What is First Aid?

The answer to this question is not as easy as it seems.

"First aid" is a catch-all phrase that refers to two
distinctly different medical needs.

•Emergency first aid is exactly that - the first

response to a life-threatening (or limb-threatening)
medical emergency, either an illness or an injury.
More advanced medical care will happen after first
aid in this case. This type of first aid includes CPR,
clearing an airway, obstruction responding
to anaphylactic shock, splinting a broken bone, and
severe bleeding control

• Non-emergency first aid is the treatment we

initiate ourselves for minor medical needs. We may
or may not seek more advanced medical care after
the initial response. This includes taking over-the-
counter medications minor and allergies
for, cleaning and bandaging cuts or abrasions, and
minor bleeding control.

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Training for each is unique. Emergency first aid
classes are taught by organizations like the American
Red Cross, National Safety Council, and American
Heart Association. There are very few classes for non-
emergency first aid. It's the kind of thing we learn from
mom or the internet.

THINGS TO HAVE IN A FIRST AID KIT

- Day Pack / Weekend Pack
- Whistle: If lost or unable to ambulate due to a broken
ankle or leg, one cannot yell long enough or loud enough to
alert others that you need help, especially if the wind is
not in your favor. A whistle can be used. It is very loud
and carries very, very well. It is recognizably a common
sound for help.
- Metal match: A fantastic tool to start a fire, even in a
light rain. A cotton ball saturated with Vaseline® is great
tinder for starting a fire with a metal match.
- Knife: You do not need a knife with a blade larger than a
3”. It is just not necessary, and will increase your chances
of cutting yourself.
- Duct tape: Multiple uses.
- Bandages, gauze: For lacerations and abrasions.
- Plastic Ziploc® bags: To hold your items and medications.
These plastic bags can be used as irrigation devices for
wounds. You can carry water in them. They can be used as
a nonstick dressing. For irrigation, they can be filled with

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 water. Poke a very tiny hole in one corner and squeeze like
you are decorating a cake, an excellent device for
irrigating out wounds.
- Safety pins: Safety pins can be used to attach the
sleeves of your shirt to the chest area of your shirt,
creating a makeshift sling. This is just one example for
this multi-purpose item.
- Toilet tissue and
Kleenex®: Obviously you would
place these items in a Ziploc®
bag to keep them dry.
- Ace® bandage or wrap: Also
excellent and have many uses, for
pressure dressing bandages and for sprains to mention a
couple.

- Over-the-counter medication

1. Ibuprofen: You can take up to 4 tablets, which is 800 mg.

of Ibuprofen for pain, every 8 hours with food. Please be
advised of allergies to medication one might have.
Ibuprofen can trigger asthma attacks in asthmatics. Be
aware of this.
2. Acetaminophen: You can take 2 tablets every 4-6 hours
for pain. It is very safe to take 3 Ibuprofen and 2 Tylenol
every 8 hours at the exact time for moderate to severe
pain, especially in the outdoors. This works very well as a
moderate analgesic.
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3. Imodium AD®.
4. Diphenhydramine (Benadryl®). Wound use (although not
recommended): Take liquid Diphenhydramine, soak a 4 x 4
gauze and apply to the wound. It does have a very mild
analgesic affect, and will stop some pain. Again,
Diphenhydramine has not been approved or recommended
for this use, but it will not cause harm to you and it does
work.
5. Rolaids® or Tums®.
6. Afrin® nasal spray (Side note: Afrin nasal spray can be
used on wounds to help stop bleeding. This works very
well.)
7. Sun block.
8. Lip balm (for chapped lips). Lip balm can also be used as a
fire starter by saturating cotton material. It is a great
fire starter because it contains Vaseline® (petroleum).
9. ASA (aspirin). I usually take four 81-mg. tablets, chewable

preferably, and wrap in aluminum foil so they stay dry. I

usually double wrap them by wrapping in cellophane and
then aluminum foil to keep watertight. Recommended use:
In sudden onset chest pain, if one is concerned about
possible myocardial infarction (heart attack), the first
line of treatment is for 81 mg. tablets of aspirin. This
should always be carried in your pack if someone in your
party has history of cardiac or has experienced chest pain
in the past.

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 - Medical kit for 7-days or Longer

• Know how to use what you carry.

• Replenish outdated medication.
• Practice. People rarely practice techniques such as
starting a fire with metal matches, splinting, etc.
• Container. Holds the contents of your medical kit. Your
container should be a well-recognized, bright colored bag,
easy to see amongst your other supplies. It must be
waterproof. For the purpose of this website, the medical
kit we will outline will be for non-medical individuals.

Medical Kit Contents:

1. All purpose scissors, able to cut cloth, including denim,

duck tape, gauze of various sizes.
2. Medi-rip® (Medi-rip® is a self-adherent) bandage.
3. Splints, preferably a SAM® splint.
4. Ace® wrap.
5. Topical antibiotic (make sure no Neomycin®;
approximately 10-12% of the population is allergic to
Neomycin, and causes local redness, and itching.)
6. Topical steroid cream, great for bites and rashes.
7. Gloves.
8. Oral rehydration salts.
9. Water purifier, either through filtration or tablets.
10. Cotton-tipped applicator/Q-tips®, great for everting
eyelids, looking for foreign bodies.
11. Forceps.
12. Superglue (Krazy glue®).

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 13. Vaseline® or petroleum jelly.
14. Paper tape.
15. Sterile dressings.
16. Lip balm.
17. Sun block.
18. Non-adherent dressings, Telfa®.
19. Steri-strips.

Dental Kit:

1. Floss.
2. Cavit® filling material. I have
used this product on a couple of
occasions and it has not worked
very well; however, it is this
author’s experience that use of
this product is better than having nothing at all.
3. Oil of Cloves for pain relief.
4. Zinc oxide.

Medications:

1. Imodium AD®.
2. Diphenhydramine (Benadryl®).
3. Afrin® nasal spray.
4. Rolaids® or Tums®, antacids.
5. Ibuprofen and Acetaminophen.
6. Meclizine, over-the-counter for motion sickness.
7. *Pepto Bismol® (*Watch for aspirin allergies. Pepto
Bismol® does have aspirin in it).

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 8. Antibiotic cream.
9. H2 Blockers like Pepcid®.
10. Milk of Magnesia®.
11. Metamucil®.
12. Deet or Picaridin, which is a new product the
manufacturer Cutter is using which works well and does
not have the odor or toxicity of Deet.
13. Antihistamine eye drops.
14. Baby wipes and toilet paper are a must.
15. Tampons for their obvious gynecological use.
However, they may also be used for nosebleeds.

IN THE FOLLOWING PAGES WE WILL DISCUSS ABOUT

FIRST AID FOR THE FOLLOWING:

 Wounds.

 Poisons.

 Animal and insect bites.

 Choking.

 Bone fracture.

 Sprain

 Muscle cramps.
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 WOUNDS
In medicine, a wound is a type of injury in
which skin is torn, cut or punctured (an open wound),
or where blunt force trauma causes a
contusion (a closed wound). In pathology, it
specifically refers to a sharp injury which damages
the dermis of the skin.

CLASSIFICATION OF WOUNDS

An open wound

A laceration to the leg

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Open wounds can be classified according to the object
that caused the wound. The types of open wound are:

 Incisions or incised wounds, caused by a clean,

sharp-edged object such as a knife, a razor or a glass
splinter.
 Lacerations, irregular tear-like wounds caused by

some blunt trauma. The term laceration is commonly

misused in reference to incisions.
 Abrasions (grazes), superficial wounds in which the

topmost layer of the skin (the epidermis) is scraped off.

Abrasions are often caused by a sliding fall onto a
rough surface.
 Puncture wounds, caused by an object puncturing

the skin, such as a nail or needle.

 Penetration wounds, caused by an object such as a

knife entering and coming out from the skin .

 Gunshot wounds, caused by a bullet or similar

projectile driving into or through the body. There may

be two wounds, one at the site of entry and one at the
site of exit, such is generally known as a through-and-
through.

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Closed wounds have fewer categories, but are just as
dangerous as open wounds. The types of closed wounds
are:
 Contusions, more commonly known as bruises,
caused by a blunt force trauma that
damages tissue under the skin.
 Hematomas, also called a blood tumor, caused by

damage to a blood vessel that in turn causes blood to

collect under the skin.
 Crush injury, caused by a great or extreme amount

of force applied over a long period of time.

 Chronic and Acute Acute or traumatic wounds are

the result of injuries that disrupt the tissue. Chronic

wounds are those that are caused by a relatively slow
process that leads to tissue damage. Chronic wounds
include pressure, venous, and diabetic ulcers.
Typically, an insufficiency in the circulation or other
systemic support of the tissue causes it to fail and
disintegrate. Infection then takes hold of the site and
becomes a chronic abscess. Once the infection hits a
critical point, it can spread locally or become systemic
(sepsis).

Anyone can develop a wound or infection. There are

however some people who may have poor healing
abilities like the elderly because of declining immune
system. Individuals who aremalnourished or who do not
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eat right foods and lack vitamins, nutrients or have protein
deficiency are at risk too. Those who are chronically ill,
bedridden or non ambulatory also have high risk factors
as well as people who have undergone prolonged
corticosteroid use or have been administered a
potent immunosuppressive drug. Radiation
therapy patients as well as diabetics, the obese and those
that have had a stroke or some sort of peripheral vascular
disease are also more likely to develop some sort of
wound infection.

MANAGEMENT OR TREATMENT

Wound, sewn with four stiches

The treatment depends on the type, cause, and depth of
the wound as well as whether other structure beyond the
skin are involved. Treatment of recent lacerations
involves examination, cleaning, and closing the wound. If
the laceration occurred some time ago it may be allowed
to heal by secondary intention due to the high rate of
infection with immediate closure. Minor wounds like
bruises will heal on their own with skin discoloration
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usually disappears in 1-2 weeks. Abrasions which are
wounds with intact skin usually require no active
treatment except keeping the area clean with soap and
water. Puncture wounds may be prone to infection
depending on the depth of penetration. The entry of
puncture wound is left open to allow for bacteria or debris
to be removed from inside.

Cleaning
For simple lacerations cleaning can be accomplished
using a number of different solutions including tap
water, sterile saline solution, or antiseptic solution.
Infection rates may be lower with the use of tap water in
regions were water quality is high.[1] Evidence for the
effectiveness of any cleaning of simple wound however is
limited.[1]

Closure
Lacerations caused by a knife or a sharp object need to
be thoroughly cleaned and the edges trimmed. If the
wounds are fresh and less than 12 hours old, they can be
closed with sutures or staples. Any wound which is more
than 24 hours old should be suspected to be
contaminated and not closed completely. Only the deeper
tissues can be approximated and the skin should be left
open. If closure of a wound is decided upon a number of
techniques can be used. These include bandages, a
Cyanoacrylate glue, staples, and sutures. Absorbable
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sutures have the benefit over non absorbable sutures of
not requiring removal. They are often preferred in
children.[2]

Dressings
The effectiveness of silver containing dressings and
creams to prevent infection or improve healing is not
currently supported by evidence.[3]

Antibiotics
Most clean open wounds do not require
any antibiotics unless the wound is contaminated or
the bacterial cultures are positive. Excess use of
antibiotics only leads to resistance and side effects. All
open wounds should be cleaned at least twice a day with
warm water and soap. Once the wound is cleaned, it
should be covered with moist gauze. This should be
followed by application of dry gauze and then the wound
covered with a bandage. The purpose of a wet to dry
dressing is the following- when the wound is opened, the
wet dressing will not stick to the wound and thus will be
less painful to remove. This wet to dry method of wound
treatment works in the majority of wounds, irrespective of
where the wound is located or its size.
When the wound is clean, it may be close with a skin
graft. No wound is ever closed if it is suspected to be
infected

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POISONS
Overview
• Poisons are substances that cause injury, illness
or death
• These events are caused by a chemical activity
in the cells
• Poisons can be injected, inhaled or swallowed
• Poisoning should be suspected if a person is sick
for unknown reason
• Poor ventilation can aggravate Inhalation
poisoning
• First aid is critical in saving the life of victims
Causes
• Medications
• Drug overdose
• Occupational exposure
• Cleaning detergents/paints
• Carbon mono oxide gas from furnace, heaters
• Insecticides
• Certain cosmetics
• Certain household plants, animals
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 • Food poisoning (Botulism)
Symptoms
• Blue lips
• Skin rashes
• Difficulty in breathing
• Diarrhea
• Vomiting/Nausea
• Fever
• Head ache
• Giddiness/drowsiness
• Double vision
• Abdominal/chest pain
• Palpitations/Irritability
• Loss of appetite/bladder control
• Numbness
• Muscle twitching
• Seizures
• Weakness
• Loss of consciousness
Treatment
• Seek immediate medical help
Meanwhile,
• Try and identify the poison if possible

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 • Check for signs like burns around mouth,
breathing difficulty or vomiting
• Induce vomiting if poison swallowed
• In case of convulsions, protect the person
from self injury
• If the vomit falls on the skin, wash it
thoroughly
• Position the victim on the left till medical help
arrives
For inhalation poisoning
• Seek immediate emergency help
• Get help before you attempt to rescue
others
• Hold a wet cloth to cover your nose and
mouth
• Open all the doors and windows
• Take deep breaths before you begin the
rescue
• Avoid lighting a match
• Check the patient's breathing
• Do a CPR, if necessary
• If the patient vomits, take steps to prevent
choking
Steps to Avoid
• Avoid giving an unconscious victim anything
orally
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• Do not induce vomiting unless told by a medical
personnel
• Do not give any medication to the victim unless
directed by a doctor
• Do not neutralize the poison with limejuice/honey
Prevention
• Store medicines, cleaning detergents, mosquito
repellants and paints carefully
• Keep all potentially poisonous substances out of
children's reach
• Label the poisons in your house
• Avoid keeping poisonous plants in or around
house
• Take care while eating products such as berries,
roots or mushrooms
• Teach children the need to exercise caution
• Check and monitor the person's airway,
breathing, and pulse. If necessary, begin rescue
breathing andCPR.
• Try to make sure that the person has indeed
been poisoned. It may be hard to tell. Some signs
include chemical-smelling breath, burns around
the mouth, difficulty breathing, vomiting, or
unusual odors on the person. If possible, identify
the poison.

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 • Do NOT make a person throw up unless told to
do so by poison control or a health care
professional.
• If the person vomits, clear the person's airway.
Wrap a cloth around your fingers before cleaning
out the mouth and throat. If the person has been
sick from a plant part, save the vomit. It may help
experts identify what medicine can be used to
help reverse the poisoning.
• If the person starts having convulsions,
give convulsion first aid.
• Keep the person comfortable. The person should
be rolled onto the left side, and remain there
while getting or waiting for medical help.
• If the poison has spilled on the person's clothes,
remove the clothing and flush the skin with water.

*** CPR combines rescue breathing and chest

compressions. Rescue breathing provides oxygen to
the person's lungs. Chest compressions keep oxygen-
rich blood circulating until an effective heartbeat and
breathing can be restored.

For inhalation poisoning:

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1. Call for emergency help. Never attempt to
rescue a person without notifying others first.
2. If it is safe to do so, rescue the person from
the danger of the gas, fumes, or smoke. Open
windows and doors to remove the fumes.
3. Take several deep breaths of fresh air, and
then hold your breath as you go in. Hold a wet
cloth over your nose and mouth.
4. Do not light a match or use a lighter because
some gases can catch fire.
5. After rescuing the person from danger, check
and monitor the person's airway, breathing, and
pulse. If necessary, begin rescue breathing
and CPR.
6. If necessary, perform first aid for eye injuries
(eye emergencies) or convulsions (convulsion
first aid).
7. If the person vomits, clear the person's
airway. Wrap a cloth around your fingers before
cleaning out the mouth and throat.
8. Even if the person seems perfectly fine, get
medical help.

19
 BITE
A bite is a wound received from the mouth (and in
particular, the teeth) of an animal, including humans.
Animals may bite in self-defense, in an attempt to predate
food, as well as part of normal interactions. Other bite
attacks may be apparently unprovoked. Self inflicted bites
occur in some genetic illnesses such as Lesch-Nyhan
syndrome.
Biting is an act that occurs when an animal uses its teeth
to pierce another object, including food, flesh and
inanimate matter.

Classification
Bites are usually classified by the type of creature causing
the wound. Many different creatures are known to bite
humans.
Arthropods
 Spider bite
 Insect bites and stings
 Flea bites are responsible for the transmission
of bubonic plague.

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  Mosquito bites are responsible for the
transmission of malaria.

Vertebrates other than humans

 Bites from dogs are commonplace, with children the
most common victims and the face the most common
target. About 4.7 million dog bites are reported annually
in the United States.
 Other companion animals, including cats, ferrets,

and parrots, may bite humans.

 Wildlife may sometimes bite humans. The bites of

various mammals such

as bats, rabbits, wolves, raccoons, etc. may
transmit rabies, which is almost always fatal if left
untreated.

Human bites
Injuries from human bites, present a particular risk to
other humans, with a major risk of sepsis from infection
by human oral ecology and the possibility of transmission
of blood-borne diseases including, syphilis and hepatitis.
Involuntary biting injuries due to closed-fist injuries from
fists striking teeth (referred to as reverse bite injuries) are
a common consequence of fist fights. These have been
termed "fight bites". Injuries in which the knuckle
joints or tendons of the hand are bitten into tend to be the
most serious.
In spite of their name, love bites are not biting injuries
(they involve bruising from sucking, and the skin is not
21
broken), although actual biting injuries are sometimes
seen as the result of fetishistic activities.
Other
 Snakebite
 Leech bite
 The "Stu Cheshire" bite
These particular bites are often caused through the due to
be affect person failing to answer themselves in a
particular verbal confrontation. The side effects are a
constant flow of verbal diarrhoea along a feeling of
prowess as they claim they never succumb to the "bite".
Ends rapidly in ridicule!

Treatment
Bite wounds should be cleaned and debrided as
necessary but not closed. Ampicillin/sulbactam is
indicated as HACEK endocarditis is the most worrying
complication. A punctate wound over a joint surface
should be regarded as an open joint injury until proven
otherwise.

Bite wounds are washed, ideally with povidone-iodine

soap and water. The injury is then loosely bandaged, but
is not sutured due to risk of infection.

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Antibiotics

Antibiotics prophylaxis is recommended for dog and cat

bites of the hand and human bites if they are more than
superficial. Evidence for the need for antibiotic
prophylaxis for bites in other areas inconclusive.
For empirical therapy, the first choice is amoxicillin with
clavulanic acid, and if the person is penicillin
allergy doxycycline and metronidazole. The anti-
staphylococcal penicillins
(e.g.,cloxacillin, nafcillin, flucloxacillin) and
the macrolides (e.g., erythromycin, clarithromycin) are not
used for empirical therapy, because they do not
cover Pasteurella species.

Rabies

Animal bites inflicted by some animals,

including carnivorans and bats can transmit rabies. The
animal is caught alive or dead with its head preserved, so
the head can later be analyzed to detect the disease.
Signs of rabies include foaming at the mouth, self-
mutilation, growling, jerky behavior, and red eyes. If the
animal lives for ten days and does not develop rabies,
then it is probable that no infection has occurred.
23
If the animal cannot be captured, prophylactic rabies
treatment is recommended in most places. Certain
places, such as Hawaii, Australia and the United
Kingdom, are known not to have native rabies. Treatment
is generally available in North America and the Northern
European states.
Tetanus
Tetanus toxoid is indicated for virtually any bite that
punctures the epidermis and tetanus immune globulin is
indicated in patients with more than 10 years since prior
vaccination. Tetanus boosters (Td) should be given every
ten years.
Prior Clean minor All other wounds
toxoid wounds
<3 doses TT: yes, TIG: no TT: yes, TIG: yes
TT: if last dose ≥
TT: if last dose ≥ 5yr, TIG:
≥3 doses 10yr
no
TIG: no
TT = Tetanus Toxoid; TIG: Tetanus Immune globulin

Mosquito bites

Antihistamines are effective treatment for the symptoms

from bites. Many diseases such as malaria are
transmitted by mosquitoes.

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Behavior

Biting is an age appropriate behavior and reaction for

children 2.5 years and younger. Conversely children
above this age have verbal skills to explain their needs
and dislikes and biting is not age appropriate. Biting may
be prevented by methods including redirection, changing
the environment and responding to biting by talking about
appropriate ways to express anger and frustration. School
age children, those older than 2.5 years, who habitually
bite may require professional help.
Biting is also a behavior found in many adult animals
(including humans), often as part of sexual petting. Some
discussion of human biting appears in The Kinsey Report
on Sexual Behavior in the Human Female.

CHOKING
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Choking is the mechanical obstruction of the flow of
air from the environment into the lungs. Choking
prevents breathing, and can be partial or complete,
with partial choking allowing some, although
inadequate, flow of air into the lungs. Prolonged or
complete choking results in asphyxia which leads to
anoxia and is potentially fatal. Oxygen stores in the
blood and lungs keep the victim alive for several
minutes after breathing is stopped completely.
Choking can be caused by:
• Physical obstruction of the airway by a foreign
body.
• Respiratory diseases that involve obstruction of
the airway.
• Compression of the laryngopharynx, larynx or
trachea in strangulation.
Foreign objects
The type of choking most commonly recognised as
such by the public is the lodging of foreign objects
(also known as foreign bodies, but consisting of any
object which comes from outside the body itself,
including food, toys or household objects) in the
airway.
This type of choking is often suffered by small
children, who are unable to appreciate the hazard
26
inherent in putting small objects in their mouth. In
adults, it mostly occurs whilst the patient is eating. In
one study, peanuts were the most common
obstruction.
Symptoms and clinical signs
• The person cannot speak or cry out, or has great
difficulty and limited ability to do so.
• Breathing, if possible, is labored, producing
gasping or wheezing.
• The person has a violent and largely involuntary
cough, gurgle, or vomiting noise, though more
serious choking victims will have a limited (if any)
ability to produce these symptoms since they
require at least some air movement.
• The person desperately clutches his or her throat
or mouth, or attempts to induce vomiting by
putting their fingers down their throat.
• If breathing is not restored, the person's face
turns blue (cyanosis) from lack of oxygen.
• The person does any or all of the above, and if
breathing is not restored, then becomes
unconscious.
Treatment
Choking can be treated with a number of different
procedures, with both basic techniques available for

27
first aiders and more advanced techniques available
for health professionals.
Many members of the public associate abdominal
thrusts, also known as the Heimlich Maneuver with
the correct procedure for choking, which is partly due
to the widespread use of this technique in movies,
which in turn was based on the widespread adoption
of this technique in the United States at the time.
Most modern protocols (including those of the
American Heart Association and the American Red
Cross, who changed policy in 2006 from
recommending only abdominal thrusts) involve
several stages, designed to apply increasingly more
pressure.
The key stages in most modern protocols include:
Encouraging the victim to cough
This stage was introduced in many protocols as it
was found that many people were too quick to
undertake potentially dangerous interventions, such
as abdominal thrusts, for items which could have
been dislodged without intervention. Also, if the
choking is caused by an irritating substance rather
than an obstructing one, and if conscious, the patient
should be allowed to drink water on their own to try to
clear the throat. Since the airway is already closed,
28
there is very little danger of water entering the lungs.
Coughing is normal after most of the irritant has
cleared, and at this point the patient will probably
refuse any additional water for a short time.
Back slaps
The majority of protocols now advocate the use of
hard blows with the heel of the hand on the upper
back of the victim. The number to be used varies by
training organization, but is usually between five and
20.
The back slap is designed to use percussion to
create pressure behind the blockage, assisting the
patient in dislodging the article. In some cases the
physical vibration of the action may also be enough
to cause movement of the article sufficient to allow
clearance of the airway.
Almost all protocols give back slaps as a technique to
be used prior to the consideration of potentially
damaging interventions such as abdominal thrusts,
but Henry Heimlich, noted for promulgating
abdominal thrusts, wrote in a letter to the New York
Times that back slaps were proven to cause death by
lodging foreign objects in to the windpipe.
The findings of a 1982 Yale study by Day, DuBois,
and Crelin that "persuaded the American Heart
29
Association to stop recommending back blows for
dealing with choking...was partially funded by
Heimlich's own foundation." According to Roger
White MD of the Mayo Clinic and American Heart
Association (AHA), "There was never any science
here. Heimlich overpowered science all along the
way with his slick tactics and intimidation, and
everyone, including us at the AHA, caved in."
Abdominal thrusts

A demonstration of abdominal thrusts

30
Abdominal thrusts, also known as the Heimlich
Maneuver (after Henry Heimlich, who first described
the procedure in a June 1974 informal article entitled
"Pop Goes the Cafe Coronary", published in the
journal Emergency Medicine). Edward A. Patrick,
MD, PhD, an associate of Heimlich, has claimed to
be the uncredited co-developer of the procedure.
Heimlich has objected to the name "abdominal
thrusts" on the grounds that the vagueness of the
term "abdomen" could cause the rescuer to exert
force at the wrong site.
Performing abdominal thrusts involves a rescuer
standing behind a patient and using their hands to
exert pressure on the bottom of the diaphragm. This
compresses the lungs and exerts pressure on any
object lodged in the trachea, hopefully expelling it.
This amounts to an artificial cough.
Due to the forceful nature of the procedure, even
when done correctly it can injure the person on whom
it is performed. Bruising to the abdomen is highly
likely and more serious injuries can occur, including
fracture of the xiphoid process or ribs.
In some areas, such as Australia, authorities believe
that there is not enough scientific evidence to support
the use of Abdominal thrusts and their use is not
recommended in first aid.
31
Self treatment with abdominal thrusts

A person may also perform abdominal thrusts on

themselves by using a fixed object such as a railing
or the back of a chair to apply pressure where a
rescuer's hands would normally do so. As with other
forms of the procedure, it is possible that internal
injuries may result.
Modified chest thrusts
A modified version of the technique is sometimes
taught for use with pregnant women and obese
casualties. The rescuer places their hand in the
center of the chest to compress, rather than in the
abdomen.
Finger sweeping
The American Medical Association advocates
sweeping the fingers across the back of the throat to
attempt to dislodge airway obstructions, once the
choking victim becomes unconscious
Some protocols advocate the use of the rescuer's
finger to 'sweep' foreign objects away once they have
reached the mouth. However, many modern
protocols recommend against the use of the finger
sweep as if the patient is conscious, they will be able
to remove the foreign object themselves, or if they
32
are unconscious the rescuer should simply place
them in the recovery position (where the object
should fall out due to gravity). There is also a risk of
causing further damage (for instance inducing
vomiting) by using a finger sweep technique.
Direct vision removal
The advanced medical procedure to remove such
objects is inspection of the airway with a
laryngoscope or bronchoscope, and removal of the
object under direct vision, followed by CPR if the
patient does not start breathing on their own. Severe
cases where there is an inability to remove the object
may require cricothyrotomy.
CPR
In most protocols, once the patient has become
unconscious, the emphasis switches to performing
CPR, involving both chest compressions and artificial
respiration. These actions are often enough to
dislodge the item sufficiently for air to pass it,
allowing gaseous exchange in the lungs.
Notable victims
• United States President George W. Bush
survived choking on a pretzel on January 13,
2002, receiving major media coverage
33
 • Jimmie Foxx, a famous Major League Baseball
player, died by choking on a bone.
• Tennessee Williams, the playwright, died after
choking on a bottle cap.
• An urban legend states that obese singer Mama
Cass choked to death on a ham sandwich. This
was borne out of a quickly discarded speculation
by the coroner, who noted a partly eaten ham
sandwich and figured she may have choked to
death. In fact, she died of a heart condition, often
wrongly referred to in the media as heart failure
but specified on her death certificate as fatty
myocardial degeneration.
• The Queen Mother was admitted to a UK
Hospital for an operation in May 1993 after
choking on a fish bone.
Other uses of abdominal thrusts
Dr. Heimlich also advocates the use of the technique
as a treatment for drowning and asthma attacks, but
Heimlich's promotion to use the maneuver to treat
these conditions resulted in marginal acceptance.
Criticism of these uses has been the subject of
numerous print and television reports which resulted
from an internet and media campaign by his son,
Peter M. Heimlich, who alleges that in August 1974
his father published the first of a series of fraudulent

34
case reports in order to promote the use of
abdominal thrusts for near-drowning rescue.

BONE FRACTURE
A bone fracture (sometimes abbreviated FRX or Fx,
Fx, or #) is a medical condition in which there is a
break in the continuity of the bone. A bone fracture
can be the result of high force impact or stress, or
trivial injury as a result of certain medical conditions
that weaken the bones, such as osteoporosis, bone
cancer, or osteogenesis imperfecta, where the
fracture is then properly termed a pathological
fracture.
Although broken bone and bone break are common
colloquialisms for a bone fracture, break is not a
formal orthopedic term.
Classification
Orthopedic
In orthopedic medicine, fractures are classified in
various ways. Historically they are named after the
doctor who first described the fracture conditions.
However, there are more systematic classifications in
place currently.

35
All fractures can be broadly described as:
• Closed (simple) fractures are those in which
the skin is intact, while open (compound)
fractures involve wounds that communicate with
the fracture, or where fracture hematoma is
exposed, and may thus expose bone to
contamination. Open injuries carry a higher risk
of infection.
Other considerations in fracture care are
displacement (fracture gap) and angulation. If
angulation or displacement is large, reduction
(manipulation) of the bone may be required and, in
adults, frequently requires surgical care. These
injuries may take longer to heal than injuries without
displacement or angulation.
Another type of bone fracture is a compression
fracture. It usually occurs in the vertebrae, for
example when the front portion of a vertebra in the
spine collapses due to osteoporosis (a medical
condition which causes bones to become brittle and
susceptible to fracture, with or without trauma).
Other types of fracture are:
• Complete fracture: A fracture in which bone
fragments separate completely.

36
 • Incomplete fracture: A fracture in which the bone
fragments are still partially joined.
• Linear fracture: A fracture that is parallel to the
bone's long axis.
• Transverse fracture: A fracture that is at a right
angle to the bone's long axis.
• Oblique fracture: A fracture that is diagonal to a
bone's long axis.
• Spiral fracture: A fracture where at least one part
of the bone has been twisted.
• Comminuted fracture: A fracture in which the
bone has broken into a number of pieces.
• Impacted fracture: A fracture caused when bone
fragments are driven into each other.
OTA classification
The Orthopaedic Trauma Association, an association
for orthopaedic surgeons, adopted and then
extended the classification of Müller and the AO
foundation ("The Comprehensive Classification of the
Long Bones") an elaborate classification system to
describe the injury accurately and guide treatment.
There are five parts to the code:
• Bone: Description of a fracture starts by coding
for the bone involved:}}
(1) Humerus, (2) Radius/Ulna, (3) Femur, (4)
Tibia/Fibula, (5) Spine, (6) Pelvis, (24) Carpus, (25)
37
Metacarpals, (26) Phalanx (Hand), (72) Talus, (73)
Calcaneus, (74) Navicular, (75) Cuneiform, (76)
Cuboid, (80) LisFranc, (81) Metatarsals, (82) Phalanx
(Foot), (45) Patella, (06) Clavicle, (09) Scapula
• Location: a code for the part of the bone involved
(e.g. shaft of the femur): proximal=1,
diaphyseal=2, distal=3 (at the ankle the malleolar
region is considered separately due to the pre-
existing Weber classification and coded as 4.
Except at the proximal femur the distal and
proximal regions of the bone are defined by a
square that is as wide as the as the distance
between the condyles. The diaphysis is
considered to be the rest of the bone between
these two squares.
• Type: It is important to note whether the fracture
is simple or multifragmentary and whether it is
closed or open: A=simple fracture, B=wedge
fracture, C=complex fracture
• Group: The geometry of the fracture is also
described by terms such as transverse, oblique,
spiral, or segmental.
• Subgroup: Other features of the fracture are
described in terms of displacement, angulation
and shortening. A stable fracture is one which is
likely to stay in a good (functional) position while
it heals; an unstable one is likely to shorten,
38
 angulate or rotate before healing and lead to poor
function in the long term.
Other classification systems
There are other systems used to classify different
types of bone fractures:
• "Denis classification": spine
• "Frykman classification": radius and ulna
• "Gustilo open fracture classification"
• "Letournel and Judet Classification": Acetabular
Fractures"Neer classification": humerus
• "Seinsheimer's Classification": femur
Signs and symptoms
Although bone tissue itself contains no nociceptors,
bone fracture is very painful for several reasons:
Breaking in the continuity of the periosteum, with or
without similar discontinuity in endosteum, as both
contain multiple nociceptors.
• Edema of nearby soft tissues caused by bleeding
of torn periosteal blood vessels evokes pressure
pain.
• Muscle spasms trying to hold bone fragments in
place
39
Pathophysiology
Main article: Bone healing
The natural process of healing a fracture starts when
the injured bone and surrounding tissues bleed,
forming a fracture Hematoma. The blood coagulates
to form a blood clot situated between the broken
fragments. Within a few days blood vessels grow into
the jelly-like matrix of the blood clot. The new blood
vessels bring phagocytes to the area, which gradually
remove the non-viable material. The blood vessels
also bring fibroblasts in the walls of the vessels and
these multiply and produce collagen fibres. In this
way the blood clot is replaced by a matrix of collagen.
Collagen's rubbery consistency allows bone
fragments to move only a small amount unless
severe or persistent force is applied.
At this stage, some of the fibroblasts begin to lay
down bone matrix (calcium hydroxyapatite) in the
form of insoluble crystals. This mineralization of the
collagen matrix stiffens it and transforms it into bone.
In fact, bone is a mineralized collagen matrix; if the
mineral is dissolved out of bone, it becomes rubbery.
Healing bone callus is on average sufficiently
mineralized to show up on X-ray within 6 weeks in
adults and less in children. This initial "woven" bone
does not have the strong mechanical properties of
40
mature bone. By a process of remodeling, the woven
bone is replaced by mature "lamellar" bone. The
whole process can take up to 18 months, but in
adults the strength of the healing bone is usually 80%
of normal by 3 months after the injury.
Several factors can help or hinder the bone healing
process. For example, any form of nicotine hinders
the process of bone healing, and adequate nutrition
(including calcium intake) will help the bone healing
process. Weight-bearing stress on bone, after the
bone has healed sufficiently to bear the weight, also
builds bone strength. The bone shards can also
embed in the muscle causing great pain. Although
there are theoretical concerns about NSAIDs slowing
the rate of healing, there is not enough evidence to
warrant withholding the use of this type analgesic in
simple fractures.
Diagnosis
A bone fracture can be diagnosed clinically, based on
the history given and the physical examination
performed by a healthcare professional. Usually there
will be an area of swelling, abrasion, bruising and/or
tenderness at the suspected fracture site.
Open fractures may be obvious if bone is exposed
but small wounds may need surgical exploration to

41
determine if they are only superficial or connected to
the fracture.
X-ray radiographs can be requested to view the bone
suspected of being fractured.
In situations where x-ray alone is insufficient, a
computed tomograph (CT scan) may be performed.
Treatment

X-ray showing the proximal portion of a fractured tibia

with an intramedullary nail.

X-ray showing the distal portion of a fractured tibia

and intramedular nail.
Pain management
42
In arm fractures in children, ibuprofen has been found
to be equally effective as the combination of
acetaminophen and codeine.
Immobilization
Since bone healing is a natural process which will
most often occur, fracture treatment aims to ensure
the best possible function of the injured part after
healing. Bone fractures are typically treated by
restoring the fractured pieces of bone to their natural
positions (if necessary), and maintaining those
positions while the bone heals. Often, aligning the
bone, called reduction, in good position and verifying
the improved alignment with an X-ray is all that is
needed. This process is extremely painful without
anesthesia, about as painful as breaking the bone
itself. To this end, a fractured limb is usually
immobilized with a plaster or fiberglass cast or splint
which holds the bones in position and immobilizes
the joints above and below the fracture. When the
initial post-fracture edema or swelling goes down, the
fracture may be placed in a removable brace or
orthosis. If being treated with surgery, surgical nails,
screws, plates and wires are used to hold the
fractured bone together more directly. Alternatively,
fractured bones may be treated by the Ilizarov
method which is a form of external fixator.

43
Occasionally smaller bones, such as phalanges of
the toes and fingers, may be treated without the cast,
by buddy wrapping them, which serves a similar
function to making a cast. By allowing only limited
movement, fixation helps preserve anatomical
alignment while enabling callus formation, towards
the target of achieving union.
Surgery
Surgical methods of treating fractures have their own
risks and benefits, but usually surgery is done only if
conservative treatment has failed or is very likely to
fail. With some fractures such as hip fractures
(usually caused by osteoporosis or osteogenesis
Imperfecta), surgery is offered routinely, because the
complications of non-operative treatment include
deep vein thrombosis (DVT) and pulmonary
embolism, which are more dangerous than surgery.
When a joint surface is damaged by a fracture,
surgery is also commonly recommended to make an
accurate anatomical reduction and restore the
smoothness of the joint. Infection is especially
dangerous in bones, due to their limited blood flow.
Bone tissue is predominantly extracellular matrix,
rather than living cells, and the few blood vessels
needed to support this low metabolism are only able
to bring a limited number of immune cells to an injury
to fight infection. For this reason, open fractures and
44
osteotomies call for very careful antiseptic
procedures and prophylactic antibiotics.
Occasionally bone grafting is used to treat a fracture.
Sometimes bones are reinforced with metal. These
implants must be designed and installed with care.
Stress shielding occurs when plates or screws carry
too large of a portion of the bone's load, causing
atrophy. This problem is reduced, but not eliminated,
by the use of low-modulus materials, including
titanium and its alloys. The heat generated by the
friction of installing hardware can easily accumulate
and damage bone tissue, reducing the strength of the
connections. If dissimilar metals are installed in
contact with one another (i.e., a titanium plate with
cobalt-chromium alloy or stainless steel screws),
galvanic corrosion will result. The metal ions
produced can damage the bone locally and may
cause systemic effects as well.
Electrical bone growth stimulation or osteostimulation
has been attempted to speed or improve bone
healing. Results however do not support its
effectiveness.
Complications

45
An old fracture with nonunion of the fracture
fragments.
Some fractures can lead to serious complications
including a condition known as compartment
syndrome. If not treated, compartment syndrome can
result in amputation of the affected limb. Other
complications may include non-union, where the
fractured bone fails to heal or mal-union, where the
fractured bone heals in a deformed manner.
In children
Main article: Child bone fracture
In children, whose bones are still developing, there
are risks of either a growth plate injury or a greenstick
fracture.

46
 • A greenstick fracture occurs due to mechanical
failure on the tension side. That is, since the
bone is not as brittle as it would be in an adult, it
does not completely fracture, but rather exhibits
bowing without complete disruption of the bone's
cortex in the surface opposite the applied force.
• Growth plate injuries, as in Salter-Harris
fractures, require careful treatment and accurate
reduction to make sure that the bone continues to
grow normally.
• Plastic deformation of the bone, in which the
bone permanently bends but does not break, is
also possible in children. These injuries may
require an osteotomy (bone cut) to realign the
bone if it is fixed and cannot be realigned by
closed methods.
• Certain fractures are known to occur mainly in
the pediatric age group, such as fracture of the
clavicle & supracondylar fracture of the humerus.

SPRAIN
A sprain (from Middle French espraindre - to wring)
is an injury to ligaments that is caused by being
stretched beyond their normal capacity and possibly
torn. A muscular tear caused in the same manner is
referred to as a strain. In cases where either ligament
47
or muscle tissue is torn, immobilization and surgical
repair may be necessary. Ligaments are tough,
fibrous tissues that connect bone to bone across the
joints. Sprains can occur in any joint but are most
common in the ankle.
Diagnosis
The diagnosis of sprain injury is made by a physical
examination. In most cases an x-ray of the affected
joint is obtained to ensure that there are no fractures.
If a tear in the ligament is suspected, then an MRI is
obtained. MRI is usually ordered after swelling has
subsided and can readily identify the presence of a
ligament injury.[2]
Causes
Sprains typically occur when the joint is
overextended. This can cause over stretching of the
ligament, tear or rupture the ligament.
Joints involved
Although any joint can experience a sprain, some of
the more common include:
• the ankle. It is the most common, and has been
said that sprains such as serious ankle sprains
are more painful and take longer to heal than

48
 actually breaking the bones in that area. See
sprained ankle for more details.
• the knee. Perhaps one of the more talked about
sprains is that to the anterior cruciate ligament
(ACL) of the knee. This is a disabling sprain
common to athletes, especially in football,
basketball, soccer, pole vaulting, softball,
baseball, and judo. See Anterior cruciate
ligament injury.
• the fingers.
• the wrist.
• the toes.
Risk factors
There are certain factors which increase risk of
sprains. Fatigue of muscles generally leads to
sprains. When one suddenly starts to exercise after a
sedentary lifestyle, sprains are quite common. Not
warming-up is the most common cause of sprains in
athletes. Warming-up loosens the joint, increases
blood flow and makes the joint more flexible. Poor
conditioning of the body can also lead to sprains.
Diagnosis of sprains is not difficult but in most cases
x-rays are obtained to ensure that there is no
fracture. In many cases, if the injury is prolonged,
magnetic resonance imaging (MRI) is performed to
look at surrounding soft tissues and the ligament.
49
Treatment
The first modality for a sprain can be remembered
using the acronym RICE. The treatment of sprains
depends on the extent of injury and the joint involved.
Medications like non-steroidal anti-inflammatory
drugs can relieve pain. Weight bearing should be
gradual and advanced as tolerated.
Rest: The sprain should be rested. No additional
force should be applied on site of the sprain. If, for
example, the sprain were an ankle sprain, then
walking should be kept to a minimum.
Ice: Ice should be applied immediately to the sprain
to minimize swelling and ease pain. It can be applied
for 20-30 minutes at a time, 3-4 times a day. Ice can
be combined with a wrapping to minimize swelling
and provide support.
• Compression: Dressings, bandages, or ace-
wraps should be used to immobilize the sprain
and provide support.
• Elevate: Keeping the sprained joint elevated (in
relation to the rest of the body) will also help to
minimize swelling.
Ice and compression (cold compression therapy) will
not completely stop swelling and pain, but will help to
50
minimize them as the sprain begins to heal itself.
Careful management of swelling is critical to the
healing process as additional fluid may pool in the
sprained area.
The joint should be exercised again fairly soon, in
milder cases from 1 to 3 days after injury. Special
exercises are sometimes needed in order to regain
strength and help reduce the risk of ongoing
problems. The joint may need to be supported by
taping or bracing, helping protect it from re-injury.
Functional rehabilitation
After any sprain, proper rehabilitation is a must;
especially when the injury has been severe. After
acute treatment, a rehabilitation program is critical in
speeding recovery of the joint. Lack of rehabilitation
can often delay return to normal function for months.
The other error most people make is to use
prolonged immobilization. This usually leads to
muscle atrophy and stiff joint. The components of an
effective rehabilitation for all sprain injuries include
increasing range of motion and progressive muscle
strengthening exercise.

CRAMPS
51
Cramps are unpleasant, often painful sensations
caused by muscle contraction or overshortening. The
common causes of skeletal muscle cramps are
muscle fatigue and a sodium imbalance. Smooth
muscle cramps may be due to menstruation or
Gastroenteritis.
Differential diagnosis
Causes of cramping include hyperflexion, hypoxia,
exposure to large changes in temperature,
dehydration, or low blood salt. Muscle cramps may
also be a symptom or complication of pregnancy,
kidney disease, thyroid disease, hypokalemia,
hypomagnesemia or hypocalcemia (as conditions),
restless-leg syndrome, varicose veins, and multiple
sclerosis.
Electrolyte disturbance may cause cramping and
muscle tetany, particularly hypokalaemia and
hypocalcaemia. This disturbance arises as the body
loses large amounts of interstitial fluid through sweat.
This interstitial fluid comprises mostly water and table
salt (sodium chloride). The loss of osmotically active
particles outside of muscle cells leads to a
disturbance of the osmotic balance and swelling of
muscle cells, as these contain more osmotically
active particles. This causes the calcium pump
between the muscle lumen and sarcoplasmic
52
reticulum to short circuit; the calcium ions remain
bound to the troponin, continuing muscle contraction.
This may occur when lactic acid is high in the cells.
As early as 1965, researchers observed that leg
cramps and restless-leg syndrome result from excess
insulin, sometimes called hyperinsulinemia.
Hypoglycemia & reactive hypoglycemia are
associated with excess insulin [or insufficient
glucagon], and avoidance of low blood glucose
concentration may help to avoid cramps.
Smooth muscle cramps
Smooth muscle contractions lie at the heart of the
cramping (or colicky) pain of internal organs. These
include the intestine, uterus, ureter (in kidney stone
pain), and various others.
Menstrual cramps

Menstruation is also likely to cause abdominal

cramps of varying severity that may radiate to the
lower back and thighs. Menstrual cramps can be
treated with ibuprofen, acetaminophen (paracetamol),
stretching exercises, or the application of heat
through means such as warm baths or heating pads.
Menstrual cramps that do not respond to self

53
treatment may be symptomatic of endometriosis or
other health problems.
Skeletal muscle cramps
Skeletal muscles can be voluntarily controlled.
Among skeletal muscles, those which cramp the
most often are the calves, thighs, and arches of the
foot. So-called Charley horse, these cramps are
seemingly associated with strenuous activity and can
be intensely painful, although it is possible for a
skeletal cramp to occur while relaxing. Around 40%
of people experiencing skeletal cramps are likely to
endure extreme muscle pain and may be unable to
move or walk on the leg that the cramp has affected.
It may take up to 7 days for the leg to return its
previous, pain-free state.
Nocturnal leg cramps

Nocturnal leg cramps are involuntary muscle

contractions that occur in the calves, soles of the
feet, or other muscles in the body during the night or
(less commonly) while resting. Only a few fibers of a
muscle may be activated. The duration of nocturnal
leg cramps is variable with cramps lasting anywhere
from a few seconds to several minutes. Muscle
soreness may remain after the cramp itself ends.
These cramps are erroneously believed to be more
54
common in older people. They happen quite
frequently in teenagers and in some people while
exercising at night. Usually, putting some pressure on
the affected leg by walking some distance will end
the cramp.
The precise cause of these cramps is unclear.
Potential contributing factors include dehydration, low
levels of certain minerals (magnesium, potassium,
calcium, and sodium), and reduced blood flow
through muscles attendant in prolonged sitting or
lying down. Less common causes include more
serious conditions or drug use.
Nocturnal leg cramps may sometimes be relieved by
stretching the affected leg and pointing the toes
upward. Quickly standing up and walking a few steps
may also shorten the duration of a cramp.
Nocturnal leg cramps (almost exclusively calf
cramps) are considered to be 'normal' during the late
stages of pregnancy. They can, however, vary in
intensity from mild to incredibly painful.
Iatrogenic causes
Statins cause myalgia and cramps among other
possible side effects, including substantially lowering
blood glucose concentration.[7] Additional factors,
which increase the probability for these side effects,
55
are physical exercise, age, female gender, history of
cramps, and hypothyroidism. Up to 80% of athletes
using statins suffer significant adverse muscular
effects, including cramps; the rate appears to be
approximately 10-25% in a typical statin-using
population. In some cases, adverse effects disappear
after switching to a different statin; however, they
should not be ignored if they persist, as they can, in
rare cases, develop into more serious problems.
Coenzyme Q10 supplementation can be helpful to
avoid some statin-related adverse effects, but
currently there is not enough evidence to prove the
effectiveness in avoiding myopathy or myalgia.
Pathophysiology
Skeletal muscles work as antagonistic pairs.
Contracting one skeletal muscle requires the
relaxation of the opposing muscle in the pair. Cramps
can occur when muscles are unable to relax properly
due to myosin fibers not fully detaching from actin
filaments. In skeletal muscle, both ATP (energy) and
magnesium must attach to the myosin fibers in order
for them to disassociate from the muscle and allow
relaxation — the absence of either of these in
sufficient quantities means that the myosin remains
attached to actin. An attempt to force a muscle
cramped in this way to extend (by contracting the
opposing muscle) can tear muscle tissue and worsen
56
the pain. The muscle must be allowed to recover
(take in Mg and resynthesize ATP), before the
myosin fibres can detach and allow the muscle to
relax.
Treatment
Conservative
Muscle cramps due to fatigue can be treated by
stretching and massage. With exertional heat cramps
due to electrolyte abnormalities (primarily sodium
loss and not calcium, magnesium, and potassium )
appropriate fluids and sufficient salt improves
symptoms.
Medication
Vitamin B complex, naftidrofuryl, and calcium channel
blockers may be effective for muscle cramps. Quinine
is likely effective for this indication however due to
side effects its use should only be considered if other
treatments have failed and in light of these concerns.

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