Basic Emergency Care

20091st Edition

DR.Mohammmad A.Ghany
5/5/2009

Basic Emergency Care (Cardiopulmonary Resuscitation and First Aid)

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

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

The Editor: Dr∕Mohammad A.Ghany

‫"ياربْ َل ّنْي أنْ أد ّ ال َاسْ َما أد ّ َفسْي َعّمني أنْ أ َاسةْ َفسْي َما‬ ‫ك‬ ‫د ِ ن‬ ‫و َل‬ ‫ةن‬ ‫ة ن ك‬ ‫َ عم‬ ‫أ َاسةْ ال َاسْ َعّمنْي أنْ الت َامخ هَوأكْثَر َراتة الق ّج َأ ّ د ّ االنتقام هَو أولْ‬ ‫و ون ة‬ ‫م‬ ‫س‬ ‫د ِ ن و َل‬ ‫َظا ِر الضعْ َ. ياربْ ال تدعني أ َاب ِالغرور إذا َ َذْت وَال تاليأس إذا فْشلت َل‬ ‫ت‬ ‫نج‬ ‫ص ت‬ ‫ف َ‬ ‫م ه‬ ‫ذ ّرني دا ِـم ً أن ال َ َل َو الت َارب التي تسْـ ِق ال ّ َاح"‬ ‫ث نج‬ ‫فش ه ج‬ ‫ئ ا‬ ‫ك‬ .

.36 – Respiration…………………………………………….24 Arrhythmia ………………………………………….40 Introduction to CPR…………………………………….5 – Cardiovascular system………………………………..........……38 Chapter 5: Cardiopulmonary Resuscitation (CPR)...11 Chapter 2: Cardiovascular emergencies………………18 – – – – – Risk factors of CV diseases…………………………....….43 Infant CPR……………………………………………………49 Child CPR…………………………………………………….....3 Chapter 1:Cardiovascular and Respiratory Anatomy and Physiology……………………………………………………..……21 Acute myocardial infarction……………………….39 – – – – – Chain of survival……………………………. know what to do? .……....4 – Respiratory system…………………………………....…...50 ..…………..….. 37 – Blood pressure…………………………………….19 Coronary artery diseases………………………..........28 Chapter 4: Basic Vital Signs…………………….Table of Contents Introduction to Emergency Medical Care……………………1 Part One: Cardiopulmonary Resuscitation.26 Chapter 3:Patient assessment and early management………………………………………….....22 Congestive heart failure……………………………........42 CPR.…..……...35 – Pulse………………………………………………………...............…….....

86 Epistaxis……………………………………………….……...90 – Contusion..……….87 Internal bleeding……………………………………….. muscular.Chapter 6: Choking……………………………………………51 – Choking. management……………………. conscious infant…………………….64 – Anatomical position…………………………. Haematoma…………………. nervous systems………………………………………………………63 – Survival needs……………………………………………..88 Chapter 4: Soft Tissue Injuries………………………….54 – Choking.……. unconscious infant………………….55 Chapter 7: External Defibrillation………………………56 – Automated external defibrillator (AED)………57 Part Two: first Aid………………………………………………….80 – – – – Shock …………………………………………………………81 Bleeding…………………………………………………….52 – Choking.…….…….……. causes. skeletal..61 Chapter 1: The Human Body Anatomy and Physiology………………………………………………………….67 – Trauma assessment……………………………………73 Chapter 3: Shock and Bleeding ……………………….91 – Abrasion………………………………………………...60 – Integumentary.64 – Body cavities……………………………………….65 Chapter 2: Trauma…………………………………………….66 – Introduction to trauma management………….……92 .…….

……….106 3rd degree burns………………………………………..….– Laceration....……93 – Amputation……………………………………………….118 Cerebral contusion……………………………………119 Epidural haematoma……………………………….95 Chapter 5: Musculoskeletal Injuries……………….……………………120 Cerebral laceration…………………………………….….. chest wound…….. Neck wound. Avulsion……………. Puncture.. Sprains.... Strains………………………100 Chapter 6: Burns………………………………………………103 – – – – 1st degree burns………………………………….……………………116 – – – – – – – – – Scalp laceration……………………………….94 – Evisceration.117 Skull fracture……………………………………….…….120 Assessment of head injury…………………………121 Management of head injury………………………122 .……118 Brain concussion…………………………………….119 Subdural haematoma………….97 – Dislocation.105 2nd degree burns……………………………….….107 Management of burns………………………………111 Chapter 7: Head Injuries…………….96 – Fracture…………………………………………………..

domestic emergency care lagged behind.Introduction INTRODUCTION TO EMERGENCY MEDICAL CARE History and Origins of EMS (emergency medical service)  Accidental Death & Disability is the Neglected Disease of Modern Society. Staffed emergency departments were often limited to large urban areas.   By the 1960s.  Emergency care developed during warfare at the beginning of the 20th century. Now it is the duty of everyone to know some basic emergency care Components of the EMS System Prehospital Care – First Responders/EMT(emergency medical technician) – Intermediates/EMT-Paramedics Emergency Departments – Patient Care Technicians/Nurses/Physicians Specialty facilities – Cardiac center – Stroke center – Trauma centers -1- .

Emergency Oxygen  Basic First Aid: Care for Injuries and Sudden Illness -2- .Introduction – Burn centers – Pediatric centers – Others Roles and Responsibilities – Personal safety – Safety of crew.Airway management & CPR .Automated External Defibrillation . patient. and bystanders – Patient assessment – Patient care – Lifting and moving patients safely – Transport/transfer of care – Record-keeping/ data collection Basic emergency care includes:  Basic Life Support: .

Part One Cardiopulmonary Resuscitation .

Chapter 1 Cardiovascular and Respiratory Anatomy &Physiology .

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

Fig.(1-1)Respiratory system Fig.(1-2)Larynx .

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

.middle and inferior).The left lung consists of 2 main lobes(superior and inferior). The diaphragm Is the muscular structure that divides the chest cavity from the abdominal cavity. the diaphragm and intercosals work together to allow the body to inhale and exhale.Visceral pleura: covers the lung.Two pulmonary veins The right lung consists of 3 main lobes (superior. The intercostal muscles fill the intercostal spaces.Hilum of the lung: It is triangular in shape.One pulmonary arteray 3. During normal respiration. Pleura Two layers 1. 2-parietal pleura: lines thoracic cavity and upper surface of Diaphragm. 2. Both are separated by a space (pleural cavity) filled with few drops of pleural fluid. Structures that enter and leave at hilum are: 1-The primary bronchus. lying on the medial surface.

Oxygen is transferred from the air in the alveoli to the bloodstream through the very thin walls of the alveoli and the capillaries. The alveoli are very small. Oxygen carried by the blood is given up to the cells. Waste carbon dioxide is picked up from the cells and returned through veins to the heart and then the . Oxygenated blood is carried from the lungs to the heart so it can be pumped into the circulatory system of the body. Respiration consists of 2 phases: Inspiration (inhalation) is an active process. This rate is faster in children and slower in adult. . The diaphragm and the intercostals contract. At the same time carbon dioxide and waste product of the body's cells. During inhalation. The diaphragm and the intercostals relax. Expiration (exhalation) is a passive process. the diaphragm lowers and the ribs moves upward and outward.Basic physiology Rate of respiration in adult is 16-20 cycle/ minute. These small sacs in the lungs are where gas exchange with the blood takes place. moves from the bloodstream into the alveoli. The blood vessels around the alveoli are capillaries. Air moves into the lungs through the series of airpassages (the airway). this leads to decrease of chest size and elastic recoil of the lung and air flow out of the lung. air is moved into the alveoli. the diaphragm rises and the ribs moves downward and inward. this leads to decrease intrathoracic pressure expansion of the lung and air flow in the lung.

therefore. such as in applying a cervical collar or during procedures to place a tube in the trachea. Fig.The trachea is also softer and more flexible in infants and children. more easily obstructed by swelling or foreign matter. 5. so more care must be taken during any pressure on the neck.The trachea is relatively narrower than in adults and.1-3) There are a number of special aspects of the respiratory anatomy of infants and children: 1In general. Infants and children (Fig. 4. 2-Their tongues take up proportionally more space in the phatynx than do an adult's.lungs where it moves from the bloodstream into the alveoli and out of the body through exhalation.(1-3) . all structures in a child are smaller and more easily obstructed than in an adult.The cricoids cartilage is less developed and less rigid in infants and children. 3.

The right ventricle receives blood from the right atrium. then back to the right atrium to start its journey all over again.  Right atrium: The superior vena cava and the inferior vena cava are the two large veins that return blood to the heart. blood is forced into the ventricles. located in the center of the thoracic cavity. The right atrium receives this blood and sends it to the right ventricle. Basic Anatomy of the Heart(Fig. it pumps this blood out to the lungs via the pulmonary arteries. The path the blood through the body is as follows: right atrium to right ventricle to lungs to left atrium to left ventricle to body. When the right ventricle contracts. this . The heart has four chambers: Two upper chambers called atria and two lower chambers called ventricles. When they contract. Both ventricles contract simultaneously to pump the blood out of the heart. The atria both contract at the same time.1-4) The human heart is a muscular organ about the size of your fist.Cardiovascular System (circulatory system) CPR The cardiovascular system consists of the heart and the blood vessels through which blood is circulated throughout the body.  Right ventricle.

 Left atrium. it pumps this blood into the aorta. The left atrium receives the oxygen rich blood from the lungs. and oxygen is obtained (taken into the blood from air the person has inhaled). it sends this blood to the left ventricle.(1-4) . for distribution to the entire body. Fig. When it contracts. It receives oxygen rich blood from the left atrium. The left ventricle is the most muscular and strongest part of the heart. When it contracts. The oxygen-rich blood is now returned to the left atrium via the pulmonary veins.blood is very low in oxygen and high in carbon dioxide in the lungs. the body's largest artery.  Left ventricle. the carbon dioxide is excreted (taken out of the blood ).

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

travels superiorly. the capillaries are are where between gases. the nutrients. Arteries begin with large vessels.Circulation of the Blood The kind of vessel that carries blood away from the heart is called an artery. Although the heart has blood moving through it. It begins at its attachment to the left ventricle. Important arteries to know:(Fig. body's cells and and waste the products exchanged bloodstream.1-6) • Coronary arteries (right and left): The coronary arteries branch of the aorta and supply the heart muscle with blood. Capillaries are tiny blood vessels found throughout the body. like the aorta. The kind of vessel that carries the blood from capillaries back to the heart is called a vein. . they gradually branch to smaller and smaller vessels. From the capillaries the blood begins its return to the heart by entering the smallest veins. small veins are called a venules.These small vessels lead to the capillaries. The smallest branch of an artery is called an arteriole . Damage or blockage to these arteries usually results in severe chest pain. it receives its own blood supply from the coronary arteries. then splits into 2 iliac arteries. then arches inferiorly in front of the spine through the thoracic and abdominal cavities. • Aorta: The aorta is the largest artery in the body.

and veins carry oxygen-poor blood). This artery is the major source of blood supply to the thigh and leg. It is also the artery that is used when determining blood pressure with a blood pressure cuff and a stethoscope.  Brachial artery.  Femoral artery:"femoral" to the bone in the thigh. It does. . follow the rule that arteries carry blood carry blood to the heart. It carries oxygen-poor blood to the lungs. Never palpate both at the same time because of the danger of interrupting the supply blood to the brain. You will be familiar with this vessel from your CPR class. The brachial artery is in the upper arm. It carries the main blood supply of the neck one on each side. the femur. . however. Pulsations for this artery can be felt in the crease between the abdomen and the groin. Its pulse can be felt anteriorly in the crease over the elbow and along the medial away from the heart while veins aspect of the upper arm.  Carotid artery: The carotid artery is the major artery of the neck. It is the pulse checked during infant CPR. an exception to the rule (arteries carry oxygen-rich blood. The pulmonary artery: The pulmonary artery begins at the right ventricle. It is the artery that is palpated during CPR pulse checks for adults and children.

you can relate the name "radial to the radius.LC): This center sends inhibitory impulses to the heart causing (Bradycardia).A. .Cardiac acceleratory center (C. The superior vena collects blood that is returned from the head and upper body.1-6) there are two venae cavae. superior and inferior venae cavae return blood to the right atrium. The inferior vena cava collects blood from the part of the body below the heart. a bone in the forearm. Important veins to know(Fig. This artery travels through and supplies the lower arm. Radial artery. Basic physiology The contraction (beating) of the heart is involuntary.Cardiac inhibitory center (C. lateral to the large tendon of the big toe. b .rhythm and force is under control of the brain: a . Again. Regulation of the heart beat rate. The radial artery is the artery felt when taking a pulse at the thumb side the wrist.  Dorsalis pedis artery The dorsalis pedis artery lies on the top (dorsal portion) of the foot.C): This center sends stimulating impulses to the heart causing (Tachycardia). The heart has its own pacemaker and special conducting system(modified cardiac muscles initiate and propagate impulses).

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

Chapter 2 Cardiovascular Emergencies .

so does risk of coronary heart disease.Cardiovascular Emergencies CPR Cardiovascular Emergencies Risk factors of cardiovascular disease What are the major risk factors that can't be changed?  Increasing age — Over 83 % of people who die of coronary heart disease are 65 or older. coronary Cigarette disease times that smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. treat or control by changing your lifestyle or taking medicine?  Tobacco heart smoke — Smokers' is 2–4 risk of of developing nonsmokers.  Male sex (gender) — Men have a greater risk of heart attack than women. Heredity (including Race) — Children of parents with heart disease are more likely to develop it themselves. African Americans have more severe high blood pressure than Caucasians and a higher risk of heart disease.  What are the major risk factors you can modify. .  High blood cholesterol — As blood cholesterol rises.

causing the heart to thicken and become stiffer. Regular. moderate-to-vigorous physical activity helps prevent heart and blood vessel disease. Nonuse use of alcohol f. What other factors contribute to heart disease risk?   Individual response to stress Drinking too much alcohol can raise blood pressure. cause heart failure and lead to stroke. Regular exercise b. Nonuse of tobacco and other drugs e. suicide and accidents. alcoholism. It contributes to obesity. Sound nutrition d.  Obesity and overweight — People who have excess body fat — especially if a lot of it is at the waist — are more likely to develop heart disease and stroke even if they have no other risk factors.  Diabetes mellitus — Diabetes seriously increases your risk of developing cardiovascular disease. Prevention of Heart Disease a.  Physical inactivity — An inactive lifestyle is a risk factor for heart disease. Periodic medical examinations . Optimal body weight c. Dealing constructively with stress a. High blood pressure — High blood pressure increases the heart's workload.

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

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

CPR

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

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

Congestive Heart Failure Congestive Heart Failure(CHF)

CPR

 CHF = Inability of heart to pump blood out as fast as it enters.  Causes 1. Coronary Artery Disease 2. Chronic hypertension (high blood pressure) 3. AMI 4. Valvular heart disease Symptoms of CHF 1. Weakness 2. Dyspnea 3. Dyspnea on exertion 4. Orthopnea=Difficulty breathing on lying down 5. Congested neck veins 6. Tachycardia 7. Pulmonary Edema  Noisy, labored breathing  Coughing  Rales, wheezing  Pink, frothy sputu May be left-sided, right-sided, or both.

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

Arrhythmia Arrhythmia

CPR

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

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

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

Chapter 3

Patient assessment and early management

Patient Assessment and Early Management • What is Patient Assessment? • Why is Patient Assessment important? Phases of patient assessment – Scene Survey – Initial Assessment – Focused History and Physical Exam – Detailed Physical Exam – Ongoing Assessment – Communication – Documentation CPR Scene Size Up – Location – Incident – Injured/Injuries – Observe  Smoke?  Fire?  High line wires  Possible Mechanisms of Injury .

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

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

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

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

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

Chapter 4 Basic Vital Signs .

..TREAT PEOPLE!!!! Pulse • Pulse Points (fig..(4-1) pulse Points .Vital signs VITAL SIGNS CPR Vital signs are an outward clue to what is going on in the patient’s body • DO NOT TREAT NUMBERS ..4-1) Dorsal Pedal Posterior Tibial (Posterior and slightly inferior to medial Malleolus) Fig..

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

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

Chapter 5 Cardiopulmonary Resuscitation (CPR) .

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

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

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

5-2) Tap shoulder and shout ―Are you ok?‖ Fig.A. Shake & Shout at the person 2.Activate EMS (emergency medical service) if unresponsive= call 997 .8. 30 to 2 8.B.C) Survey The Scene. What is the ratio of chest compressions to ventilation in child and infant CPR? ANSWERS 1. Tilt head back & lift chin up 6. then: R – check Responsiveness (Fig. Look at chest to see if it rises & listen & feel for air coming from person's nose or mouth 3.(5-2) A . In the home 5. Placing victim on his or her side 7. KNOW WHAT TO DO? IT CAN BE AS EASY AS ( RAP. 30 to 2 CPR. Flat on the floor 4.

(5-3):Open Airway.5-3) Open victims' airway by tilting head back with one hand while lifting up chin with your other hand Fig.Position on back – All body parts rolled over at the same time – Always be aware of head and spinal cord injuries – Support neck and spinal column – victim must be on a hard surface – Place victim level or head slightly lower than body A .P . Head-tilt & Chin-Lift .AIRWAY • Head-tilt/chin-lift (Fig.

listen. & feel for breathing (5-10 seconds) 3. suspect choking. Position your cheek close to victim’s nose and mouth. perform abdominal thrusts second length) into victim's mouth (use (Heimlich maneuver) Fig. Look.5-4) 1. reposition head & try again. pinch victim's nose closed & give 2 full breaths(one microshield) 4. look toward victim’s chest 2. If breaths won't go in. If not breathing.B .BREATHING (Fig.(5-4):Give 2 Full Breaths . If still blocked.

5-5) 1. Check for return of pulse every minute (Fig.CIRCULATION(Fig.C . give Rescue Breathing at rate of 1 breath every 5 seconds 3. Carotid Pulse . Check for carotid pulse by feeling for 5-10se conds at side of victim’s neck 2. but victim is not breathing. If there is a pulse.5-4):Check Breathing.

If no pulse. With your other hand directly on top of first hand. No ACLS follow-up and delay in defibrillation u Only 15% who receive CPR live to go home u Improper techniques . Physician directed (do not resuscitate orders) 5. Victim revives 2. b) Perform 30 compressions to every 2 breaths. begin chest compressions as follows: a) Place heel of one hand on lower part of victim's sternum between the nipples. c) After 30 chest compressions give: 2 slow breaths d) Continue until help arrives or victim recovers e) Chek for pulse after 2 minutes (5 cycles) 5.5 to 2 inches(4-5 cm). depress sternum 1.4. Too exhausted to continue 3. If the victim starts moving: check breathing When Can I Stop CPR? 1. Unsafe scene 4. Delay in starting 2. Forget to pinch nose) 3. Cardiac arrest of longer than 30 minutes(controversial) Why CPR May Fail? 1. Improper procedures (ex.

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

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

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

Chapter 6 Choking .

The tongue is the most common obstruction in the unconscious victim (head tilt.Choking Choking Causes CPR 1. Turning blue Management of choking If victim is coughing strongly. Swelling (allergic reactions/ irritants) 5. Spasm (water is inhaled suddenly) How to Recognize Choking? 1. breathe or cough 3.chin lift) 2. Give 5 abdominal thrusts (Heimlich maneuver)(Fig. High pitched breathing sounds? 2. do not intervene Conscious Choking A. Vomit 3. Universal distress signal (clutches neck) 4.6-1) – Place fist just above the umbilicus (normal size) – Give 5 upward and inward thrusts . Foreign body (Foods) 4. Can’t speak.

Begin CPR 4. check for object before giving breaths breaths .B. After chest compressions. Continue until successful or victim becomes unconscious Fig.(6-1): Heimlich maneuver If Victim Becomes Unconscious After Giving Thrusts 1. Try to support victim with your knees while lowering victim to the floor 2. Assess 3.

You Enter An Empty Room And Find An Unconscious Victim On The Floor 1. Repeat Fig. Assess the victim (RAPABC) 2.(6-2):Choking Infant . Give CPR if needed 3.6-2) 1. Position with head downward 2. 5 chest thrusts (check for expelled object) 4. 5 back blows (check for expelled object) 3. After giving compressions: – look for object in throat – then give breaths Choking: Conscious Infants (Fig.

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

Chapter 7 External Defibrillation .

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

(7-1):Automated External Defibrillator(AED) Operational Steps 1.Fig. Confirm cardiac arrest 3. < 8 years old 2. Assess scene and patient 2. Deliver shock if indicated Do NOT use AED if patient is: 1. Weighs < 55 pounds . Turn on power 4. Attach device 5. Initiate rhythm analysis 6.

Stop CPR. Assess patient – ABCs – Presence of transdermal medication patches (nitro patches) 3. Assess scene for safety – Water – Explosive atmosphere – Patient on conductive surfaces 2.‖ – ―Clear‖ patient – Deliver shock – Immediately reanalyze . If machine says ―shock. Start BLS 5. Attach defibrillator 6. Confirm arrest – Unresponsive – Apneic – Pulseless 4. analyze rhythm(Avoid patient contact during analysis) 7.1.

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

Part Two First Aid .

Chapter 1 The Human Body Anatomy and Physiology .

spinal column. sweat glands. and nails Protects deep tissues from injury and synthesizes vitamin D Skeletal System (Fig. sebaceous glands. and nerves Is the fast-acting control system of the body Responds to stimuli Interprets environmental stimuli (Fig. and ligaments Protects and supports body organs Provides the framework for muscles Site of blood cell formation Stores minerals Muscular System(Fig.1-1) Composed of bone.Human Body First Aid The Human Body Anatomy and Physiology Integumentary System Forms the external body covering Composed of the skin.1-1) . cartilage.1-1) Composed of muscles and tendons Provides locomotion and facial expression Maintains posture Produces heat Provides protection and support Nervous System Composed of the brain. hair.

(1-2) Anatomic position . Oxygen – necessary for metabolic reactions 3. Atmospheric pressure – required for proper breathing and gas exchange in the lungs Anatomical Position Body erect.1-2) Directional Terms Superior Inferior Anterior Posterior Medial Lateral proximal Distal Superficial Deep Fig. Water – provides the necessary environment for chemical reactions 4. thumbs point away from body (Fig. palms facing forward.Survival Needs 1. Normal body temperature –necessary for chemical reactions to occur 5. feet slightly apart. Nutrients – needed for energy and cell building 2.

and is divided into two subdivisions Thoracic Abdominopelvic 1. and rectum (Fig. rachea.Body Cavities (Fig. Dorsal cavity protects the nervoussystem. 2.1-3) . Abdominopelvic cavity is separated from the thoracic cavity by the diaphragm It is composed of two subdivisions  Abdominal cavity – contains the stomach. Thoracic cavity is subdivided into Pleural cavities (two) – each houses a lung Mediastinum – between the pleural cavities. encases the spinal cord B. etc Pericardial cavity – encloses the heart. Houses esophagus. liver and other organs  Pelvic cavity – lies within the pelvis and contains the bladder.1-3) A. intestines. encases the brain Vertebral cavity – runs within the vertebral column. spleen. Ventral cavity houses the internal organs (viscera). reproductive organs. and is divided into twosubdivisions Cranial cavity – within the skull.

Chapter 2 Trauma .

000.000 injuries/year need medical attention  12% of all hospital beds occupied by trauma  350.000 permanently disabled/year  100.Introduction to Trauma Introduction to Trauma Management Facts about trauma Trauma is  The Leading cause of death at ages 1-40  Third leading cause in all age groups  50.000 to150.000 deaths/year  One-fifth to one-third of all deaths may be preventable When does trauma death occur? See the following diagram First Aid .

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

Penetrating 2. Down and under pathway(injuries) – Paper bag pneumothorax – Aortic tear from deceleration – Head thrown forward • C-spine injury • Tracheal injury ii. Up and over pathway(injuries) – Chest/abdomen hit steering wheel • Rib fractures • Flail chest .Types of Trauma 1. Blunt – Deceleration – Compression Motor Vehicle Collisions Five major types – Head-on – Rear-end – Lateral – Rotational – Roll-over Head-on Collision  Vehicle stops  Occupants continue forward  Two pathways – Down and under – Up and over i.

• Cardiac/pulmonary contusions • Aortic tears • Abdominal organ rupture • Diaphragm rupture • Liver/mesenteric laceration – Head injuries • Scalp lacerations • Skull fractures • Cerebral contusions/hemorrhages – C-spine fracture Lateral Collision l l l Car appears to move from under patient Patient moves toward point of impact Chest hits door l l l l l Lateral rib fractures Lateral flail chest Pulmonary contusion Abdominal solid organ rupture Upper extremity fracture/dislocations l l l Clavicle Shoulder Humerus Rotational Collision l l l l l Off-center impact Car rotates around impact point Patients thrown toward impact point Injuries combination of head-on. lateral Point of greatest damage = Point of greatest deceleration = Worst patients .

report – Surface • Decreased stopping distance = Increased injury • Always note. Females stab down .Roll-Over l l l Multiple impacts each time vehicle rolls Injuries unpredictable Assume presence of severe injury Falls l Critical Factors – Height • Increased height = Increased injury • Always note. report Assess body part that impacts first Fall onto Buttocks (injuries) l l Pelvic fracture Coccygeal (tail bone) fracture Lumbar compression fracture Fall onto Feet(injuries) – Bilateral heel fractures – Compression fractures of vertebrae – Bilateral Colles’ fractures Stab Wounds Facts about:  Damage confined to wound track o Four-inch object can produce nine-inch track  Gender of attacker o Males stab up.

 Evaluate for multiple wounds o Check back. buttocks  Chest/abdomen overlap – Chest below 4th ICS = Abdomen until proven otherwise – Abdomen above iliac crests = Chest until proven otherwise l Small wounds do NOT mean small damage Gunshot Wounds l Damage CANNOT be determined by location of entrance/exit wounds l l Severity cannot be evaluated in the field or Emergency Department Severity can only be evaluated in Operating Room Conclusion  Look at mechanisms of injury  The increased index of suspicion will lead to:  Fewer missed injuries Increased patient survival . flanks.

Trauma assessment TRAUMA ASSESSMENT I-Scene Size-Up l Ensure Safety of – Yourself – Your partner – Other responders – Bystanders – Patient l Scene survey – Location? – Appearance? – Where is patient? – What is condition of vehicle? – Mechanism of Injury? Amount of force? – II-Initial Assessment  Find life threats  If life-threat is present. DEAL and CORREC  If you can’t correct it: – Oxygenate – Ventilate – Transport – First Aid Most obvious or dramatic injury usually isn’t what’s killing the patient – Listen to patient’s chief complaint .

CLEAR . face. thorax trauma » Low O2 tension B. A-B-C-D A. Airway (with C-Spine Control) OPEN .LISTEN . Breathing LOOK . Asses mental status (Level of Consciousness) – A .Verbal – P .MAINTAIN – Noisy breathing = Obstructed breathing – But all obstructed breathing is NOT noisy – Manual stabilization of C-Spine – Assume airway problems with: » Head.Alert – V .Unresponsive ii. neck.FEEL – Is patient breathing? – Is patient moving air adequately? – Give O2 immediately if: o Change in O2 saturation o Possible shock o Possible severe hemorrhage o Chest pain .Initial assessment include i.Painful – U .

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

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

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

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

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

Chapter 3 Shock & Bleeding .

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

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

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

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

Control obvious bleeding 6. Do NOT elevate the lower extremities in cardiogenic shock 10. Assist ventilations as needed 4. Stabilize fractures 7.Treatment 1. Apply high concentration oxygen 3.Administer nothing by mouth. maintain airway 2. Prevent loss of body heat 8. even if the patient complains of thirst . Elevate lower extremities 8 to 12 inches in hypovolemic shock 9. Keep patient supine 5. Secure.

Elevation First Aid . Capillary Bleed • Dark red-Oozing Control of External Bleeding 1. Arterial Bleeding • Bright red-Spurting 2.3-1) • gloved hand • dressing/bandage 2. Venous Bleed • Dark red-Steady flow 3. can cause shock and death Identification of External Bleeding 1. Direct Pressure(Fig.Bleeding Bleeding Types – External – Internal • Traumatic • Non-Traumatic Significance: If uncontrolled.

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

swelling. tenderness. Keep in sitting position 4. or distended abdomen . Apply ice over nose 6. discoloration at injury site • Bleeding from any body orifice • Vomiting bright red blood or coffee ground material • Dark. lean forward 2. 15 min adequate – Epistaxis can result in life-threatening blood loss Internal Bleeding – causes: • Trauma • Clotting disorders • Rupture of blood vessels • Fractures (injury to nearby vessels) Can result in rapid progression to hypovolemic shock and death – Signs and Symptoms • Pain. tarry stools (melena) • Tender. Pinch nostrils together 3. Keep quiet 5.1. Sit up. rigid.

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

Chapter 4 Soft Tissue Injuries .

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

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

Laceration. damage to underlying tissues • Types – Linear – Stellate Punctures • Result from stabbing force • Wound is deeper than it is long • Difficult to assess injury extent • Object producing puncture may remain impaled in wound Avulsions (Fig.4-1) First Aid • Cut by sharp object • Typically longer than it is deep • May be associated with severe blood loss. Puncture.4-2) • Piece of skin torn loose as a flap or completely torn from body • Result from accidents with machinery and motor vehicles • Replace flap into normal position before bandaging • Treat completely avulsed tissue like amputated part . Avulsion Laceration (Fig.

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

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

Chapter 5 Musculoskeletal Injuries .

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

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

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

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

orthopedic injuries are NOT life-threatening. chest. possibly femur fractures. abdomen. bleeding • Eases pain When in doubt SPLINT .Assessment. pelvis w Assess distal neurovascular function First Aid w With exception of pelvic. treat life-threats w Assess for injuries of head. Management of musculoskeletal injuries Assessment of musculoskeletal injuries w Perform initial (primary) assessment w Locate. w Do NOT let spectacular orthopedic injury distract you from ABCs w It’s the unobvious things that kill patients! w Evaluation must ALWAYS be done of distal neurovascular function: – Pulse – Skin color – Capillary refill – Sensation – Movement Management of musculoskeletal injuries w Splinting • Prevents further movement at injury site • Limits tissue damage.

pain encountered stop. after splinting 4) Cover wounds with dry. below fracture 6) Dislocations: splint bone above. immobilize as it is . pain encountered stop. below joint 7) Minimize movement 8) Support injury until splinting completed 9) Pad splint to avoid local pressure 10) Angulated fractures w Realign before splinting w If resistance. immobilize as is 11) Dislocations w Splint as is unless circulation compromised w Attempt to reposition once to restore pulse w If resistance. dislocations and sprains Principles of Splinting 1) Do NOT move patients before splinting unless patient is in danger 2) Remove clothes to allow inspection of limb 3) Note.w It may be difficult to differentiate fractures. sterile compression dressings 5) Fractures: splint joint above. record distal neurovascular function before.

Chapter 6 Burns .

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

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

But all second degree burns don’t bliste .6-3) • • Extends through epidermis into dermis • Salmon pink • Moist.• Blanches under pressure • Possible swelling. no blisters • Heal in about 7 days 2) Second Degree (Partial Thickness) (Fig. shiny • Painful • Blisters may be present • Heal in ~7 to 21 days • Burns that blister are second degree.

6-3) • Through epidermis. dry • Pearly gray or charred black • May bleed from vessel damage • Painless • Require grafting l l l Often cannot be accurately determined in acute stage Infection may convert to higher degree When in doubt.3) Third Degree (Full Thickness) (Fig. over-estimate . dermis into underlying structures • Thick.

Adult Rule of Nines(Fig.6-4):Adult rule of Nine .Complications of Burns(Common Complications) Infection and Septicemia (can occur at any time during convalescence) Renal Failure Pneumonia Diabetes (Stress Diabetes) Curling's Ulcer (A stress ulcer specific to burns) Adrenocortical insufficiency Burn Extent: Rule of Nines A.6-4) Fig(.

subtract 1% from head. Pediatric Rule of Nines(Fig. add equally to legs Rule of Palm Patient’s palm equals 1% of his body surface area Burn Severity Based on • Depth • Extent • Location • Cause • Patient Age .B.6-5) For each year over 1 year of age.

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

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

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

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

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

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

• Dressing / hydrotherapy • Debridement • grafting • Splinting

Chapter 7

Head Injuries

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

Brain Concussion Skull Fractures • Injury to rigid box around brain • Indicates significant force • What happened to brain and neck? Types of Skull Fracture • Linear(fissure) – Most common – Crack in skull – Detected only on x-ray • Comminuted Multiple cracks radiate from impact point • Depressed – Bone fragments pressed inward – Places pressure on brain First Aid Injuries to Brain Brain Concussion • Temporary disturbance in brain function • Probably due to brain being ―rattled‖ inside the skull by a blow to the head .Skull Fracture.

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

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

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

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

Printice Newjersy. (2001): Hall-Inc. 3.2 edition. (1998): The Gist of Emergency edition. Hebb M.procpr. Adult Basic Life support..published by www.. . al.and Alexander M.9th edition.org. Limmer D.americanheart.org. et Emergency Care. 2.erbook. 4.References References Basic Emergency Care 1..USA. O'keefe M. American Heart Retrieved on 13-6-2007. Barron's Series.O.com.(2008): nd Medical Technician Exam.3rd Emergency educational Association. Grant H. www. 5. www. Chapleau W. Medicine.

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