examined or the casualty is unable to differentiate between the sharp and blunt
ends of the pin. The area of the body where the change is detected indicates the
possible level of the injury.

37

EYE INJURIES

Foreign Bodies in Eye - The first indication of an eye injury is often the sensation that there is
something in the eye.

TREATMENT OF FOREIGN BODY IN EYE

1. Sit casualty down and reassure them
2. Wash your hands
3. Open casualtys eye and lift eye lids out and look under each eye lid
4. Have casualty pull upper eyelid over the lower eyelid and vigorously blow their nose
5. Recheck eye for object
6. If object still on white of eye, carefully remove with cotton bud , cloth or tissue
7. If unsuccessful flush eye with clean water or saline
8. If all fails send casualty to medical practitioner

TREATMENT OF SEVERE EYE INJURIES

1. Do not attempt to examine eyes
2. Get ambulance immediately
3. Dressings applied to both eyes
4. Bandage lightly in place
5. Rest and reassure casualty - never leave them alone
6. Prevent casualty vomiting, coughing or sneezing

Heat, Chemical or Smoke Injuries to Eye - see burns chapter

EAR INJURY

Bleeding from Ears - Bleeding from ears is usually associated with picking at skin, a ruptured ear
drum or fractured skull

TREATMENT OF BLEEDING FROM EAR

1. Place pad over affected ear
2. Lie casualty on affected side, if possible
3. If both ears bleeding sit casualty slightly up
4. If serious incident - explosion or accident call ambulance immediately
38

Foreign Object in Ear - For foreign objects in ear leave them for the medical practitioner. If it is an
insect it can be drowned using warm olive or vegetable oil. Insects, such as moths, can be removed
from ears at night by holding a light a few feet away from the affected ear. The moth will, hopefully,
then fly out from the ear.

TREATMENT OF FOREIGN OBJECT IN EAR

1. Sit casualty down with affected ear upward
2. Wash your hands
3. Attempt to remove with fingers or use warm olive or vegetable oil for insect
4. If object or insect stuck send to medical practitioner

FRACTURED JAW

There are two basic types of jaw fracture; stable and unstable. With both types of fracture the major
concern is with the casualtys airway. If the casualty is unconscious, simply place them on their side.
If the casualty is conscious then treat as follows:

TREATMENT OF FRACTURED JAW

1. Sit casualty down and lean forward
2. Allow saliva and blood to drain from mouth
3. Have casualty support their jaw with their own hand

39
CHAPTER 7

MEDICAL CAUSES OF UNCONSCIOUSNESS

STROKE (CEREBRO-VASCULAR ACCIDENT)

Stroke or Cerebra Vascular Accident (CVA) is the common term used to describe the damage
suffered when there is a sudden interruption in the blood supply to the brain. This damage may range
from minor to severe. CVAs are caused by two mechanisms; the blocking of an artery by a blood clot,
or the bursting of an artery within the skull which causes compression of the brain.

PROVISIONAL DIAGNOSIS OF STROKE

HISTORY
a. patient usually, but not always over 50 years
b. often has previous History of high blood pressure
c. may have had smaller strokes or problems in the past

SIGNS
a. loss of bladder and bowel control
b. bruising around eyes
c. loss of movement on one side of the body (Hemiplegia)
d. loss of power on one side of the body (Hemiparesis)

SYMPTOMS
a. headache
b. nausea
c. confusion
d. speech disturbance
e. loss of balance
f. visual disturbance including a dislike of bright light

TREATMENT OF STROKE

2. Call ambulance
3. Check Airway, breathing and casualtys perfusion status
4. Full examination
5. Keep casualty warm
6. Take and record observations

40
EPILEPTIC FIT

Epilepsy may be defined as a brief disorder of cerebral function often associated with an altered
conscious state and accompanied by sudden, excessive discharge of cerebral neurones which cause
spasm of the muscles.

PROVISIONAL DIAGNOSIS OF GRAND MAL EPILEPTIC FIT

HISTORY
a. patient is heard to cry out and collapse
b. local spasm or convulsions are reported
c. patient often carries medical warning card, bracelet or pendant

SIGNS
a. loss of consciousness
b. tonic (spasm)
c. cry may be heard
d. convulsions may be seen
e. patient often incontinent of urine and faeces
f. patient seems drowsy or very sleepy and confused

SYMPTOMS
a. patient may be aware of aura
b. patient may feel drowsy
c. patient may suffer hallucinations and visual disturbances

TREATMENT OF SERIOUS EPILEPTIC FIT

1. Approach to the Incident - remove dangers and leave casualty alone
2. Check airway (not possible during convulsion)
3. Call ambulance
4. Check carotid pulse
5. Check for haemorrhage
6. Full Examination
7. If casualty regains consciousness and wishes to leave:
-ensure they are aware of their surroundings
-ensure they understand what has happened
-ensure they know how they are getting home

STAGES OF AN EPILEPTIC FIT

PRODROMAL STAGE Patient feels the onset of symptoms indicating a fit. These
symptoms are very much like the symptoms that a migraine sufferer
experiences prior to the migraine attack. These symptoms may include
visual disturbances, auditory hallucinations, taste sensations in the mouth
or painful muscle contractions in the abdomen or other parts of the body.

AURA Uncommon, and often very vague feeling, that a fit is about to occur.

TONIC STAGE Loss of consciousness followed by spasm begins and there is often a
high pitched cry as the air in the lungs is forced out of the chest through
the spasm vocal cords. This stage lasts about 20-30 seconds and the
lack of effective respiration leads to cyanosis.

CLONIC STAGE Strong spasms alternate with relaxation and it is at this point that the
casualty often loses control of the bladder and bowel and froths at the
mouth.

SLEEPINESS The casualty becomes relaxed and comatose and may even fall asleep
for up to 30 minutes or more before regaining consciousness. The
casualty may remain confused for some time following a return to
consciousness.

41
DIABETES

Diabetes is a systemic disease which prevents the pancreas from producing enough insulin for the
body to metabolise sugar. The problems that affect diabetics are low blood sugar, an emergency and
high blood sugar which is often readily identified and treated by the diabetic casualtys family doctor.

LOW BLOOD SUGAR (HYPOGLYCAEMIA)

Low blood sugar is the most common problem seen by the first aider and is usually caused through a
missed meal, over-exertion or overdose of insulin. Low blood sugar causes rapid unconsciousness,
brain damage and death.

PROVISIONAL DIAGNOSIS OF LOW BLOOD SUGAR

HISTORY
a. Patient is known to be a diabetic
b. Patient has missed a meal
c. Check for medication, warning card, bracelet or pendant

SIGNS
a. Altered conscious state - mood swings
b. Cold, clammy, pale skin
c. Pale, cold, wet skin
d. Dilated pupils
e. Muscle tremor

SYMPTOMS
a. Headaches

TREATMENT OF UNCONSCIOUS DIABETIC

2. Never give any food or fluids by mouth
3. Turn the person on their side
4. Rub honey on inside of lips
5. Call an ambulance

HIGH BLOOD SUGAR (HYPERGLYCAEMIA)

High blood sugar is not often seen by first aiders because it takes a relatively long period to become a
problem and is usually treated by the casualtys medical practitioner.

TREATMENT OF CONSCIOUS DIABETIC

3. Give casualty some sugar quickly such as:
-5 - 7 jelly beans, a glass of soft drink (not diet), glass of fruit juice or 2-4 teaspoons of
sugar or honey
4. If the casualty doesnt feel better in 5-10 minutes give them some more sugar.
5. Then get the casualty to eat some carbohydrate (starchy) food such as:
-piece of fruit, glass of milk, sandwich or 2-4 dry biscuits
6. Call an ambulance
42
CHAPTER 8

CARDIAC CONDITIONS

Despite a steady decline the single most frequent cause of death in Australia during 2002 was
coronary artery disease which killed 32, 029 people
1
. Because it is such a killer you must be aware of
how to recognise acute cardiac conditions and the best way of doing this is to recognise the
significance of chest pain. All casualties who have chest pain should be considered seriously ill until
the exact cause of the pain is identified. Chest pain is divided into two groups, pain which originates in
the chest wall and chest pain due to heart disease.

There are three causes of cardiac chest pain including Angina Pectoris (Angina), Acute Myocardial
Infarction (AMI), and electrical disturbances affecting the heart.

ANGINA

Angina is caused by deposits of fat and other substances in the lining of the medium sized arteries of
the heart. This leads to a narrowing of the arteries in the heart and a restriction of blood flow to the
heart muscle. Normally casualties with narrowing of their coronary arteries suffer no discomfort unless
they exert themselves.

PROVISIONAL DIAGNOSIS OF ANGINA PECTORIS

HISTORY
a. patient has been diagnosed as suffering angina and been prescribed angina
medication by their doctor
b. pain or shortness of breath develops during physical exertion
c. pain lasts less than 10 minutes

SIGNS
a. Sometimes skin is pale, cold and moist

SYMPTOMS
a. Central chest pain, sometimes radiating to neck and arm

1. Australian Bureau of Statistics, 2003.
CHEST WALL PAIN

Chest wall pain can be due to injuries to the muscles and ribs or to disease or injury
to the lungs. The words most commonly used to identify this type of pain are
sharpness and stabbing. The gestures and body language are quite specific and
the casualty can point with a finger or fingers to the exact location of the pain.
Unlike cardiac pain chest wall pain can be made worse or better by deep breathing
and is tender to touch.

CARDIAC CHEST PAIN

Chest pain due to cardiac disease is present in 80 to 90% of all casualties suffering
acute myocardial infarction, or severe heart attack. The words casualties use to
describe it include tightness, heavy weight, constriction, dull ache or crushing. The
gestures and body language used to show the location are vague and the hand is
either spread wide or bunched into a tight fist. The casualty cannot put their finger
on the exact site of the pain.

43
TREATMENT OF ANGINA PECTORIS

1. Approach casualty
2. Loosen tight clothing
4. Assist casualty to take their own medication (this may be a spray or tablet placed under the
tongue)
5. If pain persists for more than 10 minutes or after two doses of medication given 5 minutes
apart, call ambulance immediately and treat casualty for AMI.

ACUTE MYOCARDIAL INFARCTION (AMI)

Acute Myocardial Infarction (AMI) is the sudden death of the muscle layer of the heart. This occurs
when an artery supplying the heart muscle is blocked, depriving an area of heart muscle of blood.
Your aim in treating this condition is to ensure that the casualty reaches a coronary care unit as
quickly as possible, preferably within one hour of the time the pain began. To achieve this aim you
must be able to identify AMI, rest and reassure the casualty and obtain assistance as soon as
possible.

The reason for this approach is that casualties with AMI who are admitted to a specialised coronary
care unit in the first hour after the chest pain begins have a greater chance of surviving the event.
This makes you, the first aider, the most important link in the medical chain of treatment. Without
early identification and treatment the outcomes for AMI are poor.

PROVISIONAL DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION

HISTORY
a. Patient develops pain
b. Pain develops during rest
c. Pain lasts longer than 10 minutes
d. Patient may have diabetes or angina or other heart problems

SIGNS
a. Sometimes poor perfusion (shock)
b. Rapid breathing > 20 minute

SYMPTOMS
a. Severe central chest pain, radiating to neck, jaw or arm
b. Pain does not alter with movement or deep breathing
c. There is no tenderness to touch
d. Pain described as crushing, tight, heavy, band of constriction or dull ache
e. Watch casualties body language -they often use a clenched fist or gripping
motion to describe pain
f. Patient is frightened

If you are in anyway unsure treat any chest pain as an AMI and send the casualty to hospital

TREATMENT OF ACUTE MYOCARDIAL INFARCTION

2. If chest pain is cardiac, immediately call ambulance
3. Take a careful history
5. Be prepared to perform CPR

44
ELECTRICAL DISTURBANCES OF THE HEART

A major cause of death in AMI is electrical disturbances of the heart. These electrical disturbances
may totally disrupt the electrical and mechanical activity of the heart leading to death. Your ability to
identify AMI and quickly obtain an ambulance gives the casualty the best chance of being near the
specialised electrical equipment needed to reverse any electrical disturbances which may arise. Your
ability to perform CPR will slow death until the arrival of an ambulance with this equipment. Without
your efforts all of the sophisticated care systems used in hospitals are going to be useless.

ELECTRICAL ACTIVITY IN THE HEART

The normal electrical activity of the heart is shown below at Fig. 5-1

Fig. 5-1: Normal sinus rhythm (Normal electrical signal in heart)

There may be abnormal impulses in a normal heart like those shown in Fig. 5-2.

Fig. 5-2: Normal sinus rhythm with two abnormal impulses

Sometimes abnormal beats occur which cause the heart to develop a dangerous rhythm such as that
shown in Fig. 5-3. This rhythm will result in the casualty becoming sick and showing Signs of poor
perfusion (shock).

Fig. 5-3: Ventricular Tachycardia. This rhythm will result in a rapid deterioration of the casualties condition

The ventricular tachycardia shown at Fig. 5-3 above will, if not treated, lead to the electrical conduction
within the casualties heart becoming chaotic. This condition, shown at Fig. 5-4, is called ventricular
fibrillation and the casualty will have no pulse and will be in cardiac arrest. This condition is treated in
first aid with CPR.

Fig. 5-4: Ventricular Fibrillation
45
If the casualty has suffered a large amount of damage to their heart, or if they have been collapsed for
more than about 5 minutes without CPR, the electrical conduction system gradually fails. This
condition, cardiac asystole, is shown at Fig. 5-5 below.

Fig. 5-5: Cardiac Asystole (No electrical activity)

In adults, asystole has a very poor outcome and very few casualties survive. However, effective CPR
quickly applied gives the casualty some chance.

In children, asystole is treated with CPR and the outcomes are better than with adults.

TREATMENT OF VENTRICULAR TACHYCARDIA OR VENTRICULAR
FIBRILLATION

2. Call ambulance ASAP
3. CPR
4. Obtain Defibrillator
5. Switch on defibrillator
6. Attach pads to front of chest - ensure that gel is well spread
7. Maintain CPR
8. Check pads correctly connected to defibrillator
9. Allow time to read electrical rhythm
10. Order all persons to stand clear
11. Visually check all clear
12. Only press fire button when instructed to do so by defibrillator
13. Fire defibrillator at 150 joules
14. Check for carotid pulse
15. Repeat steps 6 to 14 until ambulance arrives

46
CHAPTER 9

RESPIRATORY CONDITIONS

The causes of respiratory distress fall into three main groups; medical conditions, traumatic injury and
poisoning. Amongst the medical conditions you need to be aware of are asthma, pulmonary oedema,
Chronic Obstructive Airways Disease (COAD) and childhood airway problems. Traumatic injuries
include problems such as flail segments, Pneumothorax and haemothorax, hanging, strangulation,
choking, drowning and asphyxiation. But whatever the condition, if the casualty is poorly perfused and
showing Signs of respiratory distress then get help as soon as possible.

MEDICAL CONDITIONS

STATUS ASTHMATICUS

Status asthmaticus is a prolonged asthmatic attack that is not responding to treatment and
the casualty becomes progressively worse until they loose consciousness and die. Status
asthmaticus is a dire emergency and an ambulance must be obtained as soon as possible.

PROVISIONAL DIAGNOSIS OF ACUTE ASTHMA ATTACK

HISTORY
a. Patient has History of asthma
b. Patient may have asthma drugs in their pockets
c. Patient has been short of breath for some time
d. May have had recent respiratory infection
e. May be emotionally upset
f. Patient presents sitting upright, leaning forward and holding onto, or resting
arms upon a table, chair, bench or other support

ASTHMA

Bronchial asthma is a condition that results from the narrowing of the small air tubes
(bronchioles) that lead to the air sacs (alveoli) in the lungs. This narrowing is caused by
muscle spasm in the tubes, swelling of the mucus membrane lining the tubes and/or the
plugging of the tubes with mucus. Asthma may begin at any age but is much more likely to
begin in childhood or early adulthood and there is often a family history of asthma and
other allergic responses. Acute asthma attacks can be brought on by allergic reactions,
infections and psychological or emotional stress.

Asthma can be as frightening an experience for you as it is for the casualty. It is important
that this anxiety and distress be reduced, the casualty helped to use their own medication
and an ambulance called as soon as possible.

Asthma is an easily treatable condition and all asthma sufferers are able to self medicate
themselves using salbutamol (Ventolin) and a variety of other drugs. In first aid one of the
main principles is prevention and if an asthmatic casualty is finding that their medication is
not providing them with the usual level of relief then they should see their doctor. The
continued dependence on self medication and a reluctance to seek early medical
assistance often leads asthmatic casualties to suffer unnecessarily severe attacks.

Asthma is not a problem unless the casualty suffers an acute attack or allows a mild attack
to continue for a prolonged period. The earlier the casualty is treated by a medical
practitioner the less severe the illness. Be aware that if the medication does not relieve the
casualties symptoms within 15 to 30 minutes then it is likely that they will not work at all
and the casualty will need to see their doctor as soon as possible
47
SIGNS
a. Patient can be heard to wheeze on expiration
b. Poor perfusion with blue colour to casualties face, nostrils, lips
c. The sicker the casualty the less they can talk
d. Patient often coughing
e. Patient becomes quite and drowsy (A very bad sign)

SYMPTOMS
a. Patient is extremely anxious and distressed

TREATMENT OF ACUTE ASTHMA ATTACK

2. Call ambulance immediately if severe distress is identified
4. Check Breathing
5. If necessary support breathing with assisted ventilations
6. Check casualties perfusion status
7. If necessary perform CPR
8. If casualty conscious position them sitting up
9. Reassure casualty
10. Assist casualty take their prescription Medications
-find out how much medication casualty has already taken:
-assist casualty self medicate:
11. Ensure Flow of Fresh Air Across casualty
12. Keep close check on observations

ACUTE PULMONARY OEDEMA

Acute pulmonary oedema is caused by the build up of fluid in the lungs due to failure of the left side of
the heart. This failure may be due to AMI, poisoning and drowning. The most common cause is left
sided heart failure following AMI.

Pulmonary oedema is caused when fluid leaks out of the capillaries in the lungs and fills the spaces
between the capillaries and the air sacs (alveoli). After a time, if the fluid continues to leak out it
enters the alveoli and begins to fill them. This filling of the alveoli leads to a reduction in the total area
of lung through which the body can get oxygen from the air. This causes the casualty to become short
of breath and distressed. The build up of fluid can be so severe that it fills the lungs and airway with a
pinkish froth and the casualty dies of asphyxiation.

PROVISIONAL DIAGNOSIS OF ACUTE PULMONARY OEDEMA

HISTORY
a. Patient is often elderly
b. Previous History of heart conditions and pulmonary oedema
c. Patient has been short of breath
e. Patient takes fluid (often frusemide [lasix]) tablets and potassium
f. Condition occurs most frequently at night
g. Patient will be sitting upright, leaning forward and holding onto or resting arms
upon a table, chair, bench or other support
h. Often occurs between 10pm and 4am during cold weather

SIGNS
a. Patient Appears Poorly Perfused
b. Marked respiratory distress
c. Fluid can be heard in casualties lungs and airway
e. Patient often coughing
f. Patient cannot lie flat and normally sleeps propped up
48

SYMPTOMS
b. Towards the end the casualty becomes very quiet and tired

CHRONIC OBSTRUCTIVE AIRWAYS DISEASE

Chronic Obstructive Airways Disease (COAD) is a term used to describe a number of conditions which
affect the airway and the tissue of the alveoli. The most common conditions are emphysema and
bronchitis which are caused by smoking cigarettes. Casualties who suffer from severe emphysema
are rarely seen in public because of their inability to exercise, even to the extent of walking to the door
of their room. They are usually dependent on a strict regime of medication and the self administration
of oxygen at low concentrations.

PROVISIONAL DIAGNOSIS OF COAD

HISTORY
a. Patient has History of respiratory condition treated by a doctor
b. Patient may have medication
c. Patient has been short of breath
e. Patient will be sitting upright, leaning forward and holding onto or resting arms
upon a table, chair, bench or other support

SIGNS
a. Skin may be pink or cyanosed in colour and perhaps moist
b. Respiratory pattern fast, deep and forced respiration
c. Patient uses accessory muscles of respiration to breathe
d. Patient can be heard to wheeze on expiration
e. Patient often coughing
f. Obvious respiratory distress

SYMPTOMS
a. Patient may be anxious and distressed
b. Patient may be restless

PULMONARY EMBOLISM

Pulmonary embolism is the blocking of a pulmonary artery or one of its branches by a clot of blood, a
globule of fat or other obstruction. The outcome of such a blockage will be the death of lung tissue,
the failure of respiration and even right-sided heart failure, due to the build up of pressure in the lung.

PROVISIONAL DIAGNOSIS OF PULMONARY EMBOLISM

HISTORY
a. Patient may have been bedridden for a long period of time
b. The casualty may have a History of circulatory problems in their legs
c. The casualty may have suffered recent fractures of large bones

SIGNS
a. Poor perfusion
b. Respiratory distress
c. Jugular veins in neck will be distended

SYMPTOMS
a. There may be a severe sudden onset of sharp chest pain
b. Chest pain worse with deep breath
c. Patient is anxious
49
TREATMENT OF RESPIRATORY DISTRESS

2. Check Airway if casualty is Unconscious
3. If obviously distressed call ambulance
4. Check breathing
5. If necessary support with assisted ventilations
6. Check casualties perfusion status
7. If necessary perform CPR
8. Position casualty in most comfortable position
9. Ensure Flow of Fresh Air Across casualty
10. Take Full Set of Observations

HYPERVENTILATION (OVER-BREATHING)

Hyperventilation (over-breathing) is associated with hysteria or excitement. The direct cause is a
lowering of the amount of carbon dioxide in the blood stream by breathing too rapidly and deeply.
Short periods of hyperventilation are not life threatening

PROVISIONAL DIAGNOSIS OF HYPERVENTILATION

HISTORY
a. Patient has become excited, frightened, hysterical etc
b. Patient may have suffered this condition before

SIGNS
a. Normal pink, warm dry skin
b. Respiratory Pattern fast, deep and forced
c. Tetany of hands may be present in advanced stages
d. Rapid pulse

SYMPTOMS
b. Patient feels as if they are choking
c. Patient feels pins and needless in fingers and around lips

TREATMENT OF HYPERVENTILATION

2. Check airway, breathing and casualties perfusion status
-firmly get casualties attention
-tell casualty what is happening
-firmly tell casualty what has to be done
-get casualty to agree to co-operate
4. Get casualty to slow down their respiratory rate and depth
5. Have casualty breath slowly
-until pins and needles are gone
-and respiratory rate and depth are returned to normal

50
PLEURISY

Pleurisy is a condition in which the outer lining of the lungs and the inner lining of the chest wall are
roughened or inflamed by disease. When the casualty breathes the inflamed areas rub causing pain.
Pleurisy is not a medical emergency but because it is caused by an underlying disease casualties
should see their doctors. One of the major problems with pleurisy is that as a chest pain it needs to be
taken seriously until it can be proven not to be the pain of a heart attack.

Pain relief, using aspirin or paracetamol, and treatment of any coughing with pholcodine linctus may
also be useful. Further pain relief can be obtained by placing a warm object close to the site of the
pain.

PROVISIONAL DIAGNOSIS OF PLEURISY

HISTORY
a. Chest pain following chest infection or illness

SIGNS
a. Warm, dry skin
b. Easily localised chest pain which casualty can point to
c. Respiratory pattern is shallow and a little faster than normal
d. Normal pulse
e. Some guarding and unwillingness to breathe deeply

SYMPTOMS
a. Pain is described as sharp and stabbing
b. Pain often on the sides of the chest and sometimes, in the back
c. Pain is made worse by movement, touching or on inspiration
d. If the diaphragm is involved they may have shoulder tip pain

TREATMENT OF PLEURISY

2. Check airway, breathing and casualties perfusion status
3. Allow casualty to Find Most Comfortable Position (usually lying on the injured side)
4. Pain Relief
-wrap hot water bottle in towel and put on site of pain
-if medical aid not immediately available give manufacturer recommended dosage of
paracetamol or aspirin
-control cough with cough linctus using recommended dose
5. Send casualty to See Own Doctor

51
CROUP

Croup is caused by infection in the respiratory tract which leads to swelling of the mucosa. In babies
and younger children, because the diameter of their airway is so small in relation to its lining, even a
small degree of swelling can result in significant obstruction of their airway.

PROVISIONAL DIAGNOSIS OF CROUP

HISTORY
a. Child is between six months and four years of age
b. There is a History of recent illness
c. The condition worsens during the night

SIGNS
a. Child has a hoarse brassy sound when breathing or speaking
b. Child can have a high pitched noise (stridor) during respiration or a whooping
sound during inspiration
c. Child may have a bark like a seal when coughing
d. Use of accessory muscles of respiration
e. Tracheal tugging with windpipe being pulled into the chest
f. Muscles between ribs are pulled in during inspiration
g. Skin is warm, moist and may be cyanosed
h. Pulse is rapid and rises as the condition worsens

SYMPTOMS
a. Difficult to obtain

TREATMENT OF CROUP

1. Approach to the Incident.
2. Reassure mother and father.
3. Check and clear airway.
4. Check breathing and circulation.
5. If child hot, Remove excess clothing.
6. Run hot shower and fill bathroom with steam and place mother and child in bathroom
7. Take and Record Full Set of Observations.
8. If child conscious give Paracetamol as directed.
9. Obtain Assistance, arrange for doctor or ambulance if child severe.

EPIGLOTTITIS

Epiglottitis is inflammation of the epiglottis situated below the base of the tongue in the pharynx. The
inflammation is caused by a bacterial infection, haemophilus influenza, and the condition is a serious
medical emergency with a high risk of complete airway obstruction. It is absolutely essential that if
epiglottitis is suspected no attempt is made to examine the casualties mouth or throat and no action
taken that may upset casualty. Urgently call for an ambulance.

52
PROVISIONAL DIAGNOSIS OF EPIGLOTTITIS

HISTORY
a. Child aged 3-7 years but also adults
b. There is a History of recent throat infection
c. The condition worsens during the night

SIGNS
a. Patient will not talk or swallow and has marked drooling
b. High pitched noise (stridor) when breathing
c. Use of accessory muscles of respiration
d. Tracheal tugging with windpipe being pulled into the chest
e. Muscles between ribs may be sucked inwards during inspiration
f. Skin is hot, moist and may be cyanosed
g. Pulse is rapid and rises as the condition worsens
h. Patient has a high fever

SYMPTOMS
a. Patient has pain on swallowing
b. Patient is very quite and still

TREATMENT OF EPIGLOTTITIS

Never attempt to examine the airway of a casualty with suspected epiglottitis
1. Approach the Incident - do not disturb child
2. Calm and Reassure Mother and Child
4. Visually Check Breathing and Circulation
5. If Child hot, carefully remove any excess clothing
6. Be prepared to give Assisted Ventilations and CPR

TRAUMATIC INJURY

AIRWAY PROBLEMS

For airway obstruction see page 14 etc.
HANGING

Hanging is a reasonably common cause of death. It is often used by suicides and is used as an auto-
erotic sexual practice by some. Whatever the reasons for the hanging, the problems faced by the first
aider are not confined to simple asphyxia. As well as asphyxia the hanged casualty can suffer severe
damage to the spinal column and muscles of the neck due to stretching of these structures by the
body weight. This stretching can also cause damage to the carotid sinuses, which are located in the
neck, and this can result in disturbances of heart rhythm and blood pressure.

53
TREATMENT OF HANGING

1. Approach incident
2. Check casualties abdomen for warmth
3. If casualty still warm get help immediately
4. When help arrives, lift casualty as follows
-first support casualties head and neck
-lift casualty and loosen noose (watch your back!!)
-cut noose or rope
-allow casualty to slip to ground while supporting head and neck
5. Check and clear airway -ensure cord/rope is cleared from neck
6. Check breathing Assisted Ventilation if necessary and CPR
7. Full Examination and treat for spinal injury

You will need help to get the casualty down so first get help. Watch your back and be aware that
some suicides use steel cable and chains to hang themselves and to release the noose you must
undo the knots or use bolt cutters.

STRANGULATION

Strangulation occurs when the tracheae and larynx are compressed or crushed by pressure from
outside. True strangulation is usually the result of criminal assault.

TREATMENT OF STRANGULATION

2. Check and Clear Airway -ensure cord/rope is cleared from neck
4. Full Examination

DROWNING

People drown quietly. In drowning the victim can swallow a lot of air and water which fills their
stomach and oesophagus before flowing over into the windpipe and lungs. In children this can mean
that the stomach can be hyper-inflated so that it distends into the chest cavity and reduces the ability
of the lungs to expand. In adults the stronger body structures prevent this happening.

With both adults and children, vomiting of water and stomach contents increases the danger to the
casualties airway.

Although fresh and salt water drowning lead to differing chemical problems, the first aid treatment
remains the same.

TREATMENT OF DROWNING

1. Approach -never attempt rescue unless conditions are suitable

54
CHEST WALL INJURIES

The walls of the chest are made up of the thoracic spinal vertebrae at the back, the twelve sets of ribs
moving around the sides to the front, where 10 sets of ribs connect up to the sternum. This skeletal
structure gives the chest wall the rigidity which is essential for respiration and is the mechanism of
respiration. This mechanism of respiration can be disrupted by damage or restriction

FRACTURED RIBS

With simple rib fractures, the major problem is pain. This makes breathing difficult and is very
uncomfortable.

PROVISIONAL DIAGNOSIS OF FRACTURED RIBS

HISTORY
a. Direct blow/trauma
b. Usually 5th through 9th ribs - these are unprotected by shoulder

SIGNS
a. Respiratory pattern faster and shallower than normal
b. Deformity
c. Bruising
d. Site of fracture tender to touch

SYMPTOMS
a. Pain on breathing and casualty is able to easily localise pain

Fig. 6-1: Treatment of simple fractured ribs using arm sling

TREATMENT OF FRACTURED RIBS

2. Check airway, breathing and circulation
3. Check for major haemorrhage
4. Examine chest wall -isolate area of pain
5. Allow casualty to Find Comfortable Position (usually lying on injured side)
6. Apply Arm Sling
8. Send casualty to hospital

55
FLAIL SEGMENT

A flail segment is where a rib or series of ribs are fractured in two places allowing a segment of the
chest wall to float free from the surrounding chest wall. This reduces the amount of air that can be
taken into the lungs and can lead to asphyxia. Obviously the larger the segment the more dangerous
the injury.

PROVISIONAL DIAGNOSIS OF FLAIL SEGMENT

HISTORY
a. Direct blow/ trauma

SIGNS
a. Poor perfusion
b. Respiratory distress
c. Chest wall collapses in during inspiration
d. Site of fracture tender to touch

SYMPTOMS
a. Pain on attempt to breathe deeply
b. Shortness of breath
c. Patient is able to easily localise pain
d. Conscious state may be reduced

Fig. 6-2: Treatment of Flail segment

TREATMENT OF FLAIL SEGMENT

3. Examine Chest Wall - isolate area of injury
5. Immobilise chest wall with hands and then
-place towel or large pad over flail segment
-bandage pad firmly to chest:
-tie knots on front of uninjured side over pads
-place arm on the injured side in an Arm sling
6. Allow casualty to find most comfortable position
8. Recheck casualty frequently

SUCKING CHEST WOUND

A sucking chest wound is usually the result of sharp trauma, that is where an object such as a bullet or
knife penetrates the chest wall and either passes through or is removed leaving a hole. The
significance of this is that during inhalation air moves into the chest cavity through the hole in the chest
wall and not through the mouth. This leads to asphyxia and the collapse of the casualty. Therefore
sucking chest wounds are life threatening and quick treatment is essential.

56
PROVISIONAL DIAGNOSIS OF SUCKING CHEST WOUND

HISTORY
a. History of violence, a fight, assault or shooting

SIGNS
a. Poor perfusion
c. Fast and shallow respiration
d. Distended neck veins
f. Blood stained froth in mouth or on lips
g. Wounds to chest wall

SYMPTOMS
a. Patient apprehensive and distressed

TREATMENT OF SUCKING CHEST WOUND

3. Call ambulance immediately if injury identified
4. If necessary Assisted Ventilations and CPR
5. Check for major haemorrhage
6. Examine chest wall
-look for more than one wound
-isolate all wounds
-leave protruding foreign objects in place
7. Seal wound during inspiration and release during expiration
8. If you have time dress wound (This may not be possible on sweaty skin)
-place air-tight (plastic/rubber) dressing on wound
-tape only three sides of dressing
-ensure dressing seals during inspiration and lets air vent during expiration
9. If Conscious, let casualty find most comfortable position

PNEUMOTHORAX AND/OR HAEMOTHORAX

Pneumothorax is a condition where air gets between the outside lining of the lung and the inside lining
of the chest wall. Pneumothorax can occur as a result of injury or as a result of a surface air sac
bursting under pressure.

Haemothorax is where blood gets between the outside lining of the lung and the inside lining of the
chest wall. Pneumothorax and haemothorax are often present together, as the initial injury often
causes bleeding in addition to the escape of air.

PROVISIONAL DIAGNOSIS OF SIMPLE PNEUMO-HAEMO THORAX

HISTORY
a. History of injury to chest

SIGNS
a. Poor perfusion with cyanosis
b. Respiratory rate getting faster and shallower
c. Air may be felt in the tissues of the chest wall

SYMPTOMS
a. Pain and local tenderness
b. Patient is restless

57
TREATMENT OF PNEUMOTHORAX

3. Call ambulance
4. Examine neck and chest wall
-look at neck veins
-examine neck, shoulders and chest wall for damage and air in skin
5. If Conscious, let casualty find most comfortable position

Pneumothorax and haemothorax are uncomfortable and can cause the casualty some distress.
However, they are not necessarily life threatening, unless air and blood are trapped in the chest cavity
under pressure. This is called Tension Haemo-Pneumothorax and this is a true medical emergency.

PROVISIONAL DIAGNOSIS OF TENSION PNEUMOTHORAX

HISTORY
a. History of chest injury

SIGNS
a. Poor perfusion
b. Respirations get faster and deeper before becoming shallower
c. Distended neck veins
d. Air may be felt in the tissues of the chest wall
e. Windpipe may be pushed to the uninjured side

SYMPTOMS
a. Extreme anxiety and distress
c. Severe pain and tenderness

TREATMENT OF TENSION PNEUMO/HAEMOTHORAX

2. Check airway, breathing -CPR if necessary
4. Examine neck and chest wall
-look at neck veins:
-examine neck, shoulders and chest wall for damage and air in skin
-examine windpipe and top of breastbone to check they align
5. If conscious, let casualty find most comfortable position

58
CHAPTER 10

ABDOMINAL INJURY

ABDOMINAL PAIN

Abdominal pain can be a sign of a vast range of ailments, both major and minor. In fact anything
ranging from internal haemorrhage to flatulence. Any persistent abdominal pain must be assessed by
a medical practitioner.

TREATMENT OF ABDOMINAL PAIN

1. Examine and continuously assess casualties perfusion status
2. Arrange for casualty to see medical practitioner
3. Place pillow under casualties knee and sit them up a little
4. Give nothing to eat or drink and reassure casualty

ABDOMINAL WOUNDS AND EVISCERATION

Any puncture wound to the abdomen is a serious injury until the casualty is fully assessed in an
appropriate surgical setting. You should also remember that even minor punctures of the abdomen
can be associated with severe internal bleeding.

Evisceration is where the abdominal contents are exposed to the outside or removed from the
abdominal cavity through a wound

PROVISIONAL DIAGNOSIS OF EVISCERATION AND BLEEDING FROM
ABDOMEN

HISTORY
a. Patient suffering blunt trauma in an accident
b. Stabbing or shooting

SIGNS
a. Poor perfusion
b. Guarding and rigidity of abdomen
c. Obvious injury to body
d. Frank blood excreted from body

SYMPTOMS

TREATMENT OF EXTERNAL BLEEDING FROM ABDOMEN

1. Treat external bleeding from wound
2. Cover entire wound using Glad wrap or dressing soaked in sterile saline
5. Sit casualty up slightly and place something under knees to keep them bent
6. Give nothing to eat or drink

59
INTERNAL BLEEDING

Internal bleeding into the abdomen is a common injury which presents a major threat to life and there
is nothing you can do to control the bleeding. It is essential that the bleeding is identified and the
casualty taken to a surgical hospital as soon as possible.

PROVISIONAL DIAGNOSIS OF INTERNAL BLEEDING

HISTORY
a. Patient suffering blunt trauma in an accident
b. Stabbing or shooting
c. History of illness such as bleeding ulcers

SIGNS
a. Poor perfusion

SYMPTOMS

ABDOMINAL AORTIC ANEURYSM

An abdominal aortic aneurysm is where a weakness occurs in the wall of the aorta in the abdominal
cavity causing a ballooning out of the aorta. This condition mainly afflicts men, from their late 50s
onwards. The treatment is the same as for any abdominal pain and the casualty should be assessed
by their medical practitioner.

RUPTURED OR LEAKING ABDOMINAL AORTIC ANEURYSM

Rupture of the aorta can lead to rapid death and kills 6,000 people per year in Australia...
1

PROVISIONAL DIAGNOSIS OF RUPTURED ABDOMINAL AORTIC ANEURYSM

HISTORY
a. Older casualty, especially male
b. Onset of abdominal pain/discomfort
c. Patient reports a tearing sensation in abdomen

SIGNS
a. Possible poor perfusion
c. Possible orange sized pulsating mass in upper abdomen

SYMPTOMS
a. Pain often radiating to legs
b. Tenderness
c. Tearing sensation

TREATMENT OF INTERNAL ABDOMINAL BLEEDING INCLUDING AORTIC
ANEURYSM

3. Sit casualty up slightly and place object under knees to keep them bent
4. Take observations and reassure casualty

1. G. D. Tacy, Ruptured Abdominal Aortic Aneurysm, Emergency Medicine: The Principles and Practice, 2
nd
Edition,
Ed. G.W.O. Fulde, Maclennan and Petty, Artarmon, 1994, p.87
60
CHAPTER 11

BURNS

Burns are caused as a result of exposure to heat, chemicals and electricity. A burn is an injury caused
by heat to the skin and its underlying soft tissues. Burns also inspire a great deal of distress to
casualties, bystanders and rescue personnel. Where a casualty has been burned you have to deal
with danger, airway burns, respiratory arrest, poisoning and the burn itself.

RESCUING THE BURNT CASUALTY
Any situation where a casualty is burnt represents great danger to you. Rescue of trapped persons is
an extremely dangerous undertaking and should be left to the fire-fighting authority when they arrive.
Untrained rescuers run a very high risk of death or serious injury.

RESCUE FROM A BUILDING OR STRUCTURE
If you do decide to attempt a rescue from a burning building you must ensure
the following

1. You must know where the casualty is
2. You must plan your entry with care
3. You must identify a number of alternative escape routes
4. You must allot a set time for a search, say 60 seconds
5. You must cease the search when the allotted time elapses
6. Stay low to the ground and do not breath any smoke
7. Test all doors before you attempt to open them
8. If you have to carry a casualty out -drag them and keep low

PUTTING OUT CLOTHING FIRES
Do not be deceived by clothing fires. Clothing burns at very high temperature and can result in severe
burns to the casualty and to your face and hands. The severity of these fires is increased by the fact
that casualties often inhale the rising superheated air and they often run around, fanning the flames
and increasing the temperature.

Fig: 8-1: Roll casualty with foot keeping hands and face away from rising hot air

61
PROCEDURE FOR EXTINGUISHING CLOTHING FIRES

1. React quickly
2. Throw down, push over or trip casualty
3. Do not stand above casualty as rising hot air can burn your face and hands
4. Roll the casualty using your foot or smother flames with a blanket
5. Get water onto casualty ASAP

TYPES OF BURN

Burns are classified into two types, superficial and deep.

Superficial
Deep

Fig. 8-2: The level of Superficial and deep burns

IDENTIFYING THE AREA OF A BURN

Body area is estimated using the rule of 9s. The rule applies to both children and adults, however, the
measurements differ as a childs head is much larger in proportion to their body than an adults. The
rule of 9s is applied as follows:

SUPERFICIAL BURN

Superficial burns involve injury to the upper layers of the skin only. This leaves the deeper
skin cells, nerves and other structures alive and the skin is able to recover by itself.
DEEP BURN

A deep burn, as the name suggests, extends deep into the skin killing all the skin cells and
underlying structures including nerves. Thus deep burns are painless, although the area
surrounding a deep burn may be painful. Any deep burn is a serious burn.

62
9%
9%
9%
9%
9% 9%
9%
9%
1%
9%
9%
9%

Fig. 8-3: The rule of 9s applied to the adult male

18%
18%
18%
9%
9%
14%
14%

Fig. 8-4: Rule of 9s estimation of Burns on a child

PROVISIONAL DIAGNOSIS OF SUPERFICIAL BURN

HISTORY
a. Story of exposure to heat source, chemicals, hot liquids
b. Burnt clothing

SIGNS
a. Redness
b. Inflammation
c. Swelling
d. Blisters
e. Moist appearance

SYMPTOMS
a. Pain
b. Tenderness
c. Gritty feeling
d. Nausea with large burn
e. Dizziness with large burn

63
PROVISIONAL DIAGNOSIS OF DEEP BURN

HISTORY
a. Story of exposure to heat source, chemicals, hot liquids

SIGNS
a. Altered conscious state
b. Dry looking, black, brown or white marble appearance
c. Inflammation
d. Swelling

SYMPTOMS
a. Pain only in areas surrounding burnt area
b. No tenderness
c. No feeling or sensation on burnt area
d. Nausea with large burn

TREATMENT OF BURNS

1. Danger - ensure your own safety and then that of the bystanders
2. Get casualty out and put water on them as soon as possible
3. Airway - look for ash, soot, burns, blistering or swelling to airway
4. Breathing - look for respiratory distress
5. If not breathing - Be prepared to give CPR
7. Remove all clothing unless stuck to burned area
8. Apply running cool water for up to 10 minutes
-do not over cool the casualty, beware of hypothermia
9. Find and remove all jewellery from casualties body
10. Look for other injuries - burned casualties often suffer cuts and fractures during their attempts
to escape the flames
11. Place a dry, clean sheet over casualty
12. Reassure casualty and bystanders

SCALDS

Scalds are burns caused by hot fluids. Scalds can be very serious and it is essential that quick action
be taken to limit the extent of the burn. Scalds can be caused by hot water, hot oil or any hot liquid. In
all scalds it is very important that all clothing be quickly removed.

In scalds the hot water or oil is absorbed into the clothing and held close to the casualtys skin. This
results in the liquid being insulated from any cold water that is applied and the heat being retained
against the skin for a longer period. Young children who are scalded often have the deepest burns in
the groin area due to their nappies absorbing and holding the hot liquid. Treatment is the same as for
other burns.

CHEMICAL BURNS

Chemical burns are treated in exactly the same way as other types of burn with the exception that
water is applied for longer, up to 20 minutes. You should take care to ensure that you do not come
into contact with the chemical or the water being used to remove it from the casualties body.

Chemical burns to the eyes receive special attention. If casualty has chemical or heat burns to eye
immediate action is required in order to save the casualties sight.
64
TREATMENT OF CHEMICAL, SMOKE OR HEAT BURNS TO EYE

1. DRABCD
2. Get casualty to water or water to casualty
3. Open eyelids
4. Flush with large amounts of cool water for 20-30 minutes
6. Treat as for severe eye injury
-dressings to both eyes
-stay with casualty
-keep them calm

Fig. 8-5: Wash eyes with large amounts of water

ELECTRICAL BURNS

Electrical burns can appear to be very small at first but later extend into very large and serious burns.
No matter how minor an electrical burn seems the casualty must be sent to hospital because the
electric shock may cause electrical disruption of the heart.

High tension electrical burns are often associated with explosive injuries with the casualties arms, legs
or other parts of the body being blown off.

TREATMENT OF ELECTRICAL BURNS
NEVER ATTEMPT TO RESCUE ANYONE FROM A HIGH TENSION AREA

You do not need to touch a high tension electrical cable to be electrocuted. Electricity can arc out
from high tension equipment and electrocute anybody entering its electro-magnetic field. This field
increases with humidity and therefore rescue is an expert activity, and then only after the electrical
current is shut off.
1. Apply running cool water for up to 10 minutes
-do not over cool the casualty, beware of hypothermia
2. Look for other injuries
3. Place dry, clean sheet over casualty
5. Reassure casualty and bystanders

65
CHAPTER 12

FRACTURES, DISLOCATIONS AND SOFT TISSUE
INJURIES

The limbs are the most common site of injury. The injuries that you will encounter include bruising,
sprains, strains, dislocations, fractures, avulsions, and crush injuries. Limb injuries, even when
severe, are not directly life threatening unless associated with uncontrolled bleeding, therefore your
priority is the control of bleeding and the prevention of further injury.

BANDAGING

Bandaging in first aid should be kept simple and practical. There is little point in splinting a fractured
leg with triangular bandages and wood if the ambulance service is going to be on the scene within an
hour. They will use traction splints and therefore they will remove any splinting applied by the first
aider.

The most useful bandage in the first aid kit is the triangular bandage. It can be used to make a variety
of slings, it can be used as a bandage to hold splints on the body and it can be used as a pad and
bandage for bleeding. The triangular bandage can be folded as follows:

Phases of Triangular Bandage

Open or broad phase

Semi-broad phase

Semi-cravat phase

Cravat phase

Fig. 10-1: Folding a triangular bandage to create broad and narrow bandages

Fig. 10-2: Folding a narrow bandage for storage
66
BRUISING

Bruising on a limb may range from a small dark spot to a large area. The extent of the injury depends
on the damage to the tissues and blood vessels within the limb. Severe bruising can also occur where
a small injury occurs but the casualty has a blood clotting disorder or they are taking anti-clotting
medication. These casualties need to be monitored and if the bruise becomes large they should be
taken to hospital or to their medical practitioner

TREATMENT OF BRUISING

1. Approach incident -Check casualtys medical history and examine injury
2. Rest the casualty and the injured area
3. Ice compress on the bruise for 10 minutes
4. Compression bandage
5. Elevate Injured limb
6. If necessary send to medical practitioner - beware of anti-coagulant drugs

SPRAIN AND STRAIN

Sprains and strains are over-stretching and tearing injuries. Sprains occur when the ligaments which
bind joints are torn or over-stretched: strains occur in muscles.
It is sometimes difficult to tell the difference between a severe sprain and dislocation or fracture
involving the joint. If you are in doubt treat the injury as a fracture

PROVISIONAL DIAGNOSIS OF SPRAIN AND STRAIN

HISTORY
a. Story of playing sport or physical exertion
b. Patient has over-extended or twisted
c. Patient may have felt or heard a snap before pain

SIGNS
a. Swelling
b. Bruising
c. Unable to bear weight or use limb

SYMPTOMS
a. Pain
b. Tenderness

TREATMENT OF SPRAIN OR STRAIN

2. Take history and examine injury
3. Rest the casualty and the limb
4. Ice compress applied to injury for 20 minutes
5. Compression bandage
7. If you think there may be a fracture/dislocation treat for that injury

67

Fig. 10-3: Application of a compression bandage to ankle

FRACTURE

A fracture is a break in the continuity of a bone and there are three basic types of fracture:

Fig. 10-5: Open fracture of left leg

CLOSED

A closed fracture is where the bone is broken and there is no opening to the exterior
through a wound and no injury to other body organs

OPEN

An open fracture is where the ends of broken bone are exposed to the air either
after they are pushed through the skin or a wound leads down to the bone. An
open fracture is serious because of associated bleeding and the increased risk of
infection entering the bone itself
THERE ARE THREE GENERAL CAUSES OF FRACTURES

Direct Force: - a blow to the body breaks the bone directly where the blow is made

Indirect Force: - the force of a blow or impact to the body travels along the body
and fractures a bone further away

Abnormal Muscle Action: - severe muscle contraction can sometimes break bone

68

DISLOCATION

Dislocation occurs when a bone is moved out of place by forces twisting or pulling it. The treatment of
dislocations and fractures is the same

PROVISIONAL DIAGNOSIS OF DISLOCATION AND/OR FRACTURE

HISTORY
a. Story of a blow or other impact to the body
b. Patient engaging in physical exertion

SIGNS
a. Abnormal or no movement
b. Deformity - (sometimes)
c. Swelling
d. bruising
e. Shortening of limb (Legs)
f. Crepitus - a coarse grating sound which should be prevented

SYMPTOMS
a. Loss of power, movement or control
b. Pain
c. tenderness

GENERAL TREATMENT OF DISLOCATIONS AND FRACTURES

3. If necessary call ambulance immediately
5. Check circulation below injury (pulse and skin)
6. If ambulance will be some time in arriving apply bandage
-around feet or hand
-above the fracture
-below fracture
-to the joint above the fracture
-to the joint below the fracture
7. Tie all knots over padding or splints
8. Check circulation below bandages

TREATMENT OF SPECIFIC FRACTURES

USE OF SPLINTS

The treatment of fractured legs using wooden splints is not recommended where an
ambulance will be at the scene within a reasonable period of time, say an hour or so.
Wooden splints are also not recommended because they are:
a. hard to find at accidents,
b. they will cause pressure sores if not properly padded,
c. they are painful to apply, and
d. the ambulance officers will have to remove them to use their equipment
COMPLICATED

A complicated fracture is where other body organs are damaged by the fracture

69

Fig. 10-6: OHare Traction splint is a special splints used by ambulance officers for lower limb fractures

TREATMENT OF FRACTURED LEG WHERE AMBULANCE IS QUICKLY
AVAILABLE

4. Reassure and talk to casualty constantly
5. If the casualty experiences severe muscle spasm
- reassure casualty and get them to relax muscles
-take hold of foot of injured limb and
-gently pull on foot and stretch muscles
-straighten limb
-hold limb until ambulance arrives (this is very strenuous and cannot be done for a
prolonged period by one person)
6. Continuously check circulation below any bandages

TREATMENT OF FRACTURED LEG WHERE AMBULANCE IS NOT AVAILABLE

4. Obtain materials for splinting and bandaging
5. If the casualty experiences severe muscle spasm
-talk to and reassure the casualty constantly
-take hold of foot of injured limb and
-gently pull foot down from hip
-straighten limb
-hold limb

Fig. 10-7: Place Bandages, splint and padding
70
6. Place bandages and then splint between legs and pad heavily

Fig. 10-8: Tie knots on uninjured side over padding

7. Apply bandages
-figure 8 narrow bandage around feet
-broad bandage above the fracture
-broad bandage below fracture
-broad bandage to the joint above the fracture
-broad bandage to the joint below the fracture
-Tie all knots over padding
9. Frequently check circulation below bandages
10. Reassure casualty and treat poor perfusion

TREATMENT OF FRACTURED PELVIS

4. Rest the casualty
5. Treat for poor perfusion (Shock)
6. Padding between legs
7. Apply bandage
-narrow bandage around feet or hand
-broad bandage to the knee joint
8. Tie all knots over padding
9. Prop casualty up very slightly
10. Place rolled blanket or pillow under knees
12. Check perfusion status (shock)

TREATMENT OF FRACTURED LOWER ARM

5. Find splint -newspaper is good -and pad it well
6. Apply splint and padding under arm

Fracture Site
Padding
Padding
71

Fig. 10-09: Newspaper used as splint for forearm fracture

7. Apply narrow bandages
-around hand
-above the fracture
-below fracture
8. Tie knots on splint
9. Apply Ordinary arm sling

TREATMENT OF FRACTURED UPPER ARM

3. If necessary call ambulance immediately
4. Rest casualty and the limb

Fig. 10-10: Application of Ordinary arm sling

6. Apply Collar and Cuff sling
7. If casualty has to move over rough ground apply padding under arm
8. Two broad bandages around arm
-one above fracture
-one below fracture

72
AVULSION

Avulsion is the non surgical amputation of a limb or other body part. In most avulsion cases the limb
or body part is torn and twisted off the body. Even with apparently clean cuts there is usually some
degree of crushing and tearing of the tissues around the site of the wound. Because of the tearing,
stretching and mashing of tissues and blood vessels, avulsion can sometimes be accompanied with
severe uncontrolled bleeding

TREATMENT OF AVULSION

5. Control haemorrhage -pack stump or hole with towels etc
7. Find avulsed part and wrap in and seal in plastic, then wrap with a dry towel
8. Place wrapped part in ice

CRUSH INJURIES

With crush injuries the weight must be left in place until the arrival of the ambulance if casualty has
been trapped for more than an hour. This prevents the chemicals from burst cells from reaching the
heart and stopping it.

TREATMENT OF SERIOUS CRUSH INJURY

2. Remove weight if possible (Do not remove weight if trapped for more than an hour)
4. Control any Haemorrhage
5. Immobilise limbs
6. Elevate legs if possible
7. Rest and reassure the casualty
8. Treat poor perfusion

73
CHAPTER 13

POISONING, BITES AND STINGS

Poison enters the human body through absorption through the skin, ingestion, inhalation and injection.
Poisoning is a common problem and is either accidental or deliberate.

ACCIDENTAL POISONING

Accidental poisoning can occur at any age but children are nearly always victims of accidental
poisoning.

DELIBERATE POISONING

While deliberate poisoning is most commonly associated with murder by far the most frequent cause
of deliberate poisoning is attempted suicide and substance abuse.

ABSORBED POISON

Poisons such as insecticides can be absorbed through the skin. The treatment should be based on
the History and anyone exposed to a poison capable of being absorbed into the body must be sent to
hospital. The effects of some of these poisons are very dramatic and can be life threatening.

PROVISIONAL DIAGNOSIS OF ABSORBED POISONING

HISTORY
a. Story of contact with specific poison

SIGNS
b. Possible poor perfusion
c. Muscle tremor and twitching
d. Excessive salivation
e. Fitting

SYMPTOMS
a. Disorientation
b. Confusion
c. Loss of consciousness

TREATMENT OF ABSORBED POISON

1. Danger - Keep away from the poison
2. Wash casualty down with copious amounts of water
3. Use dish-washing liquid to wash casualty
4. Avoid contamination from the water run off
5. Have casualty strip all clothing off
6. Call for ambulance
7. Maintain airway, breathing and casualtys perfusion status
8. Only touch casualty or their clothing using heavy rubber gloves
9. Put casualtys clothing into plastic bag and send with them to hospital
10. Observe casualty closely

74
INGESTED POISON

Ingested poisoning is a common cause of poisoning and must be treated seriously. In all cases
casualties who have drunk or eaten a poisonous substance must be sent to hospital.

PROVISIONAL DIAGNOSIS OF INGESTED POISONING

HISTORY
a. Story of having taken the poison
b. Child who has had access to a poison

SIGNS
a. There are many Signs associated with poisoning

SYMPTOMS
a. Disorientation
b. Confusion

Fig. 9-1: Medication is a common agent in poisoning

TREATMENT OF INGESTED POISON

1. Danger, response, airway, breathing, compression, defibrillation
2. Attempt to identify the poison
3. Do not make casualty vomit
4. Call ambulance or take casualty to hospital
5. Keep any vomit
6. Observe casualty closely
7. Do not contaminate yourself

INHALED POISONS

Inhaled poisons represent a major threat to life and great care should be exercised in attempting to
rescue the casualty. Remember you cannot carry or drag a heavy casualty and hold your breath. The
best option is to wait for the emergency services and leave the rescue to them.

PROVISIONAL DIAGNOSIS OF INHALED POISONING

HISTORY

SIGNS
b. Possible poor perfusion - possible cyanosis
c. With Carbon monoxide poisoning the skin is bright red and warm
d. Fitting and cardiac or respiratory arrest

SYMPTOMS
a. Disorientation
b. Confusion
75
TREATMENT OF INHALED POISONING

1. Danger - wait for professional help before attempting rescue
-do not take unnecessary risks
2. Get yourself and casualty to an adequately ventilated area
-up-wind of the poison source
3. Response, Airway, Breathing, Compression and Defibrillation
4. Call ambulance and fire brigade

INJECTED POISON

The most frequent causes of poisoning through injection are substance abuse and envenomation by
insect or animal bite. The most frequent cause of poisoning in drug abuse is heroin and it presents as
follows.

PROVISIONAL DIAGNOSIS OF INJECTED POISONING

HISTORY

SIGNS
b. Possible poor perfusion - Cyanosis
c. Weakening respiratory effort
d. Pinpoint pupils from heroin
e. Respiratory and cardiac arrest

SYMPTOMS
a. Disorientation and euphoria
b. Confusion

TREATMENT OF INJECTED POISON (DRUG OVERDOSE)

1. Danger
2. Airway, Breathing, Compression and Defibrillation
3. Call ambulance

76
ANIMAL OR INSECT BITE

The majority of animal and insect bites do not cause serious illness. However, where a bite causes
tissue damage and bleeding then a medical practitioner should be consulted and tetanus
immunisation should also be checked. In Australia there are a number of poisonous animals including
snakes, spiders, fish and marine life which do poison humans. These animals vary from region to
region, so you should ensure that you know which animals pose a threat in your area and at what
times of the year they are most dangerous. However, treatment of dangerous bites is simple.

PROVISIONAL DIAGNOSIS OF SNAKE OR SPIDER BITE

HISTORY
a. Story of contact with the animal

SIGNS
b. Possible poor perfusion
c. Muscle tremor and twitching
d. Excessive salivation
e. Fitting

SYMPTOMS
a. Disorientation
b. Confusion
d. Pain in limb moving towards trunk

TREATMENT OF BITES FROM SNAKES, FUNNEL WEB SPIDERS, CONE FISH,
BLUE RINGED OCTOPUS

1. Danger -ensure that the angry animal has departed the scene and be careful
5. Cut all clothing from affected limb or area
6. Apply a dressing to bite
7. Do not wash wound
8. If bite on a limb apply compression bandage
-apply compression to bite
-then from fingers or toes all the way to the armpit or crotch
9. The bandage should be firm but not over-tight
10. Observe the casualty closely
Bandage from the bite to the fingers and then the whole way up to the armpit.

Fig. 9-2: Treatment of snake bite
77
TREATMENT OF BITES FROM RED BACK SPIDERS

1. Danger
3. Apply cold compress to bite site
4. Immobilise limb and seek medical assistance

TREATMENT OF JELLYFISH STINGS

1. Danger
3. Get casualty onto beach or boat
4. Rest and reassure
6. Cut all clothing from affected limb or area
7. Gently remove individual stings with tweezers
8. Wash wounds with vinegar if available
9. Do not rub sting

TREATMENT OF STINGS FROM BEE, WASP, SCORPION OR CENTIPEDE
These bites can be painful and uncomfortable but are rarely dangerous unless the casualty is
allergic to the particular bite. If there is a serious allergic response following a bite treat as for
anaphylactic shock.

1. Danger
2. Check airway, breathing and casualtys perfusion status
3. Rest and Reassure
4. Remove obvious sting and clean skin
5. If required apply a little ice to stung area
6. Observe casualty

PROVISIONAL DIAGNOSIS OF TICK BITE
HISTORY
1. Playing or working in scrub or bush on east coast of Australia

SIGNS
1. Altered conscious state
2. Possible poor perfusion
3. Muscle tremor and twitching

SYMPTOMS
1. Disorientation
2. Confusion
3. Loss of consciousness
4. Weakness

TREATMENT OF TICK BITES

1. Danger, airway, breathing and casualtys perfusion status
2. Check casualtys body including hair, armpits, groin, anus and all skin folds
3. Kill tick using methylated spirit
4. Remove tick, ensuring that the head parts are removed
5. Clean skin and if required apply a little ice to stung area

78
ANAPHYLAXIS

Anaphylaxis is a hyper-allergenic response to the introduction of an antigen into a casualtys body.
The most common antigens include shell fish, bee stings, peanuts and some food colourings. The
Signs and Symptoms of anaphylaxis may range from a stuffy nose to acute respiratory and circulatory
collapse and sudden death. Most people who are at risk of anaphylactic reactions are aware of the
risk and may have access to medication to be taken in an emergency.

PROVISIONAL DIAGNOSIS OF ANAPHYLACTIC REACTION

HISTORY
a. Previous attacks have occurred
b. Story of exposure to antigen

SIGNS
b. Poor perfusion
c. Blotchy rash to face and body
d. Runny nose and eyes
e. Blisters
f. Fitting
g. Bronchospasm and wheezing
h. Vomiting and diarrhoea

SYMPTOMS
a. Disorientation
b. Confusion

TREATMENT OF ANAPHYLACTIC REACTION

1. Danger
4. Rest and reassure
5. If the casualty has medication help them administer it immediately
6. Be prepared to commence Assisted Ventilation and CPR

79
CHAPTER 14

EMERGENCIES DUE TO TEMPERATURE CHANGE

As a first aider there is a good chance that you will be called to deal with an emergency due to
changes in the core temperature of a casualtys body. The core temperature of the human body is
maintained at about 37.6
o
C and changes of three degrees either lower or higher can seriously affect
the health of a casualty.

MAINTENANCE OF A CORE BODY TEMPERATURE

The temperature of the human body varies depending on what part of the body we are talking about.
For this reason the body is divided into two parts; the peripheral, consisting of the skin and muscles,
and the core, which consists of the brain, heart, lungs, liver, kidneys and the other organs of the
abdomen. When looking at the effects of environmental temperature upon the human body we need
to consider both parts.

The temperature of the peripheral part of the body, especially the skin, is not constant. It is through
the skin that heat is lost from the body. Thus on the skin the temperature will vary from close to 37
O
C
in the groin and axillae to near the environmental temperature in the hands and feet.

Temperature within the core of the body however is almost constant, at around 37.6
O
C. Any large
fluctuations in this temperature will result in problems. These problems occur because to function the
cells of the body require complex chemical reactions and these can only occur within a limited
temperature range around 37.6
O
C. Thus the core temperature of the body is maintained at this level
with only a slight variation (5
O
) in a 24 hour cycle with the temperature being lower at about 4.00am
and higher at about 6.00pm.

Body heat is created by cell metabolism, the chemical activity we have already mentioned above. Cell
metabolism produces about 292.6Kj of energy (heat) per hour and the controlled loss of this heat is
what maintains the core temperature of the body.

To maintain a constant core temperature of 37.6
O
C the body has to carefully regulate heat production
and loss and anything which interferes with this will result in temperature imbalance. Thus if more
than 292.6Kj of body heat is lost per hour the casualty will become cold (hypothermic). If heat is
prevented from leaving the body the core temperature will rise about 1
O
C every hour leading to death
within four to five hours.

Heat loss from the body is slowed by gaining heat from the environment by eating hot food, sitting in
the sun or in front of a fire, and through the wearing of clothing which insulates the body from the
environment by trapping and warming air in the fibres close to the skin. If the body needs to lose
excess heat then we move away from sources of environmental heat or we take off clothing.

The body also regulates its heat loss by altering the temperature of the skin. When the skin itself is
hot it fills with warm blood which cools before going back to the heart and core organs. Thus the rate
of heat loss from the body increases. When the environment becomes very cold the blood vessels in
the skin contract and little blood can enter the skin and this reduces the speed of heat loss. This is
why on a cold day the skin is pale and blue from lack of blood and a hot day it is flushed and warm.

80

These four processes act on the skin. A much lesser heat loss is produced through the lungs where
heat is lost during respiration. Very small amounts of heat are lost via passing urine and faeces.

TYPES OF TEMPERATURE EMERGENCY

The types of temperature emergencies you will encounter are hyperthermia (high body temperature),
and hypothermia (low body temperature). The cause of these conditions are either illness or injury,
and exposure to environmental temperature

The most common type of problem you will encounter is altered temperature due to illness or injury, so
we will deal with this subject first.

INFANTILE CONVULSIONS (FEBRILE CONVULSION)

The most common medical problem involving temperature change is infantile convulsions. Infantile
convulsions are fits caused by high temperature in young children, usually the result of a cold, flu or
other infection combined with too much clothing and a warm environment.

Infantile convulsion is very dramatic and frightening for parents and it is necessary to carefully
reassure them while you treat the child. Most parents of children who suffer infantile convulsions are
quite capable of dealing with the problem once they are aware of its causes and treatment. Thus it is
usually the first fit that you will see and this is why the parents will be so distressed. Therefore calm
down the parents, especially the mother. Her emotional distress is very easily communicated to the
child and getting the mother calm allows the child to be more easily treated.

PROVISIONAL DIAGNOSIS OF INFANTILE CONVULSION

HISTORY:
a. Story of illness (Cold, flu, cutting teeth) or infection
b. Child is heavily dressed
c. The home is well heated
d. Child began fitting

SIGNS:
a. Child can be seen to convulse -arching of back
b. Veins on head and neck are distended
c. Child is obviously distressed
d. Skin is hot

SYMPTOMS:
a. Impossible to obtain
THE FOUR PRINCIPAL MEANS OF LOSING HEAT FROM THE BODY
VIA THE SKIN ARE

Radiation: heat is lost from the body in the form of infra-red rays which radiate out
heating objects in their path,
Conduction: heat is transferred directly from the skin to any solid object which is colder
than the skin until that object reaches skin temperature,
Convection: air next to the skin is warmed by the processes of radiation and conduction
and it rises away from the body to be replaced by colder air which is then
also warmed,
Evaporation: sweat is released onto the surface of the skin from the sweat glands and it
then evaporates when air passes over it
Evaporation is the most important process with 2ml of sweat using 4.18 joules of energy to
evaporate. Evaporation of perspiration is the only way the human body can lose heat once
the air temperature rises above 37
O
C. This is why we find very humid environments very
uncomfortable even at low temperatures.

81
TREATMENT OF INFANTILE CONVULSION

2. Reassure and relax parents
3. Get mother to remove childs clothing
4. Have mother and father sponge the child with cool water
5. Fan child
6. Continue until convulsions cease and child is seen to shiver
7. Dry child and dress lightly
8. Ensure parents understand that child should be kept cool
9. Call a doctor or have parents take child to a hospital.
10. If the child is over 12 months Childrens Paracetamol can be administered.

HIGH TEMPERATURE (FEVER) DUE TO ILLNESS

Nearly everyone has experienced an episode of fever or high temperature due to an infection or
illness. In adults and older children this does not cause any severe problems unless the infection is
out of control. When a fever does become a problem it usually takes a day or so for the casualty to
become ill and most often this problem is being managed by a medical practitioner. Thus fever is not
a problem that you will be required to treat without assistance from a medical practitioner

In most cases the treatment of high temperature in adults or older children is bed rest and the
administration of Paracetamol and other medication on the medical practitioners directions

LOW TEMPERATURE DUE TO INJURY OR ILLNESS

Any casualty who suffers a severe injury or illness can, if left exposed, suffer from low body
temperature. Remember that an environmental temperature of 34
O
C is regarded as quite hot,
however the same temperature in the core of a casualtys body is very low and will lead to serious
problems. When caring for injured, ill or infirm casualties always ensure that they are protected from
wind, rain and cold. Use blankets and other coverings to insulate the casualty and ensure their
removal to a protected environment as soon as possible

EXPOSURE TO TEMPERATURE CHANGES

In Australia physical problems due to exposure to temperature are usually associated with thirst and
heat. This is only half the story. Australia is a continent and temperatures range from very hot, above
45
O
C, to very cold, below 0
O
C. This range of temperature is not simply a result of the geographical
distance Australia extends from the equator, it is also seasonal, with many parts of Australia
experiencing a wide range of temperatures over a year. Thus you may encounter casualties suffering
heat related conditions in summer and cold related conditions in winter

In looking at the effects of temperature change on the human body we need to consider three things;

a. how the body maintains a constant core temperature,
b. what impact high environmental temperature has on the body, and
c. what effect low environmental temperature has on the body

EXPOSURE TO HEAT

As we have noted the body maintains its core temperature at close to 37.6
O
C through a complex
system of balancing heat production and loss. This system is regulated from the hypothalamus in the
brain. If any part of this system is unable to operate then the body temperature will rise or drop to the
environmental temperature and if this temperature is above 37.6
O
C the casualty will suffer
hyperthermia Hyper = High and thermia = temperature). Hyperthermia is a progression from the
normal body temperature through to a temperature where death occurs. Along the way the casualty
will suffer from heat cramps, heat exhaustion and heat stroke

82
HEAT CRAMPS

Heat cramps are characterised by severe muscle pains and cramps, especially in the lower limbs and
abdomen. Because heat cramps are often ignored by the casualty it is likely that you will be aware of
their onset. However, where a casualty suffers heat cramps it is important to treat them before they
progress to heat exhaustion

PROVISIONAL DIAGNOSIS OF HEAT CRAMPS

HISTORY
a. Physical activity in a hot environment
b. Complains of cramps in calf muscles and abdomen

SIGNS
a. Cramping of muscles
b. Pink, warm and sweaty skin

SYMPTOMS
a. Possible altered conscious state
b. Weakness

TREATMENT OF HEAT CRAMPS

1. Stop casualty exerting themselves and remove to cool environment
2. Give water with added salt to drink (Ratio of one teaspoon of salt to 1000ml of water) or use a
sports drink
3. Gently stretch cramped muscles
4. Apply ice packs to the cramped muscles

HEAT EXHAUSTION

This condition results from over-exposure to high temperature and/or high humidity, especially where
the casualty has been exerting themselves. In a hot humid environment heavy work or exercise can
result in the loss of between 8 and 14 litres of water and 28 grams of salt (NaCl) per day (each litre of
sweat contains 2 grams of salt)

PREVENTION OF HEAT EXHAUSTION

If you find yourself working in such an environment it is important that you ensure that you
and others have enough fluid and salt. The most effective way of preventing dehydration is
to buffer your system as follows:

1. Before going to bed drink about a litre of water. This allows the water to be
absorbed into the cells of the body during the cool of the night when you are not
exerting yourself

2. On rising drink another litre of water. This ensures that water outside of the cells is
available for the body to sweat during work

3. During the day drink frequent sips of water, one sip every 15 minutes, to provide the
body with water for sweating during the day

83
PROVISIONAL DIAGNOSIS OF HEAT EXHAUSTION

HISTORY
a. Exertion in a hot environment
b. May complain of cramps in calf muscles and abdomen

SIGNS
b. Pale, warm and sweaty skin
c. Pulse >100, weak
d. Respirations >20

SYMPTOMS
b. Weakness
c. Headache
d. Nausea

TREATMENT OF HEAT EXHAUSTION

1. Stop casualty exerting themselves and remove to a cool environment
2. Airway, breathing and casualtys perfusion status
3. If conscious, give salt water (of one teaspoon of salt in 1 litre of water) or a sports drink
4. Strip and wash casualty with cool water
5. Cover with wet sheet and fan casualty
6. If casualty unconscious place on side and raise legs above their head
7. Call ambulance

HEAT STROKE

Heat stroke occurs when the casualtys body is no longer able to cope with its rising core temperature,
usually above 41
O
C. At 42
O
C the hypothalamus in the brain fails and the casualtys temperature will
rise even more rapidly. It takes about 15 minutes for the temperature to rise from 41
O
C to 42
O
C. Heat
stroke is a medical emergency and rapid, effective treatment must be implemented if the casualty is to
survive. Heat stroke has a mortality of 10-75%, depending upon the duration of the condition and the
effectiveness of the treatment. With effective treatment 90% of casualties will recover
1
.

The onset of heat stroke is quite sudden and the casualty often appears to be no more affected by the
heat than everyone else, although they have hot dry skin in a very hot or humid environment. They
may also display the Signs and Symptoms of heat exhaustion.

1. Sir Stanley Davidson, Davidsons Principles and Practice of Medicine, 17
th
Edition, Ed by C.R.W. Edwards, I.A.D
Bouchier, C. Haslett and E.R. Chivers, Churchill Livingstone, London, 1995, pp. 53-54.

84
PROVISIONAL DIAGNOSIS OF HEAT STROKE

HISTORY
a. Working in a hot environment
b. May complain of discomfort

SIGNS
b. Hot, flushed, dry skin
c. Pulse >100, strong
d. Respirations >20
e. Fitting

SYMPTOMS
a Altered conscious state
b. Weakness, headache and nausea

TREATMENT OF HEAT STROKE

1. Stop casualty exerting themselves and remove to a cool environment
2. DRABCD
3. Strip casualty of all clothing
4. Cover with a sheet and soak with water
5. Ensure cool air is fanned over casualty
7. Place ice packs around throat, in groin, armpits, on ankles, knees, wrists and elbows
8. Constantly monitor casualtys temperature and immediately stop all cooling when casualty feels
comfortable

COOL ENVIRONMENTS AND COLD EMERGENCIES

Those most at risk from the cold are babies, the elderly, those affected by alcohol and those who are
cold, wet and in the wind. The effects of cold on the human body are insidious and very often the
casualty is unaware any problem

EXPOSURE TO COLD

Cold by itself is usually not a problem unless you are scantily clad, ill, injured, undernourished,
exhausted, elderly or the cold itself is extreme

85
WIND CHILL CHART

Wind Speed Thermometer Reading in Celsius
Mls
Kno
t
s
KP
H
10 4 -1 -7 -12 -18 -23 -29 -34 -40 -46 -51
0 0 0 10 4 -1 -7 -12 -18 -23 -29 -34 -40 -46 -51
E
q
u
i
v
a
l
e
n
t

T
e
m
p
e
r
a
t
u
r
e

i
n

C
e
l
s
i
u
s

2 4 7.2 9 3 -3 -9 -14 -21 -26 -32 -38 -44 -49 -56
5 7 18 4 -2 -9 -20 -23 -29 -36 -43 -50 -57 -64 -71
7 11 25.2 2 -6 -13 -21 -28 -38 -43 -50 -58 -65 -73 -80
10 16 36 0 -8 -16 -23 -32 -39 -47 -55 -63 -71 -79 -87
12 20 43.2 -1 -9 -18 -26 -34 -42 -51 -59 -67 -76 -83 -92
14 24 50.4 -2 -11 -19 -28 -36 -44 -53 -62 -70 -78 -87 -96
17 29 61.2 -3 -12 -20 -29 -37 -45 -55 -63 -72 -81 -89 -98
19 33 68.4 -3 -12 -21 -29 -38 -47 -56 -65 -73 -82 -91 -100
Wind speeds
greater than 30-
50 Knots have
little effect
Little danger of
hypothermia in fit,
well fed, and properly
clothed persons
Increasing danger
of hypothermia
in fit, well fed,
and properly
clothed persons
Great danger of
hypothermia in fit,
well fed, and properly
clothed persons

Chart: 10-1. Wind Chill (After Survival in Antarctica National Science Foundation, USA)

EXPOSURE TO COLD, WIND AND RAIN

Where cold is uncomfortable, cold and wind can be dangerous and cold, wind and rain are lethal, even
for those who are well prepared. The reason for this increased danger is the ability of water to destroy
the insulatory value of your clothing by filling up the air pockets in the clothing and coming into contact
with the warm surface of the skin. Once in contact with the skin surface the water rapidly absorbs
heat and conducts it through the clothing to the exterior where wind strips the heat away.

EXPOSURE TO COLD AND WIND

Where the environmental temperature is low and wind speed is high heat loss from the
body is dramatically increased due to cold air passing through clothing and across the skin
surface. The indication of just how dangerous wind and cold are when combined is shown
by the Siple-Passel Wind-chill formula which was developed by P. Siple and C.F. Passel
from their research in the Antarctic between 1939 and 1940. The formula reads as K
0
= (
V x 100 + 10.45 -V) (133-Ta).

K
0
= cooling power of the atmosphere in kilogram calories of heat removed per hour per
square metre. V =wind velocity is measured in metres per second. Ta = temperature of
air in degrees centigrade. Skin temperature under calm conditions and assuming an
average outgoing radiation plus average convection.
86

The possible problems you face when treating hypothermia are:

a. lowered core temperature and decreasing metabolic function
b. fluid shift and increased urine output leading to dehydration
c. hypoglycaemia and loss of calorific reserve
d. enzyme system dysfunction
e. hypoxia and transfer to anaerobic metabolism
f. metabolic acidosis
g. renal dysfunction
h. increasing loss of neuro-function

TYPES OF ACCIDENTAL HYPOTHERMIA

There are three types of hypothermia
2
: Acute (immersion), Subacute (exhaustion) and Subchronic
(urban) hypothermia.

2
E.L. Lloyd, Accidental Hypothermia, Resuscitation, European Resuscitation Council and Elsevier Science, Ireland Ltd,
1996, p.114.
HYPOTHERMIA

The bodys response to even a slight drop in temperature is to slow the rate of heat loss by
shutting off blood flow to the skin, allowing it to cool so less heat is radiated to the
environment. Extra heat is then generated by muscle activity such as shivering. As the
core temperature falls the body uses these techniques even more and if the core
temperature drops to around 34
0
C the bodys defence mechanisms will begin to fail. If no
action is taken to prevent this heat loss the casualtys conscious state alters and
respiratory depression occurs leading to reduced blood oxygen levels which leads to a
further drop-off in metabolism and heat production. This process rapidly quickens, with the
onset of life threatening cardiac arrhythmias, particularly ventricular tachycardia (VT) and
ventricular fibrillation (VF), develop.

Levels of Hypothermia at
0
C

37.6 Normal rectal temperature
37 Normal oral temperature
36 Increased metabolic activity to counter heat loss
35 Maximum shivering at this temperature
34 Patient usually responsive with normal blood pressure
33 Severe hypothermia
32 Loss of consciousness, dilated pupils
31 Shivering ceases -pulse and blood pressure hard to obtain
30 Becoming more deeply unconscious with increasing muscle rigidity
29 Slow pulse and respiration
28 If heart irritated -cardiac arrhythmias -Cardiac arrest -ventricular Fibrillation
27 Voluntary motion lost including pupillary reflex
26 Patient seldom conscious
25 Spontaneous VF and cardiac arrest
24-21 Maximum risk of cardiac arrest due to VF
20 Cardiac standstill
19-18 Lowest recorded recovery after accidental hypothermia
17 Isoelectric ECG
9 Lowest recorded recovery following medically induced hypothermia
87
ACUTE (IMMERSION) HYPOTHERMIA

This occurs when the cooling of the body is so rapid that heat production is overwhelmed before the
energy reserves of the body are exhausted. The most common causes of this type of hypothermia are
immersion in cold water or where the casualty is subjected to severe cold and their body defences are
disabled through injury or poisoning.

PROVISIONAL DIAGNOSIS OF ACUTE (IMMERSION) HYPOTHERMIA

HISTORY
a. Immersion in cold water

SIGNS
a. Lethargy and slurred speech
b. May have violent shivering fits
c. Respirations 10 per min or less
d. Patients axilla (armpit) or groin is very cold to touch
e. Pale, cyanosed, very cold, marble like skin
f. Hypotension (low pulse pressure)

SYMPTOMS
b. Weakness
c. Headache
d. Nausea

TREATMENT OF ACUTE (IMMERSION) HYPOTHERMIA

1. Rescue casualty ASAP
2. Keep casualty as flat as conditions will allow
3. Aggressively treat airway, breathing and casualtys perfusion status
4. Do not give up on casualty until they are in hospital
5. Limit touching or moving casualty to an absolute minimum
6. Get casualty to a warm, dry environment ASAP
7. Ensure casualty is completely insulated from atmosphere and ground
8. Cut off all clothing
9. Place casualtys hands by their sides and keep them cool
3

10. If possible administer warm and humidified oxygen

SUBACUTE (EXHAUSTION) HYPOTHERMIA

Hypothermia is a dangerous and insidious problem. This can be particularly true when people are
exerting themselves in remote, cold and wet locations. In such conditions hypothermia results from
the lowering of energy levels amongst the group and is not simply a problem for one member of that
group. If one member of a group seems to be hypothermic then you must assume that everyone,
including yourself, is affected. It is vital that as soon as any member of a group shows the effects of
hypothermia no further physical exertion, with the exception of getting shelter, cooking food and
getting people into a dry warm environment, should be risked.

3
E.L. Lloyd, Accidental Hypothermia, Resuscitation, 32 (1996), p. 116 Warm hands and feet reduce the stimulus for heat
production and will allow reduction of vasoconstrictor tone thus increasing heat loss and increasing the risk of vasomotor
collapse.
88
PROVISIONAL DIAGNOSIS OF SUB-ACUTE (EXHAUSTION) HYPOTHERMIA

HISTORY
a. Heavy physical effort in cold, wet and windy environment

SIGNS
a. Slurred speech
b. Aggressive, unreasonable, violent or drunken behaviour
c. May have violent shivering fits
d. Respirations 10 per min or less
e. Patients axilla (armpit) or groin is very cold to touch
f.. Pale, cyanosed, very cold, marble like skin
g. Hypotension (low pulse pressure)

SYMPTOMS
b. Lethargy and weakness
c. Headache
d. Nausea

IMMEDIATE ACTION ON DISCOVERING
EXHAUSTION HYPOTHERMIA IN A GROUP MEMBER
All activity must be concurrent -Do not waste precious energy

1. Stop immediately
2. Get everyone into shelter from wind
3. Immediately insulate casualty, especially the head, from the atmosphere and ground
4. Get tents up and everyone under them
5. Cook warm drinks and a meal -all food in one pot on one fire
6. Get group into sleeping bags
7. Eat meal and sleep until group recovers
8. Do not try to walk for help, no matter how close it may be

The fundamental rule is to prevent hypothermia at all costs and always treat the group

TREATMENT OF A SEVERELY HYPOTHERMIC CASUALTY

1. Immediately treat whole group as above
2. Get casualty out of wind and rain
3. Immediately insulate casualty, especially the head, from the atmosphere and ground using
vegetation, clothing, sleeping bag and other material
4. Keep hands and feet cool
5. Get casualty a warm, sweet drink ASAP
6. Handle casualty as little as possible and avoid rough handling
7. Get casualty to eat a meal and sleep
8. If there is no airway problem get casualty to inhale warm, moist air from near own body or use
a heat and moisture exchanger
9. Perform CPR only as a last resort and only for as long as the safety of others permits

STRIPPING THE CASUALTY AND PUTTING A RESCUER INSIDE THE SLEEPING BAG
This technique has a number of major flaws:

1. It requires the casualty be stripped and this may induce cardiac arrest through the need to
roughly handle the casualty, especially if they are unconscious
2. Most sleeping bags will not take two bodies
3. No rescue party can carry two people
4. Surface warming of a severely hypothermic casualty may kill the casualty
5. The group cannot afford the energy required
89
6. Because warming the casualty requires the transfer of energy from the other group members
and because you do not know the energy reserves of the individual group members you
cannot leave one person with the casualty for too long. Thus you have to rotate the entire
group through the casualtys sleeping bag leading to dangerous movement and loss of rest to
all members of the group.
7. You cannot risk leaving one or two individuals to re-warm the casualty as they may also be quite
badly affected themselves and the extra heat loss involved in re-warming the casualty will place
them at serious risk. For these reasons stripping off to warm a hypothermic casualty should be
regarded as rescue fantasy.

ON CPR

If you are unfortunate enough to be a member of a group where a casualty appears to have suffered a
cardiac arrest from the cold, unless professional help arrives quickly, the casualty will die. A group of
cold and tired people cannot perform effective CPR and to make the attempt risks the safety of the
other group members who may be seriously ill themselves.

SUBCHRONIC (URBAN) HYPOTHERMIA

This type of hypothermia occurs where the casualty has been exposed to moderate cold over a
prolonged period, usually days. Those most commonly affected are the elderly, young children, or
those who are ill or malnourished.

A major physiological problem faced by these casualties is very large fluid shifts and when the
casualty is warmed they suffer severe pulmonary oedema. Active warming outside of an intensive
care unit or without intermittent positive pressure ventilation will result in death (100% mortality)
4
.

PROVISIONAL DIAGNOSIS OF SUB-CHRONIC (URBAN) HYPOTHERMIA

HISTORY
a. Elderly, young, ill or malnourished person living in cold environment

SIGNS
a. Aggressive, unreasonable, violent or drunken behaviour
b. May have violent shivering fits
c. Respirations 10 per min or less
d. Patients axilla (armpit) or groin is very cold to touch
e. Pale, cyanosed, very cold, marble like skin
f. Hypotension (low pulse pressure)

SYMPTOMS
a. Altered level of consciousness
b. Lethargy and weakness
c. Headache
d. Nausea

TREATMENT OF SUB-CHRONIC (URBAN) HYPOTHERMIA

1. Maintain Airway, Breathing and casualtys perfusion status
2. Insulate casualty, especially the head, from the atmosphere and ground
3. Get casualty a warm, sweet drink ASAP
4. Handle casualty as little as possible and avoid rough handling
5. Call ambulance
6. If there is no airway problem get casualty to inhale warm, moist air from near own body or use
a heat and moisture exchanger
7. Warm the casualty very slowly, at a rate of less than 0.5C per hour

E.L. Lloyd, Accidental Hypothermia, Resuscitation, 32 (1996), p.115.
90
FROSTBITE

Like burns, frostbite is either superficial or deep. Frostbite occurs at the bodys extremities, such as
the toes and fingers, and exposed skin, particularly the nose, cheeks and ears.

PROVISIONAL DIAGNOSIS OF FROSTBITE

HISTORY
a. Very cold environment
b. Limited clothing over the part
c. Tight bootlaces, wrist watch or clothing ties

SIGNS
a. Grey, mottled or white wax like skin on part

SYMPTOMS
a. Pins and needles and Stiffness
b. Pain

TREATMENT OF SUPERFICIAL FROSTBITE

1. Treat for hypothermia
2. If face or ears are affected remove glove and cover affected part until warm and normal colour
returns
3. If fingers or toes
-remove wet gloves or socks
-place fingers in groin or armpits until warm and colour returns
-cover toes with hands until colour returns
-replace wet gloves and socks with dry
-ensure laces and straps are not too tight

TREATMENT OF DEEP FROSTBITE

1. Treat hypothermia
2. Gently remove clothing from affected area
3. Remove all constrictions from limbs
4. Do not re-warm in field unless you can guarantee part will not re-freeze
-if part re-freezes then gangrene will develop
-re-warming is extremely painful
5. If unable to send casualty to hospital and risk of re-freezing is small rapidly warm the part for
20-30 minutes in water with temperature of 41- 45
0
C
6. Cover area with dry, sterile dressing
7. Do not allow casualty to smoke as nicotine reduces the blood flow to extremities

91
CHAPTER 15

PROBLEMS IN PREGNANCY AND CHILDBIRTH

This chapter is divided into two; firstly, the provision of care to a pregnant woman; and secondly, the
delivery of a baby in an uncontrolled environment.

First aid care for the pregnant woman suffering a specific illness or injury is similar to the care
provided to a non pregnant person suffering the same illness or injury. However, consideration has to
be given to the impact of a specific treatment on the baby and the mother. Thus pregnant women are
always put on their left side so that the baby is off their Inferior Vena Cava and blood return to the
heart is not compromised.

Where the casualty is seriously injured or ill the risk to the baby can be extreme and there is little that
you can do other than basic life saving treatment and get help as soon as possible.

CARE OF THE PREGNANT WOMAN

MINOR DISORDERS

During pregnancy a number of minor disorders may arise. These disorders are usually annoying or
uncomfortable and do not place the mother or baby at risk. However, they need to be assessed and
managed by the mothers medical practitioner to ensure that they are not an early warning of more
serious problems. The disorders that fall into this group are morning sickness, heart burn,
constipation, backache, varicose veins, haemorrhoids, inflammation of the leg veins, nose bleeds,
peripheral oedema, muscle cramps, fainting, tiredness, itching and increased frequency of urination.

Most of these problems can be well managed by the mother in consultation with their own medical
practitioner. Where first aid treatment of a condition, such as nose bleeds or fainting, is required you
simply follow the procedures for that condition set out in this book.

MAJOR DISORDERS

BLEEDING IN EARLY PREGNANCY

Vaginal bleeding is an important sign at any stage of pregnancy and must be investigated by the
mothers medical practitioner. Such bleeding may be a sign of a serious complication which could
endanger the mother or foetus. Therefore any pregnant woman who experiences vaginal bleeding
should be taken to her own medical practitioner or to hospital.

ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage is defined as bleeding from the vagina after the 20
th
week of pregnancy and
before the birth of the baby. This type of bleeding is very serious and is a major cause of death of
mothers and babies.

The causes of antepartum haemorrhage are the premature separation of the placenta from the uterine
wall (Placental Abruption), the implantation of the placenta over the cervical opening (Placenta
praevia) or tearing of the uterus itself. The exact cause of the bleeding is unimportant to you but you
must recognise the danger to the mother and her baby.

92
PROVISIONAL DIAGNOSIS OF ANTEPARTUM HAEMORRHAGE

HISTORY
a. Patient is pregnant
b. Unexplained vaginal haemorrhage

SIGNS
a. Poor perfusion
b. Vaginal bleeding
c. Possible guarding and rigidity of abdominal wall

SYMPTOMS
a. Severe lower abdominal pain
b. Weakness

TREATMENT OF ANTEPARTUM HAEMORRHAGE

2. Apply Dressing/pad to vagina
3. Place casualty on left side with knees drawn up
5. Observe casualty and treat poor perfusion
6. Do not palpate abdomen

ECTOPIC PREGNANCY

Ectopic pregnancy is where the foetus and placenta are implanted outside of the uterus, either in a
fallopian tube (Common-97%) or in the abdominal cavity (Rare-1% of cases)
1
. Tearing of the
Fallopian tube may occur leading to severe internal haemorrhage and the rapid death of the mother.

PROVISIONAL DIAGNOSIS OF ECTOPIC PREGNANCY

HISTORY
a. Patient may or may not be aware of being pregnant
b. Unexplained vaginal haemorrhage

SIGNS
a. Extremely rapid onset of profound poor perfusion
b. Vaginal bleeding
c. Guarding and rigidity of abdominal wall

SYMPTOMS
a. Severe lower abdominal pain

TREATMENT OF ECTOPIC PREGNANCY

2. Apply Dressing/pad to vagina
3. Place casualty on left side with knees drawn up
5. Observe casualty and treat poor perfusion

1. N.A. Beischer and E.V. Mackay, Care of the Pregnant Woman and Her Baby, W.B. Saunders, Artarmon, NSW, 1978,
p.80.
93
PRE-ECLAMPSIA

Pre-eclampsia is the first stage in the disease process that leads to eclampsia. The causes of
eclampsia are unknown but it is suspected that the substances produced by the placenta cause a
chemical imbalance in the tissues of the body. These changes lead to circulatory and kidney
problems in the casualty leading to increased fluid retention and high blood pressure. Any pregnant
women suffering from excessive fluid retention, swelling of body tissues and/or high blood pressure
must consult their medical practitioner

ECLAMPSIA

Eclampsia is the end stage of the process and is a threat to the life of the mother and her baby. In fact
eclampsia is one of the major causes of maternal death in western countries. The major aim of
treatment is to identify pre-eclampsia and get the casualty to hospital

PROVISIONAL DIAGNOSIS OF ECLAMPSIA

HISTORY
a. Patient is pregnant
b. Discomfort, swollen tissue, headaches

SIGNS
a. Headaches
b. Pulse greater than 100
c. Swelling of face and hands due to fluid retention
d. Pale, cool, clammy skin
e. Fitting and convulsions

SYMPTOMS
a. Abdominal pain
b. Visual disturbances

TREATMENT OF ECLAMPSIA

1. Prevent fitting by ensuring a calm, quiet and dark environment
2. Lie casualty down on left side
4. Maintain airway, breathing and casualtys perfusion status if required
5. Observe casualty and gently reassure

THE NORMAL DELIVERY

There are three stages of labour called, oddly enough, the First, Second and Third Stages of labour.

FIRST STAGE OF LABOUR

This stage begins with the onset of regular contractions and pains which come at about 5 to 15 minute
intervals. These contractions serve to position the baby for delivery and prepare the cervical opening
for the delivery of the baby. It is usually at the end of this first stage that the mothers waters break.

94
SECOND STAGE OF LABOUR

This is where the babys head enters the birth canal. This stage is marked by the mothers
contractions and pain becoming more frequent, with one every 2 to 3 minutes apart. At this stage the
mothers cervix fully dilates and the baby begins to press on her rectum making her feel as if she
wants to pass a bowel motion. Following this the babys head (usually and hopefully) appears at the
vaginal opening and the stage finishes when the baby is fully delivered.

THIRD STAGE OF LABOUR

This stage begins following the delivery of the baby and ends following the expulsion of the placenta
from the uterus.

DELIVERY

When presented with a pregnant women who believes that she is about to deliver you need to know
two things; one, am I going to have to deliver the baby, and if so; two, what possible complications will
I face? If this is the mothers first baby then the chances are that you will not need to deliver the baby.
If it is her second child then the delivery may be very fast indeed.

PROVISIONAL DIAGNOSIS OF RAPID DELIVERY

HISTORY
a. Mother has had other child born vaginally
b. May have had weak contractions for an hour or so

SIGNS
a. Regular contractions with a gradually decreasing interval between
Contractions and an increasing intensity
b. Contractions now less than 2 minutes apart
c. Baby is seen at vaginal opening

SYMPTOMS
a. Mother desires to use bowel

ASSESSMENT OF POSSIBLE COMPLICATIONS

HISTORY
a. Mother is under medical supervision for a specific problem, or
b. Mother has had no prenatal care
c. Baby is not due and would be premature if born now
d. Mother has had previous caesarean section
e. Mother has had problems with past pregnancies

SIGNS
a. Any Signs of pre-eclampsia
b. Any Signs of poor perfusion

SYMPTOMS

95
DELIVERY

1. Wash your hands
2. Clean area, if there is time
4. Prepare environment and mother
-ensure mother is warm
-obtain warm towels and linen to wrap baby
5. Have mother remove clothing
6. Position mother on her back, slightly sitting up with legs apart and knees bent
7. Obtain warm water and cloth
8. Position yourself so you can observe vaginal opening
9. When babys head appears at vaginal opening place your hand on the top of the head and
apply gentle pressure to prevent it popping out and splitting the vagina
10. As the babys head emerges support it with your hands and ensure that membranes are
removed from face so baby can breath
11. Ensure that umbilical cord is clear of babys neck
12. If umbilical cord is around babys neck
-try and ease it over head
-if cord too tight
-tie or clamp cord very firmly in three places 10cm, 15cm and 20cm from the babys
navel
-cut the cord between the second and third ties from the babys navel
13. Clear babys airway
14. Guide babys head down to allow delivery of upper shoulder
15. Guide babys head upward to deliver the other shoulder
16. Support baby as the trunk and legs are delivered
17. Do not pull on umbilical cord
18. Clear airway carefully
19. If umbilical cord has not already been cut
-tie or clamp cord very firmly in three places 10cm, 15cm and 20cm from the babys
navel
-cut the cord between the second and third ties from babys navel
20. Dry and wrap baby in warmed towels etc
21. Give baby to mother

PREPARE FOR DELIVERY OF PLACENTA (THIRD STAGE OF LABOUR)

1. Gently massage the uterus to assist with contractions and have mother breast feed the baby
2. When placenta is delivered place it in a container and examine it thoroughly to ensure it is
intact and not torn
3. Clean up and place pad over mothers vagina

96
BREECH DELIVERY

1. Prepare as for normal delivery
2. When baby appears at vaginal opening allow the presenting part to be born normally without
interference
3. As the babys legs and lower trunk emerge support it with your hands and guide them
downward to allow the babys head to pass through the pelvic outlet
4. When the babys hair line appears grasp the babys ankles and lift the baby up in the direction
of the mothers abdomen
5. If the babys head does not deliver and three minutes have passed you must clear the babys
airway as follows:
6. Continue to hold the baby up by the ankles
7. Form a V with your fingers and push them palm upwards into the mothers vagina either side of
the babys nose
8. Push the vaginal wall clear of the babys face and maintain this until baby delivers of its own
accord or help arrives
9. If head delivers then clear babys airway
10. Once baby is delivered treat as normal delivery

PROLAPSED CORD

A prolapsed cord is where the umbilical cord drops into the birth canal ahead of the baby and is
compressed by the baby as it delivers. Prolapsed cord is a serious and life threatening condition and
must be treated quickly

TREATMENT OF PROLAPSED CORD

1. Carry out delivery protocol
2. With presentation of cord
3. Position mother on her back with her hips well raised
4. Instruct mother to pant and not bear down
5. If possible gently push baby back off cord
6. Cover cord with a sterile, saline dressing

POSTPARTUM HAEMORRHAGE

During the third stage of labour it is normal for there to be about 150ml of blood lost. However, if the
blood loss is excessive or seems to be continuing then you need to treat the casualty for internal
haemorrhage and get an ambulance quickly.

TREATMENT OF POSTPARTUM HAEMORRHAGE

1. Gently massage the uterus to assist with contractions
2. Have mother breast feed the baby
3. When placenta is delivered place it in a container and examine it thoroughly to ensure it is intact
and not torn
4. If bleeding continues place pad over vagina
5. Elevate casualtys legs
6. take observations
7. Call ambulance and inform them of situation

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CARE OF THE BABY

Once the baby is born you have two people to care for. It will only be natural that the mother will want
to nurse her baby and take care of it and you should encourage this. However, you should carry out
an assessment of the babys condition using the APGAR Score at one and five minutes after birth

The Apgar Score assesses the babys condition by measuring skin colour, respiration, heart rate,
muscle tone, and reflex irritability.

Using the Apgar Score the highest number a baby can get is 10 and the lowest 0. The treatment is as
follows:

TREATMENT OF APGAR SCORE OF 8 TO 10

1. Clear babys airway of mucus or meconium fluid
2. Dry baby and wrap in warm towels etc
3. Get ambulance if necessary


2. Mouth to mouth and nose Respiration
3. Alert/Get ambulance immediately


2. CPR
3. Alert/Get ambulance immediately

APGAR SCORE

SCORE 0 1 2

COLOUR Blue or pale Completely pink
Pink but extremities blue

RESPIRATION Absent Slow, irregular Good or Crying

HEART RATE Absent Below 100 Above 100

MUSCLE TONE Limp Some flexion Active motion
of extremities

REFLEX Nil Grimace Vigorous cry,
IRRITABILITY cough, sneeze
95
GLOSSARY OF TERMS

Abdomen - The belly. The cavity between the diaphragm and the pelvis.

Abdominal Aortic Aneurysm - Is a weakness in the wall of the aorta in the abdominal cavity
causing a ballooning out of the blood vessel.

Accessory Muscles of Respiration - The muscles of the arms, shoulders and chest used to increase the
depth of breathing.

Acute Myocardial Infarction - Sudden death of the heart muscle.

Acute Pulmonary Oedema - Is the build up of fluid in the lungs due to the failure of the left side of
the heart.

Alveoli - Air sac in the lungs through which oxygen crosses.

Angina Pectoris - Chest pain due to a reduced of blood supply to the heart muscle.

Aorta - Largest artery in body leading from the heart to all body organs
except the lungs.

Artery - Blood vessel which carries blood away from heart.

Asphyxia - No breathing.

Asthma - Medical condition where the size of the airways is reduced due to
muscle contraction, inflammation and mucus plugging.

Asystole - Cardiac arrest where there is no electrical activity in the heart.

Atria - The upper two chambers of the heart.

Avulsion - Traumatic amputation where a part of the body is torn off.

Breech Delivery - The birth of the foetus which occurs buttocks or feet first.

Bronchi - Air tubes in the lungs.

Bronchitis - Inflammation of the bronchi.

Capillary - Smallest of the blood vessels with a wall one cell thick.

Cardiac - Pertaining to the heart.

Cardiac Arrest - The heart does not contract effectively or produce a pulse.

Carotid Pulse- Pulse found between the windpipe and the muscles of the neck.

Cell - The basic building block of the body.

Cerebro Vascular Accident - CVA (stroke). The damage suffered when there is a sudden
interruption in the blood supply to the brain

Chronic Obstructive Airways Disease - A collection of diseases where damage occurs to the airways of the
lung and the air sacs themselves.

Closed Fracture - A broken bone where there are no other injuries and where there is
no wound leading down to the ends of the broken bone.

Complicated Fracture - A broken bone where damage occurs to other organs.

Compression bandage - Bandage used to tie dressings to wounds or to splint a broken bone.

Compression of the Brain - Bleeding within the skull which exerts pressure on the brain.
96
Concussion - Brain injury where small spaces are opened up between the brain
cells.

Constrictive bandage - A very tight bandage used to stop very severe bleeding where all
else fails.

Contusion - Bruising and tearing of tissue.

Contusion of the Brain - Bruising and tearing of the brain tissue.

Croup - Condition affecting children and which blocks the airway through
swelling of the upper airway.

Diabetes - Disease process where the body is unable to produce sufficient
insulin to metabolise sugar.

Dislocation - Where the ends of bones are pulled apart.

Diuretic - An agent that promotes the excretion of urine.

Eclampsia - a form of toxemia of pregnancy.

Ectopic Pregnancy - Pregnancy occurring elsewhere than in the cavity of the uterus.

Emphysema - A chronic, irreversible disease of the lungs characterized by
abnormal enlargement of air spaces in the lungs accompanied by
the destruction of the tissue lining the walls of the air spaces.

Epiglottitis - Severe inflammation of the eppiglottis due to infection. Life
threatening especially in young children and babies.

Epileptic Convulsions - A convulsive fit caused by epilepsy.

Eviceration - The exposing or removal of organs through wounds in the body.

Exhaustion Hypothermia - Hypothermia due to over-exertion in a cold environment.

Femur - Thigh bone.

Flail Segment - A rib or ribs broken in two places.

Fracture - A break in the continuity of a bone.

Frostbite - Injury to any part of the body after excessive exposure to extreme
cold, sometimes progressing from initial redness and tingling to
gangrene.

Frusemide - An oral diuretic with a rapid and powerful action,

Glasgow Coma Scale - A system of measuring the conscious state.

Grand Mal - A general convulsive epileptic fit.

Haemorrhage - Bleeding.

Haemothorax - Bleeding in the chest cavity.

Humerus - Bone of the upper arm.

Hyperglycaemia - High blood sugar.

Hyperthemia - High body temperature.

Hyperventilation - Rapid, deep breathing.

Hypoglycaemia - Low blood sugar.

97
Hypothermia - Low body temperature.

Immersion Hypothermia - Hypothermia due to immersion in water.

Infantile Convulsion - Fitting caused by high body temperature in a child under 8 years.

Inflammation - Redness, swelling, pain, tenderness, heat, and disturbed function of
an area of the body.

Intestines - The portion of the alimentary canal extending from the stomach to
the anus and, in humans and other mammals, consisting of two
segments, the small intestine and the large intestine.

Ischaemic - Lack of blood.

Joint - Where the bones join together.

Nasopharynx - The throat immediately behind the nose.

Normal Sinus Rhythm - Is a term used in medicine to describe the normal beating of the
heart, as measured by an electrocardiogram (ECG).

Open Fracture - A broken bone where the broken ends are exposed to the air.

Oropharynx The throat immediately behind the mouth.

Pancreas - A gland, situated near the stomach, that secretes a digestive fluid
into the intestine through one or more ducts and also secretes the
hormone insulin.

Pattern of Injury - The way in which injuries occur in accidents.

Pelvis - The bones of the lower abdomen and hips.

Perfusion - The ability of the heart and circulatory system to supply the cells
with oxygen, food and water and to remove waste products from
them.

Petite Mal - A minor epileptic fit.

Pharynx - The throat.

Pleurisy - Inflammation of the pleura lining the lungs and inner chest wall.

Pneumothorax - Air leaking into the chest cavity.

Poor Perfusion - Where the patient is shocked because of inadequate perfusion.

Postpartum Haemorrhage - Where blood loss is excessive or seems to be continuing after birth.

Potassium - An alkaline substance the salts of which are largely used in
medicine to reduce blood vessel damages related to aging. It also
promotes efficient heart functions and strengthens the arteries.

Pre-Eclampsia - Is the first stage in the disease process that leads to eclampsia.

Prolapsed Cord - A prolapsed cord is where the umbilical cord drops into the birth
canal ahead of the baby and is compressed by the baby as it
delivers.

Pulmonary - Of or pertaining to the lungs.

Pulmonary Embolism - Blockage of the pulmonary artery by foreign matter or by a blood
clot.

Pulmonary Oedema - Water leaking from the capillaries into the air sacs of the lungs.

98
Radial Pulse - A pulse in the wrist found directly over the radius bone.

Radius - The bone in the lower arm nearest to the thumb.

Respiratory Arrest - No breathing.

Respiratory Distress - Poor perfusion with cyanosed skin and the use of the accessory
muscles of respiration.

Scalds - To burn with or as if with hot liquid or steam.

Skull - The bones which contain the brain.

Sprain - The over-stretching or tearing of a tendon in a joint.

Status Asthmaticus - Is a prolonged asthmatic attack that is not responding to treatment
whereby the casualty becomes progressively worse until they loose
consciousness and die.

Status Epiltpticus - An epileptic fit which continues for longer than two minutes or where
a series of fits is seen.

Sternum - A long, flat bone located in the centre of the chest, serving as a
support for the collarbone and ribs. Also called breastbone.

Strain - The over-stretching or tearing of a muscle.

Stroke - Damage to the brain caused by spontaneous bleeding or the
blockage of an artery.

Toxemia - Blood poisoning resulting from the presence of toxins in the blood.

Tracheae - Windpipe.

Transient Iscahaemic Attack - A short, stroke like attack.

Triage - A process for sorting injured people into groups based on their need
for or likely benefit from immediate medical treatment.

Ulna - Bone in lower arm on little finger side.

Urban Hypothermia - Low body temperature caused by living in very cold environment
without adequate heating or food.

Vein - One of the systems of branching vessels or tubes conveying blood
from various parts of the body to the heart.

Ventricles - The lower two chambers of the heart.

Ventricullar Fibrillation - The chaotic contraction of heart muscles which produces no pulse.

Ventricular Tachycardia - Heart rate over 100 which is caused by an electrical impulse
originating in the ventricles of the heart.

Vertebrae - Bones of the spine.

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