First Aid Reference Guide PDF

FIRST AID REFERENCE GUIDE sja.ca St. John Ambulance Canada would like to thank Bell Let’s Talk for its funding and support of our mental health awareness project. By including mental health and wellness material in this guide, we are opening the conversation about mental health in first aid classes...

FIRST AID REFERENCE GUIDE sja.ca St. John Ambulance Canada would like to thank Bell Let’s Talk for its funding and support of our mental health awareness project. By including mental health and wellness material in this guide, we are opening the conversation about mental health in first aid classes across Canada. FIRST AID REFERENCE GUIDE Fourth Edition Fourth edition – January 2019 Copyright © 2019 Priory of Canada of the Most Venerable Order of the Hospital of St. John of Jerusalem. All rights reserved. Users are not permitted to perform any of the following actions without the express written consent of the Priory of Canada of the Most Venerable Order of the Hospital of St. John of Jerusalem (St. John Ambulance Canada): Remove any copyright notices or other proprietary notices from this book. Revise, alter, adapt or modify the content of this book. Create any derivative works incorporating, in part or in whole, the content of this book. Provide or make electronically available this book, or part of it, on any website or through any other electronic means. Certification Knowledge of the information contained in this book does not constitute an endorsement of a user’s qualifications by St. John Ambulance. A user’s qualifications are recognized by St. John Ambulance only after the successful completion of a St. John Ambulance training course, which includes practical activities and formal assessment of knowledge and skills, and the issuance of a training certificate. Library and Archives Canada Cataloguing in Publication First Aid: Reference Guide, formerly published as First on the scene: the complete guide to first aid and CPR. — 4th ed. Includes index. ISBN 978-1-897513-00-2 1. First aid in illness and injury. 2. CPR (First aid). I. St. John Ambulance II. Title: First Aid : First on the Scene. RC86.8.F59 2006 616.02’52 C2006-901819-7 Chain of Survival® is a registered trademark of the Heart and Stroke Foundation of Canada EpiPen® Auto-Injector is a registered trademark of the EM Industries, Inc. Tylenol® is a registered trademark of McNeil Consumer Products. Tempra® is a registered trademark of Mead Johnson Canada. Water-Jel® is a registered trademark of Water-Jel Technologies Inc. Viagra® is a registered trademark of Pfizer Pharmaceuticals. Printed in Canada sja.ca Stock No. 6504-16 Medical advisory group for St. John Ambulance St. John Ambulance is a leading provider of first aid training in Canada offering its courses to over half a million Canadians each year. St. John Ambulance is committed to providing Canadians with first aid training that is based on scientific evidence and that reflects emerging trends in first aid and emergency care. A Medical Advisory Group has been established to support the adoption of evidence based practice and to contribute to shaping the future of first aid by providing technical expert advice to St. John Ambulance. The purpose of the Medical Advisory Group is to a) provide advice and recommendations to SJA on the appropriateness of first aid practices in accordance with the scientific evidence and b) advise on emerging trends in first aid and emergency care that may impact SJA programs. Below are the names and credentials of the members of our Medical Advisory Group. We are proud to have them as part of our community. Dr. Robert Boyko, MD, CCFP(EM), FCFP Dr. Trevor Jain, BSc, MD, CCFP(EM), MSc Dr. Brian Metcalfe, BSc, MD, CCFP(EM) Dr. Jonathan Wallace, PCP, BSc, MD, CCFP(EM,FPA) FRACGP Steven Anas, PCP Kevin Morgan, BAHSc, A-EMCA St. John Ambulance St. John Ambulance is a charity and international humanitarian organization dedicated to helping Canadians improve their health, safety and quality of life through training and community service. Revenue generated from first aid/CPR training supports St. John Ambulance’s charitable work in Canada and around the world. Coast-to-coast, more than 12,000 front-line volunteers serve communities by providing first aid services at public events and during emergencies. St. John Ambulance volunteers also improve quality of life through programs that help seniors, the disadvantaged, and youth. As Canada’s leading authority in first aid and CPR services since 1883, St. John Ambulance offers innovative programs and products to save lives at work, home, and play. To contact your local St. John Ambulance, visit www.sja.ca. Fast facts Established in 1883 in Canada with roots going back 900 years Issues over 500,000 certificates in first aid and CPR to Canadians each year Supports humanitarian relief efforts across Canada and around the world St. John Ambulance front-line volunteers provide service at approximately 10,000 public events annually More than 1 million volunteer hours of community service are provided annually More than 100,000 individuals were assisted by St. John Ambulance volunteers in 2014 365 Canadians were formally recognized for their efforts to save a life in 2015 Approximately 3,000 St. John Therapy Dog teams provided over 200,000 volunteer hours in 2014 This Reference Guide was developed in accordance with the 2016 Canadian Consensus Guidelines on First Aid and CPR, an evidence-based set of recommendations on training and standards of practice for first aid and CPR. The guidelines are released by the Canadian Guidelines Consensus Task Force comprised of the Heart and Stroke Foundation, the Canadian Red Cross, St. John Ambulance, the Canadian Ski Patrol, and the Lifesaving Society. Disclaimer The information (“Information”) provided in this book is for general use and knowledge and does not contain all information that may be relevant to every situation. The Information cannot be relied upon as a substitute for seeking guidance from appropriate professionals, such as physicians. Users acknowledge and agree that St. John Ambulance is not responsible or liable for the user’s actions or decisions resulting from the information (including information regarding medication or other drugs) in this book, including but not limited to choosing to seek or not to seek advice from medical professionals such as physicians. St. John Ambulance cautions users of this book not to prescribe or administer any medication, including over-the-counter medication, except in instances where permitted by law. Inclusion of symptom relief medication in workplace first aid kits falls outside the scope of this book. Access and dispensing of symptom relief medication in the workplace must be done in accordance with the employer directives and any applicable law. Although St. John Ambulance takes great care to reflect the most current and accurate information at time of publication, it does not represent or warrant that the information contained in this book will be accurate or appropriate at time of reading or use due to evolving medical research, protocols, regulations and laws. It is the responsibility of the user of this book to be knowledgeable of changes in acceptable practices when providing first aid, and applicable laws and regulations in which first aid may be provided. The information in this book is provided “as is” and without warranties or conditions of any kind either express or implied. To the fullest extent permitted by applicable law, under no circumstances, including, but not limited to, negligence, shall St. John Ambulance be liable for any direct, indirect, incidental, special or consequential damages that result in any manner from the use of or reliance on information and answers provided in this book. Emergency Phone Numbers Police Fire Ambulance Poison Control Emergency Contact Name Phone Home Phone Street Address Table of Contents Chapter 1 Introduction to First Aid Roles and responsibilities First aid and the law Safety and personal protection Help at the emergency scene Signs and symptoms and mechanism of injury Good communication Injuries and illnesses Stress management in emergency situations 12 12 15 17 22 23 27 29 31 Chapter 2 Emergency scene management Steps of ESM Scene Survey Primary Survey Secondary survey Ongoing casualty care Multiple casualty management (triage) Lifting and moving Extrication 34 34 35 35 43 52 62 66 79 Chapter 3 Airway and breathing emergencies Hypoxia Effective and ineffective breathing Breathing emergencies caused by illness Choking 82 82 83 85 93 Chapter 4 Cardiovascular emergencies and CPR Cardiovascular disease Angina and heart attack Chain of Survival® Stroke and transient ischemic attack (TIA) Cardiac arrest Cardiopulmonary Resuscitation (CPR) Automated External Defibrillation—AED 106 106 108 109 113 115 115 124 Chapter 5 Wounds and bleeding Dressings, bandages, and slings Types of Wounds Bleeding Internal bleeding Amputations 130 130 139 142 145 146 8 Minor Wound Care First aid for hand and foot injuries Chest injuries Abdominal injuries Crush injuries Scalp and facial injuries Eye injuries Burns Bites and stings 147 148 154 155 157 158 162 167 180 Chapter 6 Bone and joint injuries Fractures Dislocations & Sprains Head and spinal injuries Pelvic injury Chest injury Splinting materials First aid for specific bone & joint injuries Strains 188 188 189 193 200 201 203 205 223 Chapter 7 Other first aid emergencies Diabetes Seizures and convulsions Opioid Overdose Environmental Emergencies Cold-related injuries Heat-related injuries Poisoning Emergency childbirth and miscarriage Mental Health Awareness 226 226 228 231 235 235 244 249 253 260 Chapter 8 Basic Life Support for Healthcare Providers Age categories for resuscitation Artificial respiration Cardiopulmonary resuscitation (CPR) Quick first aid reference 268 268 270 278 289 Appendix A 286 Appendix B 304 Index 328 9 Chapter 1 Introduction to First Aid Roles and responsibilities First aid n the workplace First aid and the law Safety and personal protection Signs and symptoms and mechanism of injury The importance of medical help Stress management in emergency situations Introduction to Introduction to First Aid 1 Chapter 1 Introduction to First Aid This guide covers a wide range of information that will help you respond appropriately in a first aid or medical emergency. The introductory chapter contains background information, definitions and other material related to giving first aid. Chapter 2 explains casualty management including issues that relate to assessment of the casualty. This chapter also includes topics that are important to understand in the first critical moments at the emergency scene. Chapter 5 deals with issues of particular interest to health care providers—responders with a specific duty to respond within the health care system. This guide is used to support the teaching of these and other courses: Standard and Emergency First Aid Basic and Intermediate First Aid CPR at all levels including Basic Life Support/Health Care Provider (BLS/HCP) Some content contained in this guide will not pertain specifically to the level of training you have received. First aiders should always remember not to exceed their training, or the regulations/ legislation of their province or territory. Roles and responsibilities What is first aid? First aid is emergency help given to an injured or suddenly ill person using readily available materials. A person who takes charge of an emergency scene and gives first aid is called a first aider. The injured or ill person is called a casualty. The three priorities of first aid, in order of importance, are to: 12 Preserve life Prevent the illness or injury from becoming worse Promote recovery Introduction Introduction to First Aidto First Aid What can a first aider do? First aiders do not diagnose or treat injuries or illnesses (except, perhaps, when they are very minor)—this is what medical doctors do. A first aider suspects injuries and illnesses, and gives first aid at the scene. Besides giving first aid, it is important to: Protect the casualty’s belongings Keep unnecessary people away Reassure family or friends of the casualty Clean up the emergency scene and work to correct any unsafe conditions that may have caused the injuries in the first place First aiders within a workplace may have obligations and protections under federal, provincial, and territorial legislation regarding administering medications. Refer to federal, provincial, or territorial legislation and regulations for the requirements in your area. When assisting with medications, the first aider should check the label and ensure the following “5-rights” are met: Right Person – the name of the casualty is the name on the medication Right Medication – is this the right medication for this situation? Right Amount – what are the dosing instructions Right Method – how is this medication to be taken? (By mouth, inhaled, etc.) Right Time – is this the right time to take this medication? 13 1 Introduction to First Aid 1 A casualty’s age in first aid and CPR The procedures related to the provision of first aid and cardiopulmonary resuscitation (CPR) differ in some ways, depending on the age and size of the casualty. In first aid and CPR: An infant casualty is under one year old A child casualty is from age one to age eight An adult casualty is over eight years of age It is important to recognize that these ages are guidelines. The size of the casualty must be considered. First Aid in the Workplace Workplace first aid is emergency care given by a person who is trained (and designated) to be the first aid provider to a co-worker who is injured or suddenly ill. All provinces and territories have a provision within legislation relating to first aid in the workplace. Refer to your provincial or territorial regulations for what is required in your area. Giving first aid as part of your job When giving first aid is part of your job, you have a duty to use reasonable skill and care based on your level of training. There are regulations to protect the first aider. For example in workplaces regulated by the Canada Labour Code, Section 126(3) of the Code states: “No employee is personally liable for anything done or omitted to be done in good faith by the employee when the employee is assisting the employer, as requested by the employer, in providing first-aid or in carrying out any other emergency measures.” Every workplace in Canada is required under federal, provincial, or territorial regulations to have a first aid kit. The size and contents of the first aid kit will be determined by those regulations. First aid providers are encouraged to be familiar with the contents of their workplace first aid kit, its location, and to conduct regular inspections of the kit. 14 Introduction to First Aid First Aid as part of OHS Provincial and territorial regulations and legislation contain requirements for first aid training in their jurisdiction. Most regulations require at least one designated first aid provider at work at all times. The level of training required by the first aid provider will depend on the size of the workplace, the distance to medical help, and the risk of injury in the workplace. To help ensure compliance with regulations, it is recommended to have more than one person on each shift trained in first aid to account for holidays, illness, and breaks. OHS Legislation Provinces and territories are responsible for establishing Occupational Health and Safety legislation to protect workers. All workplaces that fall under provincial or territorial jurisdiction concerning regulations are required to adhere to the legislation and regulations of that province or territory. Those work places that fall under federal jurisdiction are subject to the Canada Labour Code. Housed within the legislation and regulations are provisions for adequate first aid coverage for a workplace, usually based on some or all of the following: The number of workers The potential risks The distance from medical care First aid and the law Note that St. John Ambulance is not giving legal advice. This guide is not intended to replace advice given by a lawyer or legal professional. Principles of the Good Samaritan Across Canada Good Samaritan laws and principles protect first aiders from lawsuits. You are a Good Samaritan if you are a bystander who helps a person when you have no legal duty to do so. As a Good Samaritan, you give your help without being paid, and you give it in good faith. Whenever you help a person in an emergency situation, you should abide by the following principles: 15 1 Introduction to First Aid 1 You identify yourself as a first aider and get permission to help the injured or ill person before you touch them—this is called consent You use reasonable skill and care in accordance with the level of knowledge and skill that you have You are not negligent in what you do You do not abandon the person Consent The law says everyone has the right not to be touched by others. As a first aider, you must respect this right. Always ask if you can help. If the casualty cannot answer, you have what is called implied consent, and you can help. If the casualty is an infant or a young child, you must get consent from the child’s parent or guardian. If there is no parent or guardian at the scene, the law assumes the casualty would give consent if they could, so you have implied consent to help. A person has the right to refuse your offer of help. In this case, do not force first aid on a conscious casualty. If you do not have consent to help, there may be other actions you can take without touching the casualty, such as controlling the scene, and calling for medical help. Be aware of difficulties in communicating when a casualty: Is hard of hearing Speaks a different language Is visually impaired Is a child Is in pain Shows signs of mood disorder Reasonable skill and care As a Good Samaritan, when you give first aid you are expected to use reasonable skill and care according to your level of knowledge and skills. 16 Introduction to First Aid Negligence 1 Give only the care that you have been trained to provide, and always act in the best interest of the casualty. Abandonment Never abandon a casualty in your care. Stay until: You hand them over to medical help You hand them over to another first aider They no longer want your help—this is usually because the problem is no longer an emergency, and further care is not needed Check your applicable workplace legislation/ regulations Giving first aid in Quebec The Quebec Charter of Human Rights and Freedoms declares that any person whose life is in danger has the right to be helped. This means that you are required to help a person whose life is at risk, provided you do not put your own life, or anyone else’s, in danger. Safety and personal protection In any emergency, first aid providers must always be aware of hazards and give first aid safely. A hazard is anything that poses a risk of injury or death to a first aid provider. There are three basic types of risks to be aware of: The energy source that caused the original injury—is the mechanism that caused the original injury still active, causing injury to others? Example: where an injury has been caused by machinery, is the machinery still running? There may be hazards caused by external factors. Example: passing vehicles may pose a risk at the scene of a motor vehicle incident There may be hazards associated with first aid procedures or a rescue. Example: moving a heavy casualty could place the first aider at risk of injury 17 Introduction to First Aid 1 Some hazards can be controlled by the first aid provider. When controlling hazards, keep the following principles in mind: Use mechanical means whenever possible (broom, dustpan, tools, etc.) Be careful when lifting or moving objects on or near a casualty Have someone assist you where possible Turn on lights where no other risks to doing so exist Ensure safe footing – many injuries to first aiders are a result of slips and falls. Hazards that require specialized training to control (electrical hazards, fire, gases, etc.) should only be controlled by those who are properly trained. Most workplaces that deal regularly with these types of hazards will have a specialized response team. Refer to your workplace’s policies and protocols. When dealing with chemical hazards, a Safety Data Sheet (SDS/ MSDS) should be accessible and will provide information on how to control the hazards along with first aid directions. Preventing infection Airborne pathogens Examples of infections that can be spread through the air are: Meningitis is a bacterial or viral infection which causes swelling that affects the spinal cord and brain Tuberculosis is a bacterial infection that primarily affects the lungs, but can affect any part of the body Influenza, or “the flu,” is a viral infection which is easily spread, and can vary from being mildly debilitating to fatal Body fluid and blood-borne pathogens Exposure to blood or body fluids (i.e. vomit, feces) poses a health risk to first aiders. There are three diseases that first aiders should be aware of: 18 Human immunodeficiency virus (HIV) is the virus responsible for AIDS. There is no vaccine to protect people from this virus. The best defence remains adequate Introduction to First Aid protection to help prevent infection. Hepatitis B is one of the three common forms of hepatitis, a viral disease that can cause severe liver damage. Some people who have Hepatitis B have no symptoms but are still contagious. There is a vaccine to prevent Hepatitis B. Hepatitis C causes much of the same liver damage as Hepatitis B, but there is currently no vaccine available to prevent this disease. Sharp objects If a sharp object touches infected blood and then pricks or cuts your skin, you could become infected. First aiders do not use sharp objects like scalpels and needles, but there may be broken glass or other sharp objects that have been in contact with blood or other bodily fluids. Always wear gloves and handle sharp objects with extreme care. Personal Protective Equipment Personal Protective Equipment (PPE) is clothing and equipment used to protect the first aider and to minimize the risks of health and safety hazards when in contact with a casualty. PPE can be gloves, a pocket mask used for ventilations, a helmet, eye protection, safety boots, etc. Use a face mask or shield when providing artificial respiration or CPR. Always follow the manufacturer’s directions for disinfecting and cleaning reusable items. Single-use masks, one-way valves, and gloves are disposed of by double bagging with other contaminated articles. If used in the workplace, follow provincial/territorial and/or company protocols for disposal of hazardous items. Disposable gloves prevent direct hand contact between the first aider and the casualty. Wear gloves when you might touch blood, bodily fluids, tissue or anything that has come in contact with one of these. If you tear a glove, wash your hands as soon as possible, and put on a new pair. Dispose of contaminated gloves by sealing them in a plastic bag and double-bagging them. 19 1 Introduction to First Aid 1 How to remove gloves Once gloves have been used, they are contaminated and are a possible source of infection. Take them off without touching their outer surface following the steps below. 20 Introduction to First Aid Protecting the first aider Areas of the body that may have come into contact with a casualty need to be cleaned with hot, soapy water, an anti-septic solution, or a mixture of bleach and water (at a ratio of 1:10). Spills should be cleaned, then sanitized with the bleach and water solution for 20 minutes. Anyone who has been exposed to possible contaminants should take a hot shower with soap and rinse thoroughly. Anyone who has been exposed to contaminants from a needle stick or sharps injury should seek medical attention. If an injury occurs due to violence, or a first aider and/or casualty becomes at risk due to violence, you must protect yourself and call for help. Your skills as a first aider are valuable only when the area is safe. Clean up After an emergency, it is important to clean-up the area and equipment used properly. Any hard surfaces should be disinfected. Fabrics, where possible, should be laundered. Porous surfaces or materials that cannot be laundered may need to be disposed of. Items intended to be reused (scissors, forceps) should be wiped of blood and fluids, immersed in a 10% bleach solution (or other disinfecting solution) for 10 minutes, then rinsed and dried One-time use items (gauze, gloves) should be put into a garbage bag and tied. That garbage bag can then be put into the regular garbage. Any surfaces contaminated by blood or other fluids should be cleaned with a bleach solution or other disinfecting solution Sharps In an emergency, sharp objects (or “sharps”) may be the cause of the injuries, or used in the first aid. It is important to dispose of these sharp objects properly for both the safety of first aid providers and others. Sharps can include needles, knives, and broken glass. These items may contain contaminated blood and can cut the first aider, exposing them to the contamination. 21 1 Introduction to First Aid 1 Cleaning up glass should always be done with mechanical means such as a broom and dustpan. The cleaned up glass should be placed in a puncture-proof container like a cardboard box. When handling knives, always grasp by the handle and carried blade down. Cleaning knives should follow the steps above for hard surfaces. Needles should be disposed of in a sharps container. These plastic containers have thick walls and a secured lid that prevents accidental punctures. Ambulances will carry sharps containers and any needles found or used during an emergency can be placed in these containers. Always handle needles by the barrel (the plastic part with the plunger) and never try to re-cap a used needle. Needles must never be disposed of into the general garbage. Help at the emergency scene Bystanders should be asked to leave unless asked to stay and assist. Other first aiders may offer to help. Identify yourself and accept their assistance. If someone is more qualified to handle the situation, you may ask that person to take control. First responders include ambulance personnel, police officers and firefighters. They will take charge of the scene as soon as they arrive. Other authorities may be called to the scene (e.g. an electrical utility crew may arrive if there are downed power lines). Identify yourself and continue giving first aid. Off-duty doctors, nurses and other health professionals may identify themselves and offer to help. 22 Introduction to First Aid Ten ways a bystander can help 1. Make the area safe 2. Find all the casualties 3. Find a first aid kit 4. Control the crowd 5. Call for medical help 6. Help give first aid, under your direction 7. Gather and protect the casualty’s belongings 8. Take notes 9. Reassure the casualty’s relatives 1 10. Lead the paramedics to the scene of the emergency Signs and symptoms and mechanism of injury When referring to injuries, first aiders need to understand signs and symptoms. A sign is something we can see, feel, hear or smell (e.g. bleeding, bruising, agonal breathing, skin discolouration). A symptom is something the casualty is feeling (e.g. nauseous, weakness, pain) and must tell you. Mechanism of injury encompasses both what happened to the casualty, and how the injury has affected the casualty. It identifies the cause of the injury. Mechanisms of injury that require an ambulance right away: A fall from 6.5 meters (20 feet) or more A vehicle collision with signs of a severe impact Severe damage to the inside of the vehicle, a bent steering wheel, or a broken windshield Casualty was thrown from a vehicle The vehicle has rolled over Casualty was struck by a vehicle Crush injuries 23 Introduction to First Aid 1 When any of these mechanisms are apparent, call an ambulance as soon as you can. When we understand the cause of the injury, we are able to predict what injuries may be present and what injuries are not likely, even in situations in which there are no visible signs of injury and/or the casualty is unable to describe their symptoms. Signs and symptoms Examples of Signs and Symptoms Signs you can see Blood, deformity, bruising, unequal pupils, painful expression and/ or flinching, sweating, wounds, unusual chest movement, skin colour, swelling, foreign bodies, vomit, incontinence Signs you can hear Noisy or distressed breathing, groans, sucking wounds (chest injury), bones scraping together, quality of speech Signs you can feel Dampness, skin temperature, swelling, deformity Signs you can smell Casualty’s breath (fruity breath, acetone/nail polish breath, or alcohol), vomit, incontinence, gas fumes, burning, solvents or glue Symptoms the casualty may tell you about Pain, fear, heat, cold, loss of normal movement, loss of sensation, numbness, tingling sensation, thirst, nausea, faintness, stiffness, feeling faint, weakness, memory loss, dizziness, sensation of a broken bone 24 Introduction to First Aid The importance of medical help In first aid, any type of medical care is referred to as medical help. Unless an injury is very minor, you should always make sure the casualty receives medical help following first aid. Medical help may be given at the scene, en route to a medical facility, or in a hospital. Know the EMS telephone number for your community. This is often 9-1-1 in urban areas. If you are outside of your community, find the EMS phone numbers in the first few pages of the telephone book, or search online. Calling for medical help is important. The period immediately following a severe, life-threatening injury is known as the golden hour. This time is “golden” because the faster a casualty makes it to a hospital emergency room or operating room, the better the chances of survival and recovery. You can ask a bystander to call for medical help. Provide the person with: Necessary phone number A description of the casualty’s condition Directions to follow to reach the scene Instructions to report back to you after getting medical help If you are alone, you must decide whether to stay with the casualty or leave to get help. The correct decision will depend on the specifics of the situation. If you have a mobile phone, call from the scene and perform first aid with the dispatcher’s assistance. Medical care As a first aider you are not trained to diagnose the nature and extent of an injury or illness; a medical doctor has the training to do this. As a rule, make sure the casualty receives medical care following first aid. For minor injuries, this may not be necessary. Medical care is either given by a medical doctor or under the supervision of a medical doctor. Paramedics give medical care because they work under the supervision of medical doctors. Medical care is given in hospitals but it can also be given at the emergency scene or on the way to a medical facility. 25 1 Introduction to First Aid 1 Call an ambulance or drive the casualty to the hospital? Always call an ambulance if you can; only transport the casualty to medical help yourself if that is the only possible way to get medical help. Transporting an injured person is often difficult and timeconsuming. An ambulance or other rescue vehicle is well-equipped, and the casualty can begin receiving medical help as soon as it arrives. When an ambulance arrives, do not stop the first aid you are providing until the crew has arrived to the casualty and indicates they are ready to take over. Give a short report to the ambulance crew on the situation; the condition of the casualty; and what you have done so far. Use MIST to help remember what to report: M – Mechanism of Injury I – Injuries or illnesses found S – Signs and symptoms T – Treatment (first aid) provided so far The Good Samaritan principles only protect you when giving care at the scene of the emergency, or while transporting the casualty when this is needed to save the casualty’s life and medical help is not available. Transporting the casualty unnecessarily leaves you liable if it results in further injury should an accident or incident occur while en route to a hospital or medical station. 26 Introduction to First Aid Good communication Communication is necessary in every emergency situation, regardless of the details. As the first aider, there are many people you may need to communicate with – the casualty, bystanders, family members, other first aiders, EMS providers, and other professionals (e.g. police, fire, hydro). Effective communication skills will help you to assess the casualty’s condition, and explain what you are doing and why. Some rules for effective communication: Be calm and direct Be respectful Do not use medical terms Call the casualty by name Do not diagnose the casualty’s condition Always be honest, reassuring, and choose your words carefully As a first aider, the first thing you do when you arrive at an emergency scene is take charge of the situation. You stay in charge until you hand control of the scene over to more qualified people. While in charge, many other people may offer to help. When handing the scene over to someone other than the casualty, describe the complete history of the incident and pass along any notes you have taken. Be sure to include: Your name The time you arrived The history of the illness or injury, including signs and symptoms observed What first aid has been given Any changes in the casualty’s condition since you took charge Principles of communication Though each situation is different, the following general guidelines help improve communication. 27 1 Introduction to First Aid 1 Focus Maintain your attention on the casualty. Position yourself at eye level and maintain eye contact. Terminology Refrain from using medical terminology when communicating with the casualty or bystanders. Explanations and answers must be clear, concise and easily understood. Body Language Refrain from using body language that could be perceived as threatening or aggressive. Professionalism Always maintain your professionalism. Explain everything you are doing and why. If what you are doing may be painful, let the casualty know. Barriers to communication Despite following the principles of communication above, there are certain barriers that may arise making communication difficult. Language – the casualty or bystanders may not speak the same language as the first aid provider Physical – the casualty or bystanders may have a hearing, speech, or visual impairment Cognitive – the casualty or bystander may not understand the questions or requests Cultural – different cultures approach interactions with others which may impact communication Environment – noisy situations can make communication very difficult Technical – failure or limitations of communication devices (radios, phones) can hinder communication When faced with these barriers, the first aid provider may have to attempt several different ways to gather information or give directions. 28 First aid providers should also remember to keep things simple, clear, and to the point. Drawn out descriptions using large words can make it very difficult for the casualty or those around to understand. An example would be “Get me the AED” instead of “I need you to find an Automated External Defibrillator so I can perform cardiopulmonary resuscitation.” 1 Injuries and illnesses Injuries When something from outside the body damages tissues, the damaged area is called an injury. How serious an injury is depends on: What tissues are injured—an injury to a vital organ, or tissues of a vital system, like the nervous system, is serious How bad the injury is—for instance, a bone broken in half may not be as serious as the same bone shattered into many pieces How much tissue is injured—a burned hand may be more serious than a burned finger Injuries and energy Injuries and energy Injuries result from too much energy being applied to the body. For instance: A thermal burn is caused by too much heat energy An acid burn is caused by too much chemical energy Snow-blindness is caused by too much light energy A broken bone is caused by too much mechanical energy A stopped heart from an electric shock is caused by too much electrical energy The body can take a certain amount of energy without being injured. But too much of any sort of energy will cause injury. Three factors determine whether an injury will occur. They are: How intense the energy was How long the energy was applied to the body What part of the body the energy was applied to 29 1 Most injuries are caused either by something hitting the body or the body hitting something—this is mechanical energy. When something moves, it has mechanical energy. How much mechanical energy something has depends on how fast it is moving and how much it weighs. Illness We often think of first aid in the context of injuries only. But when someone becomes very sick, the result can be a medical emergency in which first aid can save a life. Some illnesses, like heart attacks or strokes come on very fast. Other illnesses progress more slowly and it can be hard to decide exactly when you have a medical problem that calls for a doctor’s attention. Get medical help when any of the following is present: Sudden severe pain in any part of the body Sudden changes in vision, headache or dizziness Severe or persistent diarrhea or vomiting Sudden weakness or slurred/jumbled speech Persistent high temperature Changes in level of consciousness Rash of unknown origin Repeated fainting Obvious depression, suicide threats or attempts Whenever you are very worried about yourself or someone in your care If the casualty is an infant, the following are also reasons to get medical help (in addition to the reasons above): 30 The baby has had a seizure The baby is blue or very pale You think the baby is having trouble breathing The baby cries a lot, or won’t stop crying Stress management in emergency situations 1 First aiders may experience a certain level of stress as a result of the assistance they provide. Stress is the body’s normal reaction to physical and psychological events. It can be seen in certain attitudes and behaviours in both casualties and first aiders. It is a biological response and may be reflected in: An increase in heart rate An increase in blood pressure An increase in blood sugar Dilation of the bronchi and pupils Possible reactions of casualties Casualties may react to stressors in different ways and first aiders must observe and adjust to such reactions which can include: Denial—the casualty may deny the seriousness of the situation and refuse assistance Resignation—the casualty may be resigned to dying even if their life does not seem to be in danger, and doesn’t want to make any effort to do what is needed Aggressiveness—the casualty may be hostile Assertiveness—the casualty is positive, cooperative, and may even want to take charge of their own care including directing the first aiders Stress management Managing stress in an emergency situation can make a significant difference in the quality of first aid provided. Appropriate mental preparation and regular first aid skill practice can help first aiders react effectively when faced with an emergency situation. The negative impact of stress can be reduced by understanding it and taking measures to try and overcome it. After serious incidents, it is important for first aiders to process their emotions. When faced with a highly stressful situation some first aiders may experience prolonged effects of stress and they should seek medical assistance. 31 Chapter 2 Emergency Scene Management Four steps in ESM Step one: scene survey Step two: primary survey Step three: secondary survey Step four: ongoing casualty care Shock Fainting Multiple casualty management (triage) Lifting and moving Emergency scene management Chapter 2 Emergency scene management 2 Emergency scenes generally begin with confusion as people realize there is an emergency unfolding in front of them. No one knows what to do first, who should be in charge, or how they can help. In this situation, the first aider needs to follow a sequence of actions that ensures safe and appropriate first aid is given and everyone’s safety is protected. First aiders use emergency scene management (ESM) to do this. Emergency scene management is the sequence of actions you should follow to ensure safe and appropriate first aid is given. Steps of ESM 1. Scene survey—during the scene survey you take control of the scene, find out what happened and make sure the area is safe before assessing the casualty. 2. Primary survey—assess each casualty for life-threatening injuries and illnesses, call or send someone to call 9-1-1, and give life-saving first aid. 3. Secondary survey—the secondary survey is a step-by-step way of gathering information to form a complete picture of the casualty’s overall condition. 4. Ongoing casualty care—during ongoing casualty care you continue to monitor the casualty’s condition until medical help takes over. These steps are generally done in the order above. The initial scene survey, primary survey and the start of life-saving first aid usually happens within one or two minutes. The secondary survey is not always necessary. 34 Emergency scene management Scene Survey Take charge of the situation Call out for help to attract bystanders Assess hazards and make the area safe Find out the history of the emergency, how many casualties there are and the mechanism(s) of injury Identify yourself as a first aider and offer to help, get consent Assess responsiveness 2 Send or go for medical help as soon as you identify a serious problem and then begin the primary survey. If you have a mobile phone, you can dial 9-1-1 or your local emergency number, and put the device on speaker phone, if possible. This allows the first aider to remain with the casualty. Primary Survey Check for life-threatening conditions, the ABCs: A = Airway B = Breathing C = Circulation The sequential steps of the primary survey should be performed with the casualty in the position found unless it is impossible to do so. The primary survey should begin immediately after the scene survey. Check the airway If the casualty is conscious, ask “what happened?” How well the casualty responds will help you determine if the airway is clear. Use a head-tilt-chin-lift to open the airway of an unresponsive casualty. If you suspect a head or spinal injury, and have been trained, use a jaw-thrust without head-tilt. 35 Emergency scene management Check for breathing 2 If the casualty is conscious, check by asking how their breathing is. If the casualty is unconscious, check for breathing for at least five seconds, and no more than 10 seconds. If breathing is effective, move on to check circulation. If breathing is absent or ineffective (gasping and irregular, agonal), begin CPR. Check circulation Control obvious, severe bleeding Check for shock by checking skin condition and temperature Check with a rapid body survey for hidden, severe, external bleeding and signs of internal bleeding Rapid body survey The rapid body survey is a quick assessment of the casualty’s body which is performed during the primary survey. By running your hands over the casualty’s entire body from head to toe (and under heavy outwear), you are able to feel for severe bleeding, internal bleeding and any obvious fractures. When performing the rapid body survey: 36 Wear gloves when possible, and check gloves for blood every few seconds Be careful not to cause any further injuries while performing the survey Look at the casualty’s face to notice any responses to the rapid body survey Emergency scene management Provide first aid for life-threatening injuries or conditions. Maintain an open airway with a head-tilt chin-lift or by placing the unresponsive breathing casualty into the recovery position Provide CPR if the unresponsive casualty is not breathing or not breathing normally (gasping) Control severe bleeding Provide support for obvious fractures Give first aid for shock by providing first aid for lifethreatening injuries and maintaining the casualty’s body temperature Evaluate the situation and decide whether to do a secondary survey 2 Do a secondary survey if: The casualty has more than one injury Medical help will be delayed more than 20 minutes Medical help is not coming to the scene and you have to transport the casualty If you do not do a secondary survey, steady and support any injuries found and give ongoing casualty care until medical help arrives. How to turn a casualty face up You should give first aid in the position in which the casualty is found as much as possible. But sometimes you have to turn a casualty over to assess for life-threatening injuries or to give lifesaving first aid 1. Extend the arm closest to you over the head. 37 Emergency scene management 2. Tuck the far arm against the casualty’s side. 3. Cross the far foot over the near foot. 4. Support the head and neck. Firmly grip the clothing at the waist. Roll the casualty over 5. Position the casualty for giving first aid 2 38 Emergency scene management ESM when a head or spinal injury is suspected If you suspect a head or spinal injury, protect the head and neck from any movement. Head or neck movement could result in lifelong disability or death. Adjust your first aid to this situation as shown below 2 1. As soon as you see there might be a head or spinal injury, tell the casualty not to move 2. Once you have consent to help the casualty, steady and support the head and neck. Keep elbows firmly supported on thighs or ground. Then, assess responsiveness. 39 Emergency scene management 3. If there is a bystander to help, show them how to support the head and neck so you can continue your assessment. 4. Continue your assessment. 2 40 Emergency scene management 5. If a second bystander is available, show them how to steady and support the feet to prevent movement. 2 6. Keep the head and neck supported (and the feet if possible) while giving further first aid until handover to medical help. When moving a casualty with a suspected head or spinal injury, move them as a unit as much as possible. This means rolling the head, trunk and legs together, or lifting the whole body at the same time. Do what you can to prevent movement. 41 Emergency scene management Turning a casualty face up when a head or spinal injury is suspected 2 You should give first aid in the position in which the casualty is found as much as possible. But sometimes you have to turn a casualty over to assess for life-threatening injuries or give life-saving first aid When you suspect a head or spinal injury, turn the casualty as a unit so the head and spine stay in the same relative position 42 1. The first aider at the head supports the head—placing the right hand along the right side of the casualty’s head and the left hand along the left side 2. The other first aider extends the casualty’s near arm over their head and gets a good grip on the casualty at the shoulder and waist. 3. At the same time, the two first aiders roll the casualty towards the second first aider. Emergency scene management 4. If extra help is available, have the third first aider support the legs to prevent twisting of the neck and spine. With a fourth, put one first aider at the shoulders and another at the waist. 2 Secondary survey A secondary survey follows the primary survey and any life-saving first aid. It is a step-by-step way of gathering information to form a complete picture of the casualty. In the secondary survey, the first aider is looking for injuries or illnesses that may not have been revealed in the primary survey. You should complete a secondary survey if: The casualty has more than one injury Medical help will be delayed for 20 minutes or more You will transport the casualty to medical help The secondary survey has four steps: 1. History 2. Vital signs 3. Head-to-toe exam 4. First aid for any injury or illness found 43 History 2 A SAMPLE history is used to gather a brief medical history of the casualty. This information may be useful for health care professionals who will continue to assist the casualty. If the casualty is unable to respond, some of the SAMPLE history could be answered by a close family member. S = symptoms – what the casualty is feeling (such as pain, nausea, weakness, etc.) A = allergies – any allergies, specifically allergies to medications M = medications – any medications or supplements they normally take, have taken in the past 24 hours, or any doses they may have missed P = past or present medical history – any medical history, especially if it is related to what they are experiencing now. Ask if they have medical alert information L = last meal – last meal they ate and when, anything else taken by mouth E = events leading to the incident – what was happening before the injury/illness? How did the injury occur? Vital signs There are four vital signs to check on the casualty 44 1. Level of consciousness (LOC) 2. Breathing 3. Pulse 4. Skin condition and temperature Check your applicable workplace legislation/ regulations Level of consciousness (LOC) A common method of obtaining a casualty’s LOC is using the acronym AVPU. When using AVPU to indicate LOC, it is a scale which ranges from good (A), to not as good (V), to bad (P), to worse (U) 2 A = Alert – An alert casualty will have their eyes open and will be able to answer simple questions. An alert casualty is oriented to person, place and time. V = Verbal – The casualty will respond when spoken to, but may not be able to effectively communicate. They may not be oriented to person, place or time. P = Pain – This casualty will only respond when a painful stimuli is delivered, such as pinching them or rubbing your knuckles on their sternum. They may move or make noise, but they will not communicate. U = Unresponsive – the unresponsive casualty will not respond to any stimulus. Please note that an alternative to quickly estimate a casualty’s LOC is to evaluate their eye, verbal and motor skills. If their eyes are open, they can clearly speak, and obey a command such as “squeeze my fingers,” they are alert Breathing To assess the breathing rate, watch the casualty closely for a total of 30 seconds. It is OK to place your hand on their upper abdomen to feel the rise and fall. Check the quality of the breathing. Carefully count each breath over the 30 seconds and multiply that number by two for breaths per minute. 45 Normal breathing rates 2 Age Too slow Normal Too fast Infant Below 25 30-50 Above 60 Child Below 15 20-30 Above 40 Adult Below 10 10-20 Above 30 Pulse The pulse rate is the number of beats your heart takes in one minute, and it is an essential skill for assessing all casualties. The most common places to assess a pulse is at the wrist or neck, and for infants, the inside of the upper arm. To assess the pulse, use two fingers and gently place them on either the inside of the wrist (just below the hand on the thumb side), or on the side of the neck (carotid artery), or for infants, the inside of the upper arm, on the brachial artery. Press just gently enough to feel the pulse. You may have to feel around the area until you find it. Once you have found the pulse, count the number of beats over 30 seconds and multiply that number by two. Normal pulse rates Age Normal pulse range Infant 120-150 Child 80-150 Adult 60-100 Skin condition and temperature When assessing the skin we look for the temperature (warm or cold), the colour (normal skin tones or pale) and whether the skin is dry or wet. Use the back of your gloved hand to feel the casualty’s forehead and cheeks. If their skin normal, they will have normal skin colour, and their skin will be warm and dry. If the skin is pale, cold and wet (sweaty), this could be an indication of shock. 46 Head-to-toe exam The head-to-toe exam is a complete and detailed check of the casualty for any injuries that may have been missed during the rapid body survey. Do not examine for unlikely injuries. You may need to expose an area to check for injuries, but always respect the casualty’s modesty and ensure you protect them from the cold. Only expose what you absolutely have to. Ask the casualty if they feel any pain before you start. Note any responses. Speak to the casualty throughout the process. Explain what you are checking for as you proceed. Always watch the casualty’s face for any facial expressions that may indicate pain. Do not stop the exam. If you find an injury, note it and continue. Do not step over the casualty. If you need to, walk around them. During a detailed exam, you are looking for all bumps, bruises, scrapes, or anything that is not normal. If the casualty is unconscious, look for medic alert devices during your survey, such as a tag, bracelet, necklace, watch, or other indicator. Look, then feel 47 2 Start at the head: 2 Check the skull for anything abnormal Check the ears for fluid Check the eyes, are the pupils the same size? Check the nose for drainage Check the mouth, are the teeth intact? Are the lips blue or pale? Check the neck: Are the neck veins bulging? Is there a medical alert necklace? Check the collarbones Check the shoulders on both sides Check the arms: 48 Check each arm completely Check the fingernails for circulation by squeezing and watching the blood return Ask the casualty to squeeze two of your fingers in both hands at the same time. Do they have an adequate strength and is the strength equal? 2 Check the chest and under: Does it hurt the casualty to breathe? Does the chest rise and fall with breaths as it should? Reach around the back as far as you can 49 Check the abdomen and under: 2 With flat hands, check the abdomen carefully Do not push into the abdomen. Gently feel for pain, tenderness, or rigidity Place a flat hand on their abdomen and ask the casualty to push against it. Does this cause pain? Reach around the back as far as you can Check the pelvis: 50 Place your hands on top of the pelvic bones and very gently squeeze for stability Check the legs, ankles, and feet: Check each leg completely one at a time Is one leg shorter than the other? Carefully check the stability of the kneecap and under the knee Squeeze or pinch a foot. Ask the casualty what you just did to see if they answer correctly. Place both hands on both feet. Ask the casualty to push and then pull against you. Feel for equal strength. Ask the casualty to wiggle their toes and watch for the response. Check circulation 2 First aid for injuries found When you have completed your exam, give appropriate first aid for any injuries or illnesses found. If the casualty has more than one injury, give first aid to the more serious injuries first. Document Upon completion of the secondary survey, document your findings as accurately as possible. This information may be valuable to medical professionals who will continue to assist the casualty. Documentation is also important in a workplace emergency as it may be used as part of an investigation. Documentation of the incident and the first aid given should be completed on preprinted forms and maintained as required by provincial regulations/ legislation for reference by investigators. 51 Ongoing casualty care Once first aid for injuries and illnesses that are not life threatening has been given: 2 The first aider will hand over control of the scene to the casualty, or someone else, and end their involvement in the emergency The first aider will stay in control of the scene and wait for medical help to take over, or The first aider will stay in control of the scene and transport the casualty to medical help The first aid must maintain the casualty in the best possible condition until handover to medical help by: Giving first aid for shock Position the casualty based upon their condition Monitoring the casualty’s condition Recording the events of the situation Reporting on what happened to whoever takes over Instruct a bystander to maintain manual support of the head and neck (if head/spinal injuries are suspected). Continue to steady and support manually, if needed. Recovery Position This position protects the casualty and also reduces bending and twisting of the spine. This position protects the airway if you must leave the casualty. 52 1. Position the arm closest to you at 90 degrees in front of the casualty, keeping it out of the way when rolling them. 2 2. Position the arm furthest from you on the casualty’s chest. Bend the far knee. 3. Reach behind the casualty’s shoulder and roll casualty towards you by pulling on the far knee. 53 4. Adjust the position of the arms and leg so the casualty is in a stable position. Place the far arm at 90 degrees to the casualty with the palm down. 5. Give ongoing care. 2 After the handover In first aid, we prepare ourselves to care for an injured or ill person. We don’t often think about what happens after the casualty has left our care. Immediately following the handover of the casualty you may have a number of practical details to attend to. These details can include cleaning up after the emergency, correcting any unsafe conditions that caused the injury, or making a report on the incident and your involvement. Once these practical matters are out of the way, we expect things to “return to normal.” However, you will likely find yourself thinking about the situation and the details of what happened while you were involved. Following a stressful event, many people review the details and try to evaluate what they did and how they could have done it better. 54 This reviewing of the events is completely normal and you can expect it to happen. But if thoughts of the incident continue for many weeks, or if they affect your day-to-day life, you may be experiencing the negative effects of critical incident stress (CIS). Critical incident stress is a common reaction to a stressful emergency situation. The effects of CIS can interfere with your daily life—your job, your relationships, your peace of mind. If this happens to yourself, you need to do something about it, and help is readily available. Start by talking to your family doctor or a doctor at a walk-in clinic. A doctor will understand what you are going through and will suggest a course of action. The effects of critical incident stress can appear many weeks, months or years after the event. Shock Shock is a circulation problem where the body’s tissues don’t get enough oxygenated blood. Shock is a danger because any physical injury or illness can be accompanied by shock, and it can quickly progress into a lifethreatening condition. Pain, anxiety and fear do not cause shock, but they can make it worse, or make it progress faster. This is why reassuring a casualty and making them comfortable is important. Medical shock should not be confused with electrical shock or being shocked and surprised. Medical shock is life-threatening, as the brain and other organs cannot function properly. The following information provides some causes of shock. Severe shock can also result from medical emergencies such as diabetes, epilepsy, infection, poisoning or a drug overdose. *For casualties with dark skin colour, the colour changes may be observed in the following areas of the body: lips, gums and tongue, nail beds and palms, earlobes, membrane of the inner eyelid. 55 2 Common causes of severe shock Cause of shock 2 How it causes a circulation problem Severe bleeding - internal or external (includes major fractures) Not enough blood to fill blood vessels Severe burns Loss of blood plasma (fluid) into tissues—not enough blood to fill blood vessels Crush injuries Loss of blood and blood plasma into tissues—not enough blood to fill blood vessels Heart attack Heart is not strong enough to pump blood effectively Spinal cord or nerve injuries Brain can’t control the size of the blood vessels—the blood can’t get to the tissues properly severe allergic reactions Many things can be affected— breathing, heart function, etc. 56 Signs and symptoms of shock Signs Symptoms Pale skin at first, turns blue-grey* Restless blue-purple lips, tongue, earlobes, fingernails Anxious Cold and clammy skin Disoriented Breathing shallow and irregular, fast or gasping for air Confused Changes in level of consciousness Afraid Weak, rapid pulse—radial pulse may be absent Dizzy Thirsty 2 57 First aid for shock The following actions will minimize shock: 2 1. Give first aid for the injury or illness that caused the shock 2. Reassure the casualty often 3. Minimize pain by handling the casualty gently 4. Loosen tight clothing at the neck, chest and waist 5. Keep the casualty warm, but do not overheat — use jackets, coats or blankets if you have them 6. Moisten the lips if the casualty complains of thirst. Don’t give anything to eat or drink. If medical help is delayed many hours, give small amounts of water or clear fluids to drink — make a note of what was given and when 7. Place the casualty in the best position for their condition Continue ongoing casualty care until handover The above first aid for shock may prevent shock from getting worse. Whenever possible, add these steps to any first aid you give. Positioning a casualty in shock Putting the casualty in the right position can slow the progress of shock and make the casualty more comfortable. The position you use depends on the casualty’s condition. The casualty should be as comfortable as possible in the position you use. No suspected head/spinal injury; fully conscious Place the casualty on their back, if injuries permit. Once the casualty is positioned, cover them to preserve body heat, but do not overheat. No suspected head/spinal injury; less than fully conscious Place the casualty in the recovery position. When there is decreased level of consciousness, airway and breathing are the priority—the recovery position ensures an open airway. 58 Conscious with a breathing emergency and/or chest pain If a conscious casualty is experiencing chest pain or is having difficulty breathing, have them sit in a semi-sitting position, or any position that makes breathing easier for them. 2 Suspected head/spinal injury If you suspect a head or spinal injury, steady and support the casualty in the position found. This protects the head and spine from further injury. Monitor the ABCs closely. As injuries permit A casualty’s injuries may not permit you to put them into the best position. Continue to support the head and neck and, if needed, use a head-tilt chin-lift to maintain the open airway. Always think of the casualty’s comfort when choosing a position. Fainting Fainting is a temporary loss of consciousness caused by a shortage of oxygenated blood to the brain. Common causes of fainting include: Fear or anxiety Lack of fresh air Severe pain, injury or illness The sight of blood An underlying medical problem Fatigue or hunger Long periods of standing or sitting Overheating A person who has fainted is unconscious. Place them in recovery position to protect the airway and prevent possible choking. Place the casualty in a comfortable position as they regain consciousness. 59 First aid for fainting 2 Ensure a supply of fresh air and loosen tight clothing at the neck, chest and waist. Make the casualty comfortable as consciousness returns and keep them lying down for 10 to 15 minutes. Continue to monitor breathing and consciousness. Do not assume a person has “just fainted,” unless there is a quick recovery. If the recovery is not quick or complete, stay with the casualty until medical help takes over. If you have to leave to get medical help or you have to give first aid to other casualties, turn the casualty into the recovery position being as careful as you can if there are any injuries. Feeling faint or “impending faint” Sometimes when a person is about to faint, there are warning signs. The person: Is pale Is sweating Feels sick, nauseous, dizzy or unsteady First aid for an impending faint 60 1. Place the casualty on their back. 2. Ensure a supply of fresh air—open windows or doors. 3. Loosen tight clothing at the neck, chest and waist. 4. Stay with the casualty until they has fully recovered. Decreased level of consciousness (LOC) Consciousness refers to the level of awareness one has of themselves and their surroundings. There are different levels of consciousness ranging from completely conscious to completely unconscious. Many injuries/illnesses can cause changes in a casualty’s level of consciousness, including: A breathing emergency A heart attack A head injury Poisoning Shock Alcohol or drug abuse Medical condition (epilepsy, diabetes, etc.) 2 Semi-consciousness and unconsciousness are breathing emergencies for casualties lying on their back, because the tongue may fall to the back of the throat and block the airway. Saliva and other fluids can also pool at the back of the throat and choke the person. A progressive loss of consciousness means the casualty’s condition is getting worse. Always monitor a casualty’s level of consciousness and note any changes. A first aider can use the acronym AVPU (alert, verbal, pain, unresponsive) to assess and describe levels of consciousness. Decreased consciousness is always an urgent situation. The person can quickly become unconscious, and this is a breathing emergency. When you recognize decreased consciousness, get medical help as quickly as possible. First aid for unconsciousness 1. Start ESM. Perform a scene survey. Call or send for medical help as soon as unresponsiveness is determined. 61 2. Do a primary survey. 3. Do a secondary survey if necessary. 4. Turn the casualty into the recovery position, if injuries permit. Give ongoing care. 2 If injuries make it necessary for the casualty to be face up, monitor breathing continuously. If necessary, hold the airway open. Always ensure an open airway. Loosen tight clothing at the neck, chest and waist, and continue ongoing casualty care until handover. Record any changes in level of consciousness and when they happen. A decreased level of consciousness also requires urgent medical help. Multiple casualty management (triage) The process of making decisions at an emergency scene where multiple people are injured is called triage. In triage, first aiders quickly examine all casualties and place them in order of greatest need for first aid and for transportation. The idea is to do the most good for the greatest number of casualties. 62 Casualties are categorized into three levels of priority: Highest priority—casualties who need immediate first aid and transportation to medical help Medium priority—casualties who probably can wait one hour for medical help without risk to their lives Lowest priority—casualties who can wait and receive first aid and transportation last, or casualties who are obviously dead 2 Note: in the event of a lightning strike, where more than one person is injured, the principles of multiple casualty management are reversed. Give first aid to unresponsive non-breathing casualties since the casualties that are still breathing are recovering. 63 The first aid priorities for injuries Priority 2 High priority Condition Causes Foreign body blocking airway Choking on food Tongue or fluids blocking airway Unconscious, lying on back Swollen airway Allergic reaction, airway infection Injured chest and/or lungs Chest injury, broken ribs Brain not controlling breathing properly Poisoning, drug overdose, stroke, electric shock Not enough oxygen reaching blood Not enough oxygen in air, carbon monoxide poisoning Severe bleeding External bleeding or internal bleeding Severe shock Bleeding, serious illness, poisoning Medium priority Fractures that could affect breathing Broken ribs, shoulder blade Injuries that have potential for life-long disability Fractures—open, severe or multiple bones Broken upper leg, pelvis, crushed arm Head/spinal injuries Fall from a six-foot ladder Critical burns Critical burns to the hands Low priority Minor fractures Minor injuries or obviously dead Broken lower leg, lower arm, hand, finger, etc. Minor bleeding Bleeding not spurting or freeflowing Non-critical burns Moderate degree burns to the forearms behavioural problems Grief or panic Obviously dead Obvious massive injuries, no pulse or other signs of circulation Airway High priority Breathing High priority Circulation 64 Triage sequence of actions Begin ESM Determine how many casualties there are in the scene survey. 2 Start with the nearest casualty, and move outward Do a primary survey Give first aid for life-threatening injuries If the person is obviously dead, go to the next nearest casualty Repeat step 2 for each casualty Always move to the next nearest casualty Categorize Decide which casualties have the highest priority, second priority, and lowest priority. Arrange transportation Arrange for the highest priority casualties to be transported to medical help as soon as possible Perform secondary survey Begin with the highest priority. Give appropriate first aid, and move on Give ongoing care for each casualty until transported In a multiple casualty situation, constantly assess the casualties and the situation and make changes to priorities. 65 Lifting and moving 2 Always try to give necessary first aid where the casualty is found, then wait for the paramedics to move the person. However, there are times when this is not possible. You may have to move a casualty when: There are life-threatening hazards to yourself or the casualty e.g. danger from fire, explosion, gas or water Essential first aid for wounds or other conditions cannot be given in the casualty’s present position or location The casualty must be transported to a medical facility If life-threatening hazards make it necessary to move a casualty right away, you may need to use a rescue carry. In urgent and dangerous situations where casualties are moved with less than ideal support for injuries, the casualty’s injuries may be made worse by improper movement and handling. The chance of further injury can be reduced with proper rescue carry techniques. Always move the casualty the shortest possible distance to safety and to provide essential first aid. Use bystanders to help you and support any injuries the best you can during the move. Keep the risks to the casualty, yourself and others to a minimum. Rolling Cots (Stretchers) If your workplace uses rolling cots to transport injured workers, it is crucial that you have proper training on how to operate and handle the cot before you use it. Failure can result in the cot tipping or dropping, and causing further injury. Occupational Hazards When working in and around occupational hazards such as confined spaces, trenches, machinery, and hazardous gases, workers should know the proper response protocols. Ensure you have the appropriate training for the type or rescue you will be undertaking as well as the proper equipment to keep yourself safe while rescuing another worker. 66 Helicopters In some locations, a helicopter may be sent to transport an injured worker to hospital. Anyone working around helicopters should have proper training and everyone should follow these guidelines: Never approach without permission of the pilot or crew chief Always follow directions from the pilot or crew chief on from which direction to approach the aircraft Know the restricted and danger areas around the aircraft and remain outside these areas unless you need to enter The tail and tail-rotor of the helicopter poses a significant danger and should be avoided Transporting a casualty Generally speaking, first aid providers will not transport casualties to the hospital, leaving that to ambulances. However, there are instances where you may choose to transport someone to the hospital yourself. The injuries are minor and the casualty is stable The response time for EMS to arrive is prohibitively long (i.e. remote areas) If the above conditions are met, and the casualty is a family member or close friend—do not transport strangers to the hospital in your own vehicle whenever possible Care during transport Every effort must be taken to ensure that injuries are not made worse while transporting a casualty to a medical facility. Take steps to keep the casualty comfortable and in a position that will not cause unneeded movement of injured limbs. Have another person accompany you to monitor the casualty if possible. Do not drive fast. If a casualty needs to be transported quickly, an ambulance should be called. Follow all local traffic laws. Find the smoothest route possible to make the ride as comfortable as possible. 67 2 Meeting an ambulance crew enroute 2 Some work locations are isolated and response times of EMS are extended. In these instances, where provincial regulations permit, casualties can be transported toward medical help with the plan to meet an ambulance part way. When selecting a meeting point, be sure the location is clear to both sides and it is easily found. Identify any landmarks or businesses that can aid in finding the location. In the event you arrive before the ambulance, contact EMS and get an update on the ambulance location before moving the meeting location. Lifting techniques and proper body mechanics Moving any casualty from an emergency scene poses dangers to the rescuer as well as the casualty. If the casualty must be moved, select the method that will pose the least risk to the casualty and to you. You can be of little help to a casualty if you injure yourself in the rescue. Using incorrect body mechanics in lifting or moving a casualty may leave the rescuer suffering muscle strains. Use the following lifting guidelines: Stand close to the object to be lifted. Bend your knees, not your waist. Tilt the object so that you can put one hand under the edge or corner closest to you. Place your other hand under the opposite side or corner, getting a good grip on the object. Use your leg muscles to lift, and keep your back straight. When turning, turn your feet first; don’t twist your body. When lowering the object, reverse the procedure. 68 2 Rescue carries A rescue carry is an emergency method of moving a casualty over a short distance to safety, shelter or to transportation. Select the type of carry based on the circumstances. The size and weight of the casualty relative to the rescuer The number of rescuers available to assist The type of injury The distance to move the casualty Whenever possible, ask one or more bystanders to help you. When help is available: Remain with the casualty Give instructions to the bystanders about what to do and what safety precautions to take Fully coordinate the rescue activities 69 Drag carry 2 This carry is used by the single rescuer to drag a casualty who is either lying on their back or in a sitting position. The drag carry provides maximum protection to the head and neck, and therefore should be used when you are moving a casualty with this type of injury. If time permits, tie the casualty’s wrists together across their chest before dragging. To perform a drag carry: 1. Stand at the casualty’s head facing their feet. 2. Crouch down and ease your hands under the casualty’s shoulders. Grasp the clothing on each side. Support the casualty’s head between your forearms to stop movement. 3. Drag the casualty backward only as far as necessary for their safety. As an alternate method, the first aider can use a blanket to support and drag the casualty. Because of the risk of aggravating any injuries, only use drag carries in the most extreme cases when there is an immediate threat to life. 70 Human crutch If a leg or foot is injured, help the casualty to walk on their good leg while you give support to the injured side. 2 1. Take the weight of the casualty’s injured side on your shoulders by placing the casualty’s arm (on the injured side) around your neck and grasping the wrist firmly. 2. Reach around the casualty’s back with your free hand, and grasp the clothing at the waist. 3. Tell the casualty to step off with you, each using the inside foot. This lets you, the rescuer; take the casualty’s weight on the injured side. Chair carry The chair carry enables two rescuers to carry a conscious or unconscious casualty through narrow passages and up and down stairs. Do not use this carry for casualties with suspected neck or back injuries. Specially designed rescue chairs are available and should be used for this type of carry. If the casualty is unconscious or helpless: 1. Place an unconscious casualty on a chair by sliding the back of the chair under their legs and buttocks, and along the lower back. 2. Strap their upper body and arms to the back of the chair. 71 2 3. Two rescuers carry the chair, one at the front and one at the back. The rescuer at the back crouches and grasps the back of the chair, while the rescuer at the front crouches between the casualty’s knees and grasps the front chair legs near the floor. 4. The rescuers walk out-of-step. Going down stairs The casualty faces forward The front rescuer faces the casualty A third person should act as a guide and support the front rescuer in case they lose their footing Extremity carry Use the extremity carry when you don’t have a chair and do not suspect fractures of the trunk, head, or spine. 1. One rescuer passes their hands under the casualty’s armpits, and grasps the casualty’s wrists, crossing them over their chest. 2. The second rescuer crouches with their back between the casualty’s knees and grasps each leg just above the knee. 3. The rescuers step off on opposite feet—walking out-of-step is smoother for the casualty. Blanket lift with four bearers 1. 72 Roll the blanket or rug lengthwise for half its width. Position bearers at the head and feet to keep the head, neck and body in line. Place the rolled edge along the casualty’s injured side. 2. Kneel at the casualty’s shoulder and position another bearer at the waist to help log-roll the casualty onto the uninjured side. Turn the casualty as a unit so the casualty’s body is not twisted. 3. Roll the casualty back over the blanket roll to lay face up on the blanket. Unroll the blanket and then roll the edges of the blanket to each side of the casualty. Get ready to lift the casualty—have the bearers grip the rolls at the head and shoulders, and at the hip and legs. 4. Keep the blanket tight as the casualty is lifted and placed on the stretcher. Before using a blanket, test it to ensure that it will carry the casualty’s weight. Do not use this lift if neck or back injuries are suspected. Stretchers There may be times when medical help cannot be contacted, or for other reasons, cannot come to the scene. When this happens, transport the casualty to medical help. If the casualty can’t walk, or if the injury or illness allows only the gentlest movement, a stretcher should be used. Principles for stretcher use Complete all essential first aid and immobilization before moving the casualty onto a stretcher. Bring the blanketed and padded stretcher to the casualty, rather than moving the casualty to the stretcher. As the first aider in charge, take the position that permits you to watch and control the most sensitive area of the body, usually at the head and shoulders, or the injured part. 73 2 2 Tell the bearers what each is expected to do. If the move is difficult, and time permits, it’s a good idea to practice with a simulated casualty. This reduces risks and reassures the conscious casualty. Test an improvised stretcher with someone equal to or heavier than the casualty to ensure that it will hold. Check the clearance of an improvised stretcher to ensure that it will pass through hallways, doors and stairways without harm to the casualty. Use clear commands to ensure smooth, coordinated movements. Commercial stretchers The most common of the commercial stretchers is the rigid-pole, canvas stretcher. It has hinged bracing bars at right angles between the rigid poles at either end that must be locked in the extended position before the stretcher is used. Improvised stretchers If a commercially prepared stretcher is not available, you can improvise one by using two rigid poles and a blanket, clothing or grain sacks. Do not use non-rigid stretchers for casualties with suspected head or spinal injuries. Improvised blanket stretcher 74 1. Place the blanket flat on the ground and place a pole onethird of the way from one end. Fold the one-third length of blanket over the pole. 2. Place the second pole parallel to the first so that it is on the doubled part of the blanket, about 15 cm (6 inches) from the doubled edge. 3. Fold the remaining blanket over the two poles. The casualty’s weight on the blanket holds the folds in place. 2 Improvised jacket stretcher A non-rigid stretcher can also be improvised from two jackets and two or four poles. 1. Button and zipper the jackets closed and pull the sleeves inside out so that the sleeves are inside. Lay the jackets on the ground so that the top edge of one jacket meets the bottom edge of the other. 2. Pass the poles through the sleeves of the two jackets on either side to complete the stretcher. 3. If the casualty is tall, prepare another jacket as before and add it to the stretcher with the head of the jacket towards the middle. 75 Four-bearer method—no blanket 1. All bearers kneel on their left knees, three on one side of the casualty and one on the other, as shown below. Bearer 4 helps in lifting and lowering the casualty, and also places the stretcher under the casualty. 2. Bearer 4 joins hands with bearers 1 and 2. When assured that each bearer has a firm hold on the casualty, bearer 1 directs the others to “Get ready to lift” and then gives the command “Lift.” Lift the casualty smoothly to the height of the raised knees. 3. On bearer 1’s command “Rest,” the casualty is gently laid on the raised knees of bearers 1, 2 and 3. 4. Bearer 1 tells bearer 4 to position the stretcher. Bearer 4 then resumes their position supporting the casualty by linking their hands with one from each of bearers 1 and 2. Position the stretcher. 5. When everyone is in position, bearer 1 instructs the team to, “Get ready to lower” and then, “lower.” The team lowers the casualty gently onto the stretcher. Secure the casualty to the stretcher. 2 76 Three-bearer method, no blanket The three-bearer method is essentially the same as the four-bearer method, except the first aider and one bearer share the weight on one side of the casualty. The third bearer links hands with the first aider from the opposite side to take up the weight of the trunk. The casualty is lifted and rested on the bearers’ knees while the stretcher is positioned and bearer 3 links hands again with the first aider to help lower the casualty to the stretcher. Carrying a stretcher A stretcher should be carried by four bearers. As the first aider in charge, decide on the carrying method and give clear instructions to the bearers. After the casualty has been strapped to the stretcher, position yourself so you can watch the casualty and at the same time give direction to the other bearers. Assign the remaining bearers (depending whether you are two or four) to respective corners or ends of the stretcher. Bearers crouch by the carrying handles of the stretcher, facing in the direction of travel. When the bearers have a firm footing and a good grip on the stretcher, give the command, “Get ready to lift,” and then, “Lift.” Ask the bearers if they are ready. When they are, give the command, “Go forward.” When it is necessary to stop, give the commands “Stop,” Get ready to lower,” and then, “Lower.” To ensure the smoothest carry for the casualty: Four bearers carrying a stretcher step off together on the foot nearest the stretcher and keep in step Two bearers step off on opposite feet and walk out-of-step 77 2 Head-first carry Although stretcher casualties are usually carried feet first, certain conditions call for a head-first carry: 2 Leg injuries during a long downhill carry or when descending stairs, a head-first carry decreases pressure on the lower limbs and minimizes discomfort Uphill carries and going up stairs if there are no injuries to the legs—a head-first carry decreases blood flow to the casualty’s head and is more comfortable Loading an ambulance or transferring the casualty to a bed—it is safer to do this head first, and easier to watch the casualty Obstacles When crossing uneven ground, a stretcher should be carried by four bearers and kept as level as possible. Bearers must adjust the height of the stretcher to compensate for dips and rises in the terrain. Crossing a wall Avoid crossing a wall, even if it means a longer carry. Where a wall must be crossed, follow these steps: 78 1. Lift the stretcher onto the wall so that the front handles are just over it. The rear bearers hold the stretcher level while the front bearers cross the wall. All lift together and the stretcher is moved forward until the rear handles rest on the wall. 2. The front bearers hold the stretcher level until the rear bearers have crossed the wall and resumed their positions at the rear of the stretcher. 3. The stretcher is then lowered to continue the journey. Extrication Extrication is the process of freeing casualties who are trapped or entangled in a vehicle or collapsed structure and cannot free themselves. Provide as much support as possible to the casualty during extrication. Whenever possible, give essential first aid and immobilize the injuries before the casualty is moved. 2 When there is an immediate danger and you are alone and must move a casualty from a vehicle, proceed as follows: 1. If necessary, disentangle the person’s feet from the vehicle and bring the feet toward the exit. Ease your forearm under the person’s armpit on the exit side, extending your hand to support the chin. 2. Ease the person’s head gently backward to rest on your shoulder while keeping the neck as rigid as possible. 3. Ease your other forearm under the armpit on the opposite side and hold the wrist of the casualty’s arm which is nearest the exit. 4. Establish a firm footing and swing around with the person, keeping as much rigidity in the neck as possible. Drag the casualty from the vehicle to a safe distance with as little twisting as possible. 79 Chapter 3 Airway and Breathing Emergencies Hypoxia Effective and ineffective breathing Inhalation injuries Breathing emergencies caused by illness Asthma Severe allergic reaction Choking Airway and breathing emergencies Chapter 3 Airway and breathing emergencies When a person’s breathing is affected through injury or illness, their life can be in immediate danger. As a first aider, you have to be able to recognize a breathing emergency very quickly and know what first aid to give—the casualty’s life may depend on it. 3 Hypoxia Choking and breathing emergencies cause a lack of oxygen in the blood, a condition called hypoxia. This can damage vital tissues and eventually cause death. The causes of hypoxia are grouped under three headings: 1. Lack of oxygen —for example: The oxygen level is low, such as at a high altitude The oxygen is displaced by other gases, such as a build-up of silo gas in a grain silo The oxygen in a small space is used up—for instance in a confined space 2. Blocked airway—for example: A casualty chokes on a foreign object, such as food An unconscious casualty’s airway is blocked by their tongue A casualty’s airway becomes swollen due to an allergic reaction 3. Abnormal heart and lung function—where the heart and lungs are not working properly due to: 82 An illness such as pneumonia or congestive heart failure An injury preventing effective breathing A drug overdose or poisoning Airway and breathing emergencies Effective and ineffective breathing The normal breathing rate varies for infants, children and adults. A breathing rate that is too slow or too fast is a sign of a breathing emergency. Breathing rhythm refers to the interval between breaths. In normal breathing, the intervals are even and breathing is effortless—this is regular breathing. Breathing depth refers to the amount of air moved in and out of the lungs with each breath. Signs of effective breathing include: Breathing that is quiet Equal expansion of both sides of the chest when the person inhales The person is alert and relaxed Skin colour is normal Speaking without taking a breath every few words When a person is not getting enough oxygen, the body responds by breathing faster and deeper. Signs of ineffective breathing include: The casualty is struggling for breath or gasping for air Breathing rate is too fast or too slow Breathing rhythm is irregular Breathing depth is too shallow or too deep Breathing is noisy or raspy The person is “getting tired” from trying to breathe The person is sweating Decreased level of consciousness The lips, ears and fingernail beds turn blue—called cyanosis Chest movement may be abnormal 83 3 Airway and breathing emergencies First aid for ineffective breathing Always send or go for medical help at the first sign of a breathing emergency. The first aid for ineffective breathing has two parts: 3 1. Give first aid for the injury or condition and position the responsive casualty in the semi-sitting position if possible 2. If breathing stops the casualty will become unresponsive, get medical help immediately and begin CPR This table lists some of the causes of breathing emergencies. To give first aid, first determine the cause of the breathing emergency, and then decide on the best first aid actions. Causes of airway and breathing emergencies Injuries Medical conditions Poisoning Broken ribs Asthma Inhaled poison – e.g. carbon monoxide or hydrogen sulfide Near drowning Stroke Swallowed poison – E.g. household cleaners or medication overdose Knife or gunshot Allergic reaction wound Burns to the face or airway Pneumonia Head injury Congestive heart failure Compression of the chest preventing chest expansion Emphysema/bronchitis Injected poison – e.g. bee sting Inhalation injuries Inhalation injuries happen when the casualty inhales hot steam or hot (superheated) air, smoke or poisonous chemicals. 84 Airway and breathing emergencies Signs and symptoms of inhalation injuries include signs of shock: Dizziness, restlessness, confusion Pallor or cyanosis Abnormal breathing rate or depth Together with a history of fire and: Noisy breathing Pain during breathing Burns on the face, especially the mouth and nose Singed hair on the face or head Sooty or smoky smell on breath Sore throat, hoarseness, barking cough, difficulty swallowing 3 First aid for an inhalation injury 1. Perform a scene survey and do a primary survey. Give first aid for the ABCs. 2. Place a conscious casualty in the semi-sitting position and loosen tight clothing at the neck, chest and waist. 3. If breathing stops, begin CPR starting with compressions. 4. Give ongoing casualty care until handover to medical help. Breathing emergencies caused by illness Illnesses that can lead to severe breathing difficulties include asthma, allergies, chronic obstructive pulmonary disease (e.g. emphysema), congestive heart failure, stroke and pneumonia. Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease is a term used to describe a group of respiratory conditions such as chronic bronchitis and emphysema. Casualties present with on-going shortness of breath and appear to be struggling to breathe. Some people may use supplemental oxygen delivered by nasal prongs from a small canister they carry when they have a more serious case of COPD. 85 Airway and breathing emergencies Asthma 3 Asthma is a reactive airway illness in which the person has repeated shortness of breath, characterized by wheezing and coughing. A mild asthma attack is not a health emergency and can be managed by the casualty. A severe asthma attack can be fatal and requires immediate first aid. In response to a ‘trigger’ the person’s airway can spasm, swell and secrete thick mucus, which narrows the airway passage. Some common triggers that can cause asthma are: Colds, upper airway infections Pet dander Insect bites, stings Foods Pollen, paint and smoke Signs and symptoms of a severe asthmatic attack: Shortness of breath with obvious trouble breathing Coughing or wheezing Fast, shallow breathing Casualty sitting upright trying to breathe Bluish colour in the face (cyanosis ) Anxiety, tightness in the chest Fast pulse rate, shock Restlessness at first, and then fatigue First aid for a severe asthma attack 86 1. Perform a scene survey and a primary survey; send for medical help. 2. Place the casualty in the most comfortable position for breathing. This is usually sitting upright with arms resting on a table. 3. Help the casualty take prescribed medication. 4. Give ongoing casualty care. 5. If the unconscious casualty stops breathing, begin CPR. Airway and breathing emergencies A person with asthma may carry medication in the form of a: Metered-dose inhaler (MDI) Turbuhaler Diskus® Usually the person can give themselves this medication without help. If the person needs help, a first aider can assist. 3 An inhaler delivers a pre-measured amount of medication. Always read and follow the manufacturer’s instructions. Check the prescription label to confirm the casualty’s name and expiry date. To assist with a Metered Dose Inhaler The metered dose inhaler (or “puffer”) is the more common method of delivering medication for asthma. 1. Shake the container, then remove the cap. 2. Tell the casualty to breathe out completely, 3. Tell the casualty to breathe in slowly and deeply—as the casualty does, the MDI will be pressed to release the medication. The MDI can be in the mouth, or just in front of the mouth. Check your applicable workplace legislation/ regulations 87 Airway and breathing emergencies 4. 3 Tell the casualty to hold their breath for 10 seconds so the medication can spread out in the lungs. Then tell them to breathe normally, so the medication won’t be expelled. If more doses are needed, wait at least 30-60 seconds before repeating these steps. Spacers (Aerochamber®) When the medication comes out of the inhaler, it may be deposited on the back of the throat and not reach the lungs or the casualty may be gasping for air and unable to hold their breath. To deal with this, use a spacer if available. It traps the particles of the spray, allowing the casualty to inhale more effectively over several breaths. Spacers make it simple to inhale the medication, and should always be used when available. Small children and other casualties who have difficulties coordinating proper inhalation with the release of the medication will often have spacers with them. It allows them to inhale two or three times before the medication is completely dispelled. A mask can be attached to the device to make taking the medication easier. 88 Airway and breathing emergencies If the casualty complains of throat irritation after using the inhaler, have them gargle or rinse the mouth with water. Severe allergic reaction An allergic reaction occurs when the immune system reacts to a substance the body encounters. Most allergies are annoying but not dangerous. Anaphylaxis is a severe allergic reaction which usually happens when a substance to which the casualty is very sensitive enters the body, although it can also be caused by exercise or have no known cause. Anaphylaxis can happen within seconds, minutes or hours of a substance entering the body. As a rule, the sooner the casualty’s body reacts, the worse the reaction will be. Anaphylaxis is a serious medical emergency that needs urgent medical attention. Common early signs and symptoms of an allergy may include itchy flushed skin with hives; sneezing and a runny nose; coughing. If it’s a severe reaction there may be swelling of the face and neck, especially the lips and tongue. Breathing may become difficult if the swelling is internal too. There may be nausea and vomiting and the casualty may be anxious and feeling sense of impending doom as their blood pressure drops and they go into shock. This is a true medical emergency and requires immediate first aid. First aid for a severe allergic reaction 1. Perform a scene survey and a primary survey. Send for medical help. 2. Place the casualty in the most comfortable position for breathing—usually sitting upright. 3. Assist the casualty with their medication, usually this is an epinephrine auto-injector. 4. Give ongoing casualty care. It is important to be familiar with, and follow the manufacturer’s instructions, which is located on the side of the auto-injector. Check the expiry date. If the only auto-injector is an expired product, it may still save a life and should be administered anyway, if the indicated liquid remains clear. Check your applicable workplace legislation/ regulations 89 3 Airway and breathing emergencies To use the auto-injector: 1. Remove the EpiPen® from the storage tube. Hold it firmly with the orange tip downward. Remove the blue safety release. 2. Use the auto-injector on only the fleshy part of the mid-outer thigh. Auto-injectors can be given through lightweight clothing. 3. Press the orange tip of the EpiPen® firmly into the midouter thigh until the unit activates. 4. Hold the auto-injector in place for several seconds, then pull it straight out. 3 90 Airway and breathing emergencies 5. After the injection, keep the casualty warm and avoid any exertion. Call 9-1-1 as soon as you have given the first dose. 3 If the casualty shows no improvement within 5 minutes or if their condition deteriorates before help arrives a second dose may be given if it is available. This will require a second EpiPen®. Individuals who are feeling faint or dizzy because of impending shock should be placed flat on their back unless they are vomiting or experiencing respiratory distress. It is important that the casualty does not sit or stand immediately as this could cause a drop in blood pressure. The medication will begin to wear off within 10 to 20 minutes—get medical help right away. If you or anyone else is injected by mistake, get medical help. Follow manufacturer’s directions for proper care of the used device. Put the used unit back in the storage container and take it to the hospital with the casualty. 91 Airway and breathing emergencies Choking A person chokes when the airway is partly or completely blocked and airflow to the lungs is reduced or cut off. The choking casualty either has trouble breathing or cannot breathe at all. Open and clear airway 3 Partly blocked airway Completely blocked airway 92 Airway and breathing emergencies Causes of choking Foreign objects Infants and children—food, toys, buttons, coins, etc. The tongue Tongue falls to the back of the throat when lying on back Swelling Injury to the throat area causes swelling of the airway 3 Adults— Saliva, blood or vomit consuming drinks pools in the throat quickly with food in your mouth Illness causes swelling, e.g. allergic reaction, asthma, epiglottis, croup In elderly people—food, pills Swollen airway With good air exchange, the obstruction is mild and person can still cough forcefully, breathe and speak. With poor air exc