HLTAID001 Provide Cardiopulmonary Resuscitation
HLTAID003 Provide first aid
HLTAID004 Provide an emergency first aid response in an education and care setting
Accredited Education and Training Pty Ltd and its authors have used reasonable endeavours to ensure the information contained herein was correct at the time of publishing. However, neither Accredited Education and Training Pty Ltd or its author(s) provides any warranty nor accepts any responsibility for the accuracy or completeness of the material. No reliance should be made by any user on the material contained herein.
The information contained in this manual is not intended as a substitute for professional medical advice, emergency treatment or formal first aid training. Do not use this information to diagnose or develop a treatment plan for a health problem without consulting a qualified health care provider. If you are in a life threatening or emergency situation, seek medical assistance immediately.
Accredited Education and Training Pty Ltd reserves the right at any times to make changes as it deems appropriate.
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Welcome to Geographe Safety Compliance Services
This workbook has been designed to assist you in developing your knowledge and skills that are required to provide Emergency Life Support to a casualty in the event of an emergency.
Our trainers will ensure that your course in interesting, and relevant to the needs of your workplace, or your situation. All our trainers are fully qualified and experienced health care professionals, who have recent work experience within the health industry. Our trainers all hold a Certificate IV in Training and Assessment, along with other qualifications relevant to the provision of First Aid.
To achieve competency in this qualification, you are required to undertake a formal assessment that will look at your knowledge and skills. Your assessment will include:
All assessments will take place within the class and will follow the principles of assessment (fair, valid, reliable and flexible). At the end of your assessments you will be classified as Competent or Not Yet Competent.
All students who are found competent will receive a Certificate / Statement of Attainment.
Not Yet Competent
Achieving a Not Yet Competent result is not the end of your journey. Everyone learns at a different rate, and occasionally additional studies are required before achieving competency. All students who are found Not Yet Competent will be given one other opportunity to be assessed (at a time mutually agreed with your trainer). Your trainer will advise you of further study or practice required prior to your second assessment.
Recognition for Prior Learning:
We will recognise previous learning relevant to the course. Talk with your trainer for more detail.
Qualifications / Assessment Procedures:
Students completing all assessment requirements will receive an accredited certificate pertaining to the course attended. All students receive a Statement of Attainment unless completing a general information session, then a Statement of Attendance will be issued.
It is recommended that CPR is updated annually.
Assessment during training may include oral responses to questions, written response to questions, roll plays, multiple choice test paper and external written test paper. Students will be given an opportunity for at least one reassessment for any competencies not achieved on the first attempt.
Allergies / Health Problems:
Please notify the trainer if you have an allergy or reaction to Latex, Rubber or Plastic or if you have any back or knee problems or any other health issues which may affect your participation in this course.
CPR courses should be updated every 12 months
All First Aid courses should be updated at least every 3 years
ANY ATTEMPT AT RESUSCITATION IS BETTER THAN NO ATTEMPT
Cardiopulmonary Resuscitation (CPR) is an emergency procedure that is used on casualties who are unconscious and not breathing. CPR involves chest compressions (pressing down on the chest) and artificial respiration (rescue breathing / mouth to mouth). It has the power to restore blood flow and oxygen to someone suffering cardiac arrest, keeping them alive until an ambulance arrives. CPR skills should be refreshed at least once a year.
Remember - Any attempt at resuscitation is better than no attempt!
Prior to assisting any casualty, a First Aider must ask for and receive permission from the casualty before giving first aid. This can be a simple verbal ok from the casualty, or even just a nod of the head. First Aiders must remember that people have the right to refuse assistance. If the casualty is unconscious, then consent is implied. This means that the law assumes that the person would want their life to be saved at this point.
When the casualty is a minor, you should ask their parent or guardian. When their parent or guardian is not available, consent is likewise implied if unconscious
The Wrongs Act (1958) (VIC)
Section 31B of the Wrongs Act (1958) states:
Worried? Remember: No Good Samaritan or volunteer in Australia has ever been successfully sued for consequences of rendering assistance to a person in need!
The Civil Liability Act (2002) (NSW)
Part 8 (Section 57) of the Civil Liability Act (2002) states:
56) Who is a good Samaritan
57) Protection of good Samaritans
58) Exclusion from protection
extracted from The Australian Journal of Emergency Management, Vol. 18 No 4. November 2003
Queensland - The Queensland legislation, originally enacted as the Voluntary Aid in Emergency Act 1973 and subsequently as the Law Reform (Miscellaneous Provisions) Act 1995 is the oldest but its operation is limited to doctors and nurses. For the protection to apply a doctor or nurse must be rendering assistance at or near the scene of the emergency or providing assistance whilst a person is being transported from the scene of the emergency to hospital or other ‘adequate medical care’. They must act in good faith and without gross negligence and without ‘fee or reward’ or an expectation of receiving a ‘fee or reward’. (Eburn 2000, 66).
New South Wales - The Civil Liability Act 2002 (NSW) provides that a Good Samaritan can incur no personal civil liability in respect, of their acts or omissions (s 57), if certain requirements are met. The relevant conditions that must be met before the Act will apply there must be ‘an emergency’; the Good Samaritan must be ‘assisting a person who is apparently injured or at risk of being injured’ (s 57); and the Good Samaritan must be acting in good faith and without expectation of payment or other reward (s 56).
The protection afforded by the Act will not apply if the Good Samaritan causes the injury in the first place, so the driver of the motor vehicle that runs over a pedestrian cannot rely on the section for protection when they provide first aid to the person they have injured; nor can a Good Samaritan rely on the section if they are intoxicated or if they fraudulently impersonate a professional rescuer (s 58).
South Australia - The Wrongs Act 1936 (SA) protects any person who ‘in good faith and without recklessness’ comes to the aid of another who is in need or apparently in need of emergency assistance (s 38(2)). Emergency assistance is by definition, limited to medical assistance or other assistance to protect life and safety, not property (s 38(1)). The Act also protects a medically qualified person who, without expectation of payment, gives advice via telephone or other telecommunications device about the emergency treatment of a person (s 38(3)).
Victoria - The Wrongs Act 1958 (Vic) is similar to the legislation in South Australia. Some key differences are that the ‘advice’ provision can be relied upon by any person, not just a ‘medically qualified person’ as in South Australia (s 31B(2)). The ‘Good Samaritan’ needs to act in good faith, but unlike South Australia, there is no requirement that the action be ‘without recklessness’(s 31B(2)). Unlike New South Wales, the ‘Good Samaritan’ can rely on the legislation even if they created the emergency or accident in the first place (s 31B(3)).
Duty of Care
Duty of care is a legal obligation requiring a person to act in a certain way. All First Aiders have a duty of care towards casualties to exercise reasonable care and skill in providing first aid treatment. This is because you will have the knowledge and skills required to manage an emergency situation.
If you choose to provide first aid assistance (which is voluntary under common law when this role does not form part of your employment / position requirements), you have a duty to use your knowledge and skills in a responsible way.
Under common law, First Aiders are not legally required to assist every casualty they may come across – assistance is voluntary. If the First Aider has agreed to take on a role through either employment or a community service, such as being employed as a first aid officer, then that person does have a duty of care to assist others in the context of their employment if necessary.
Although assistance is voluntary for First Aiders in the public, it is important to note that once a person chooses to and begins to assist a casualty; they take on a duty of care to continue assisting the casualty until they are stable. Situations that allow cessation of assistance include:
You need to be aware that Duty of Care requirements do differ across Australia, so you should check your legal obligations when moving or working interstate.
Codes of Practice
Codes of practice state ways to manage exposure to risks. These were known as Advisory Standards until November 2004.
If a code of practice exists for a risk at your workplace, you must:
Ministerial Order 706 (effective from 22 April 2014)
On 14 July 2008, the Children’s Services and Education Legislation Amendment (Anaphylaxis Management) Act 2008 came into effect amending the Children’s Services Act 1996 and the Education and Training Reform Act 2006 requiring that all licensed children’s services and schools have an anaphylaxis management policy in place.
All schools must review and update their existing policy and practices in managing students at risk of anaphylaxis to ensure they meet the legislative and policy requirements outlined below.
Any school that has enrolled a student or students at risk of anaphylaxis must by law have a School Anaphylaxis Management Policy in place that includes the following
After providing first aid to a casualty, it is always a very good idea to make detailed notes or fill out a casualty report, no matter how minor. This will help you to recall the incident if you are ever asked about it at a later stage. If you complete this very soon after the event, your records could be used by a court of law. This means it is imperative that your notes are legible, accurate, factual, complete, and only state what you observe – not your opinions.
Information that should be included in your report includes:
You should also
If you are employed as a First Aider in your workplace, you may have reporting obligations under your State or Territory Workplace Health and Safety (WHS) legislation. You can check this with your workplace WHS representative.
Legal and Ethical Issues
THE FOLLOWING DOES NOT CONSTITUTE LEGAL ADVICE. INDEPENDANT LEGAL ADVICE SHOULD BE SOUGHT BY INDIVIDUALS AND / OR ORGANISATIONS IF REQUIRED IN THEIR OWN JURISDICTION.
FAMILY ATTENDANCE DURING CPR
It is not necessary to remove family members during resuscitation. All studies to date on both adults and children have demonstrated no detrimental emotional or psychological impacts, with most studies actually finding that being present during resuscitation was associated with improved measures of coping and positive emotional outcomes.
STANDARD OF CARE
Lay persons or volunteers acting as “Good Samaritans‟ are under no legal obligation to assist a fellow person. However, the ARC encourages the provision of assistance to any person in need. Should a lay person choose to assist, a standard of care is expected appropriate to their training (or lack thereof). Generally speaking, this standard is low. All Australian States and Territories have enacted Statutes which provide some measure of protection for the Good Samaritan / volunteer. They are required to act with “good faith‟ and without recklessness. The law differs from state to state: In New South Wales and Queensland the Good Samaritan / volunteer is required to act with reasonable care and skill – a standard which is in fact no different from the common law standard which pre-dated the legislation. In the Northern Territory, persons are required by Statute law to render assistance to any other in need.
The standard of care required of a person who has a duty of care to respond, is higher. All must, like any other persons in our community who hold themselves out to have a skill, perform their tasks to a standard expected of a reasonably competent person with their training and experience. This does not mean a standard of care of the highest level. For example, medical practitioners and other allied health workers such as nurses and paramedics are expected to meet a standard of care appropriate to their relevant fields of work.
REFUSAL OF TREATMENT
Competent adults are legally entitled to refuse any treatment even if life-sustaining or their decisions are not for their own benefit. Substitute decision-makers, such as parents or guardians of minors, can likewise refuse treatment but only if in the “best interests‟ of their charge.
Several States / Territories have legislature which gives statutory force to the common law principle that competent persons may refuse treatment. A refusal of treatment certificate (or similar) is required to be completed by the person when competent (an advance directive) or by the legal agent or guardian (e.g. enduring power of attorney) of an incompetent person in conjunction with a medical practitioner. In health institutions / facilities, refusal of treatment orders, such as DNAR (Do-not-attempt-resuscitation) or NFR (not for resuscitation) should be documented in case notes and signed. Such decisions should be recorded on appropriate certification in jurisdictions where they exist. It has long been settled law that parents or guardians of minors, in conjunction with doctors, may make legal and ethical decisions on withholding and withdrawing life-sustaining treatment.
COMMUNICATION WITH CASUALTIES AND BYSTANDERS
Providing first aid can be a very stressful and daunting experience – both for the casualty and first aider as well as bystanders. The manner in which a first aider communicates with a casualty and bystanders is often at the bottom of their priority list, especially when confronted with a potentially serious situation. However, it is important to always communicate in a respectful and sensitive manner. This is not to say that it isn’t necessary to sometimes be assertive, especially if the situation is critical, however this should be done in a respectful and considerate manner. Doing so can often assist to calm everyone down as well as to achieve cooperation from the casualty and bystanders.
It is also important to be culturally aware – for example, some cultures do not like men coming into physical contact with females who are not in their family and may respond negatively if this is attempted. If possible explain your intentions in a respectful manner or, alternatively, talk a family member through the basic steps of first aid in order to achieve the same goal without compromising their cultural or religious beliefs.
FIRST AID ON CHILDREN
Where possible, consent of a parent or guardian should be sought prior to undertaking first aid on a minor. Substitute decision-makers, such as parents or guardians of minors, can refuse treatment but only if in the “best interests‟ of their charge.
If the casualty is unable to provide informed consent, and no responsible person is present the legal requirement to obtain parental / guardian consent is typically waved under emergency / life-threatening circumstances. Under the common law doctrine of emergency, a doctor or other healthcare professionals may treat a patient as long as they act reasonably and honestly believes, on reasonable grounds, that the treatment is necessary to prevent a serious threat to the casualty’s life or health (Note: various Australian states have different definitions of emergency treatment and their own legislation allowing urgent treatment, hence professional advice should be sought).
In most professional settings involving the care of children, parental / caregiver consent is required on registration to allow appropriately trained workers or volunteers to respond in the event of an emergency situation, including provision of provide first aid if appropriate, or to contact an ambulance.
EDUCATION AND CARE SERVICES NATIONAL LAW (EXCERPTS)
Education and Care Services National Regulations 2011
Centre-based services - regulation 136(1)
The approved provider of a centre-based service must ensure that the following persons are in attendance at any place where children are being educated and cared for by the service, and immediately available in an emergency, at all times that children are being educated and cared for by the service:
Services must have staff with current approved qualifications on duty at all times and immediately available in an emergency. One staff member may hold one or more of the qualifications.
Premises on school site - regulation 136(2)
If children are being educated and cared for at service premises on the site of a school, suitably qualified staff must be in attendance at the school site and immediately available in an emergency. Services must have staff with current approved qualifications on duty at all times and immediately available in an emergency. One staff member may hold one or more of the qualifications.
Family day care - regulation 136(3)
The approved provider of a family day care service must ensure that each family day care educator and family day care educator assistant engaged by or registered with the service:
Each family day care services staff member, including educator assistants, must hold all three qualifications
Incidents, injury, trauma and illness
An approved service must have in place policies and procedures in the event that a child is injured, becomes ill, or suffers a trauma and should be followed. These must include the requirement that a parent be notified, as soon as possible, and within 24 hours of an incident, injury, illness or trauma relating to their child (including the death of a child).
The National Regulations require that an incident, injury, trauma and illness record be kept and that the record be accurate and remain confidentially stored until the child is 25 years old. Information should be recorded as soon as possible, and within 24 hours after the incident, injury, trauma or illness. A sample ‘Incident, injury, trauma and illness record” is included on page 161. This may be adapted for use by individual services, or providers may develop their own.
The National Law requires the regulatory authority to be notified of any serious incident at an approved service. A serious incident means:
First aid kits
A centre-based service must provide an appropriate number of suitable first aid kits that are easily recognisable and readily accessible to adults. The service must have policies and procedures about the administration of first aid to children being educated and cared for by the service.
A family day care educator must provide a suitable first aid kit at the residence or family day care venue that is easily recognisable and readily accessible to adults. First aid kits should also be taken when leaving the service premises for excursions, routine outings or emergency evacuations.
When determining how many first aid kits are ‘appropriate’, the service should consider the number of children in attendance as well as the proximity of rooms to each other and the distances from outdoor spaces to the nearest first aid kit. For example, larger services may require a kit in each room or outside space, whereas a kit between two rooms might be appropriate in a smaller service with adjoining rooms.
An approved service must have a policy for managing medical conditions which sets out practices in relation to the following:
Staff members and volunteers must be informed about the practices to be followed. If a child enrolled at the service has a specific health care need, allergy or other relevant medical condition, parents must be provided with a copy of the policy. Where a child has been diagnosed as at risk of anaphylaxis, a notice stating this must be displayed at the service.
Administration of Medication
Regulation 93 - Medication (including prescription, over-the-counter and homeopathic medications) must not be administered to a child at a service without authorisation by a parent or person with the authority to consent to administration of medical attention to the child. In the case of an emergency, it is acceptable to obtain verbal consent from a parent, or a registered medical practitioner or medical emergency services if the child’s parent cannot be contacted. Regulation 94 of the Education and Care Services National Regulations is an exception to authorisation requirement when it is an anaphylaxis or asthma emergency. In the case of an anaphylaxis or asthma emergency, medication may be administered to a child without authorisation. In this circumstance, the child’s parent and emergency services must be contacted as soon as possible. The medication must be administered:
In the case of a family day care service, or a service that is permitted to have only one educator, a second person is not required to check the dosage and witness the administration of the medication. The National Regulations set out requirements for confidentiality and the storage of medication records.
A child over preschool age may self-administer medication under the following circumstances:
Basic Human Anatomy
The human body is made up of many different anatomical and physiological systems, each performing a vital role. Whilst each system has an important role within the human body, several are particularly useful for a first aider to have a basic knowledge of. This section will provide basic information regarding the human anatomy / physiology that is important.
The skeletal system is a system of 206 bones that provides structure to our bodies and protects our internal organs from damage. Muscles, ligaments and tendons are closely linked with this system and all play vital roles in allowing movement and function of limbs and body parts.
A First Aider needs to be aware of the basic anatomy of the skeletal system, especially when dealing with possible fractures or dislocations to be aware of when providing first aid treatment to a casualty.
This system is made up of the heart, blood and blood vessels. Blood moving from the heart delivers oxygen and nutrients to every part of the body. The blood stream also removes waste products via transportation to the kidneys and other organs.
Heart – a muscular organ in the chest that pumps blood around our body. The average adult resting heart rate is between 60 – 100 beats per minute.
Blood – Most blood is composed of a clear liquid called plasma. Red blood cells make blood look red and allow oxygen to be delivered around the body. White blood cells are part of your body’s defence against disease. Platelets are cells that help your body repair itself after injury such as through coagulation.
Blood Vessels – Arteries transport blood away from the heart. Veins transport blood back to the heart. Arteries narrow into arterioles. Capillaries are the smallest vessels which connect the arterioles to the venuoles. It is at this level that the majority of transfusion with cells takes place.
A basic knowledge of this system will help in understanding the mechanics of CPR and DRSABCD.
The nervous system is made up of your brain, spinal cord and a huge network of nerves that thread throughout our entire body.
The nerves receive and conduct information to the brain for processing to enable coordination of all of our actions and reactions – from applying correct pressure when gripping a cup, to retracting your hand from a sharp or hot object.
A basic knowledge of this system is useful when dealing with burns and pain management.
As all cells in our body need oxygen to survive, our respiratory system is vital to our survival. This system comprises of 2 parts:
Airway - mouth, nose trachea, larynx, bronchi and bronchioles.
Lungs – literally large bags of air which contain small air sacks that are called alveoli.
As we breathe, diffusion of oxygen from the alveoli into the blood stream and carbon dioxide out of the blood stream takes place.
This process is essential to our survival – as little as 5 minutes without oxygen can cause permanent brain damage.
A basic understanding of this system is useful when learning about airway management and CPR.
This system involves the bones, ligaments, tendons and muscles which support the body, protect the internal organs, and enable movement.
Muscles contract and relax to provide movement of your body. Most muscles are attached to bones (like your biceps – involved in arm movements), whilst some muscles are attached to large masses of tissues (like your diaphragm which makes your lungs expand and contract).
Muscles can be damaged through injury and can result in tears or strains requiring medical aid.
A First Aider needs to be aware of the mechanics of the musculoskeletal system when dealing with strains or sprains.
Other anatomical Systems:
Child Psychological and Anatomical / Physiological Considerations
Children are not just smaller adults; they differ anatomically, physiologically, psychologically and cognitively. The same type of trauma often results in different injuries due to their different size and stages of development. For example, children’s bones are a lot more flexible due to their cartilaginous make-up which, together with their smaller height, means that if they are hit by a car for example, children are more likely to suffer chest and abdominal injury, as opposed to fractures (such as of the long bones) which is the most common injury to adults in the same situation.
As can be seen above, children’s ribs are more horizontally shaped than adults. This is significant to know for several reasons. Firstly, with inspiration, children’s ribs move up rather than up and out like adults. This limits inspiration and creates a different breathing motion which childcare workers should take the time to recognise (in order to help be able to identify normal vs. abnormal breathing). Obviously, the difference in a child’s size alone should alert the first aider to the fact compressions during CPR should be much softer than that of an adult. A child’s rib shape and relative flexibility further mean that less force is needed to compress a child’s chest to the required 1 / 3rd chest depth. In infants especially, the diaphragm is essential for breathing hence pressure on the abdomen can limit the ability for an infant to breathe.
Physiologically there are also differences, specifically respiration and heart rate changes as children develop. This can impact on assessment and evaluation of normal vs. abnormal breathing or pulse assessment (for trained professionals). This is in part due to higher metabolic rates requiring greater oxygen requirements. The table below provides a range of normal values for children of various ages. While it is unreasonable to expect first aiders to remember each of these values, if you are involved in child-care take note of the normal values of children within the age group you care for:
Airways & respiratory system:
Children have much smaller / narrower airways. This results in a greater likelihood of obstruction which is compounded by the childhood tendency of taking small items and finding a nice place for them in one’s mouth. Loose deciduous teeth can also become dislodged into the airway as can small food items. In conditions such as asthma or anaphylaxis, it takes a lot less swelling to cause obstruction to a child’s airways than an adult. The larynx also sits a lot higher in children, which makes visualisation of the airways more difficult.
Impact on airway positioning
Children have proportionally larger tongues, which is critical to remember when positioning the head and neck to open the airway. The larger occiput of infants causes forward tilt of the head when lying supine, hence to achieve neutral position it may be necessary to raise the chin slightly, taking care not to hyperextend the neck.
Other various differences between adults and children:
The illustration below demonstrates some of the differences to be aware of when learning first aid in a child care setting:
As discussed in the post-incident debriefing section, children have unique psychological needs which a first-aider should be mindful of. Careful, age-appropriate explanations and a holistic approach to a situation are vital to alleviate anxiety, achieve compliance and to help reduce the potential of lasting psychological impact. This is difficult to achieve, particularly during an emergency situation where stress levels are high and even more so if the first aider has never been involved in such a situation before. The best advice to keep in mind is:
Chain of Infection
Whether or not infection happens will depend on a number of things. This is best explained by looking at the chain of infection.
The Six links to the Chain of Infection
In order for infection to occur, the six links to the Chain of Infection must occur.
Infectious Agent: any disease-causing micro-organism (pathogen) i.e. bacteria, virus.
Reservoir: Where the pathogen is located (i.e. blood, saliva).
Portal of Exit: The route of escape of the pathogen from the reservoir (i.e. saliva via coughing, blood via cut in skin).
Mode of Transmission: How the pathogen gets from the reservoir to its new host (i.e. propelled through air, direct contact).
Portal of Entry: The route in which the pathogen enters the new host (breaks in skin (cuts, wounds), inhalation, ingestion, sexual contact).
Susceptible Host: The organism that accepts the pathogen (you or the casualty).
How To Break The Chain of Infection
Correct Hand Washing: Appropriate hand washing by the First Aider remains the most important factor in preventing the spread of micro-organisms. Good hand-washing techniques include:
Use barrier equipment whenever possible (gloves, masks, face shields, eye protection, aprons and tongs). Barriers will dramatically decrease the chance of infection spreading, both to the casualty and to you!
Needle Stick Injuries
Needle stick injuries are an opportunity for a pathogen to penetrate directly into the blood stream of another person if not handled carefully. HIV (AIDS) and Hepatitis B are just a few of the possible blood borne viruses that can be communicated from one person to another. The risk of actual infection depends on a number of factors, including firstly what pathogens are on the needle stick, and also how long it has been outside of the body. Viruses such as HIV generally only survive outside the body for several minutes but can survive hours if conditions are right. If injured by a used needle stick, one should always contact medical assistance so that testing and preventative measures can be done to decrease the risk of infection.
Ways to reduce the risk of needle stick injuries:
If you do become contaminated by a sharp you should follow the following steps
First Aider Characteristics
As a First Aider, you could be dealing with difficult, life threatening situations. People around you may be screaming, moaning, or in a panic. A proficient First Aider will be:
Calm & Collected – As you approach an emergency – take a few deep breaths. This will help you slow down your racing heart and encourage you to take a moment to collect your thoughts. By taking a few moments you will be able to absorb what is happening around you - what dangers are present, what injuries has been sustained by the casualty. By collecting your thoughts, you will be able to logically approach the situation and remember your training. Concentrate on what you are doing and try not to get distracted or flustered.
Reassuring – Many conditions can be exacerbated if a casualty becomes overly anxious and distressed. The casualty may be in shock, confused, or concerned. Talk to your casualty as a person and reassure them that things are under control. If other people are present that are trying to help but are also finding the situation distressing, it helps to reassure them that you know what you are doing, and the situation is in hand. This will encourage them to follow your instructions and help them to stay focused.
Assertive – There is a big difference between assertion and aggression. You need to be bold in your statements, and confident in your instructions. People will be relying on you to direct them. If you present yourself as someone who is confident in your own abilities, people will more readily take instructions from you. If you are the only First Aider on site, take control and provide assertive instructions to people with short explanations as to why those tasks are useful. If people understand what they are doing and know that you have things in control they will more readily assist you in what needs to be done to assist the casualty and keep everyone safe. If the casualty is anxious or going into shock, sometimes assertive instructions may be necessary to prevent them from moving or doing something that may exacerbate their condition.
Sensitive – It is important to be sensitive to a casualty’s needs and the fact they are likely very stressed / anxious. It is likewise important to be culturally aware. There are many cultures with specific beliefs and attitudes which may cause people to respond negatively if a first aider forces themselves into a situation without considering the ramifications first. Good communication will often resolve any potential conflicts and enable a first aider to assist in a positive and helpful manner. Remember, you are much more likely to receive respect and cooperation from people if you are respectful to them!
Good communicator – You need to be clear in your instructions, as to not create confusion. A clear instruction meets 3 criteria:
Safe Manual Handling
Manual handling includes pulling, pushing, lifting, moving, carrying, restraining or holding any person or object.
Safe manual handling involves:
Assessing the situation
Sizing up the load
Use good lifting techniques
Refer to Recovery Position (step 24) for techniques for moving a casualty.
Basic First Aid Kit
A basic first aid kit should, as a minimum, include the following:
Caring For The Unconscious
A casualty who IS breathing, but NOT conscious.
Combinations of different causes may be present in an unconscious victim (see section on causes of unconsciousness). Before losing consciousness, a victim may experience yawning, dizziness, sweating, change from normal skin colour, blurred or changed vision, or nausea. Unconscious victims should be handled with care, to avoid unnecessary twisting or movement of the head or spine. That being stated, care of the airways takes precedence over any injury, including those which present a risk of spinal injury.
The Australian Resuscitation Council recommends using the following acronym when caring for the unconscious
D R S A B C D
Checking for danger before approaching any situation is critical. By rushing into a situation without adequately assessing the situation you can put yourself and others at needless risk. Dangers will depend greatly on the situation; hence it is important to assess each individual scene for unique dangers. These can include fire, traffic, fumes, gas leaks, smoke or even broken glass or blood.
If danger is present you need to make a logical decision as to whether it is safe to continue or not. Sometimes dangers can be removed, or the casualty may be able to be moved away from the danger. However, some dangers may present a great risk to yourself and others, and sometimes the best thing you can do is call 000 / 112 and enlist professional assistance to deal with the situation.
Once there is no immediate danger in assisting the casualty, you need to determine if they are conscious or not. Approach carefully and call out in a friendly tone – tapping their feet can also assist in obtaining a response.
If there is no response to this and it is safe to do so, implement TALK and TOUCH.
CALL FOR HELP, EMERGENCY NUMBER 000 / 112 (mobile phone)
SEND FOR HELP
Once you have determined the casualty is unconscious, you should next immediately send for help. Yell out for assistance! If there are any bystanders, instruct them to call 000. If you are alone and have access to a phone, call 000 and clearly explain the situation.
Remember, early access, early CPR, early defibrillation and early advanced care all maximise the chance of a casualty’s survival. The earlier paramedics are notified and attend, the better the chance the casualty will survive.
In an unconscious casualty, care of the airway takes precedence over any injury. Airways should be checked with the casualty in the supine position (on their back)
Open casualty's mouth and check for signs that the airway may be blocked. By using the ‘Pistol Grip’ you can open the casualty’s mouth without placing pressure on their neck. If the casualty has anything obstructing their airways, you will need to turn the casualty into the Recovery Position and use 2 fingers to scoop out any foreign objects, fluid or vomit.
If the airways appear clear, then you do not need to move the casualty at this point, you can proceed onto checking Breathing
LOOK - LISTEN - FEEL FOR BREATHING.
Get very close to the casualty, placing your ear just above their mouth. Can you feel breathing on your cheek? Can you hear breathing? By looking towards the casualty’s feet and placing a hand on their abdomen you will also be able to check for chest movement. If the casualty is breathing, they should be turned into the Recovery Position.
If there is NO SIGN OF BREATHING or casualty is NOT BREATHING EFFECTIVELY, you will need to proceed immediately onto CPR.
If the casualty IS breathing effectively, then CPR is not necessary, do not proceed to compressions (see full DRS ABCD flowchart from page 33)
If the casualty is breathing, then place them in the recovery position (next page). Check for signs of good circulation. With the casualty in the recovery position, look at the inside of their lip – it should be pink. Check the colour of their skin. If they start turning blue – there may be a circulation problem and you should alert 000 / 112.
Next, check for internal and external bleeding.
Are there pools of blood? Is the casualty soaked in blood? You can also check for internal bleeding by placing you hand on the casualty’s abdomen and feeling for any abdominal distension. If the abdomen or thighs looks swollen or feels hard, or if there are areas of deep purple discolouration then this may indicate internal bleeding. If the casualty has vomited or coughed up blood this may also indicate internal bleeding.
If internal bleeding is suspected (blood from ears, abdominal / thigh swelling) call 000 / 112 immediately. If bleeding from ear, put in recovery position with the bleeding ear downwards. If external bleeding is identified, apply pad and pressure bandage, then elevate the effected limb
Once you have followed DRSABCD and established the casualty is breathing, you need to place them into the recovery position. This is extremely important as it is the best position for an unconscious, breathing casualty. An unconscious casualty lying on their back can very easily choke on their own tongue or regurgitated vomit.
Recovery Position for a Child (1-8) or Adult (8+)
REMEMBER - WHEN MOVING THE PERSON ONTO THEIR SIDE MAKE SURE THEIR NECK AND BACK DO NOT MOVE.
Recovery Position for an infant (Under 1 year old)
Your heart is a muscle that pumps blood to all parts of the body. The blood provides your body with the oxygen and nourishment it needs to function. Waste products carried by the blood are removed from the body by organs such as the kidneys.
When you are exercising, your heart will pump blood up to 4 times faster – that’s 20 litres per minute compared to the average 5 litres per minute while at rest.
The right side of the heart obtains de-oxygenated blood via the main veins (Superior and Inferior Vena Cava) and pumps this blood to the lungs where oxygen is absorbed and carbon dioxide is released. The oxygenated blood returns to the heart via the pulmonary vein into the left atrium. The blood is pumped then into the left ventricle which pumps blood into the body’s main artery – the aorta. The aorta is the body’s largest artery and carries blood to smaller arteries which distribute it to all parts of the body. On the return trip, the now de-oxygenated blood carries blood back to the heart via veins into the right atrium and the cycle continues.
The heart is composed of four chambers as marked on the diagram:
Blood circulation around the body
The right and left sides of the heart pump blood through the pulmonary circulation (to the lungs) and the systemic circulation (to the rest of the body). The right side of the heart receives deoxygenated blood (blood that has little to no oxygen in it) from the body through the two large main veins, the superior vena cava (SVC) and the inferior vena cava (IVC). This blood circulates into the right atrium, to the right ventricle, and then to the lungs via the pulmonary trunk so the blood can take up oxygen.
The blood absorbs oxygen from the pulmonary circulation in the lungs and returns the blood to the heart via the pulmonary veins. The now oxygenated blood enters the left atrium, and then passes through the left ventricle which pumps the blood into the aorta - the main artery in the body. From the aorta, the oxygenated blood circulates throughout the body, transporting the oxygen from the lungs, as well as nutrients, waste products and many other components of blood to and from cells to maintain homeostasis (maintaining the body’s internal environment and the needs of the cells). By the time the blood has passed throughout the systemic circulation, the blood has lost most of its oxygen and returns via the veins to the right side of the heart where it continues again to the lungs. This information is summarised in the flowchart below.
The blue text describes when the blood has little to no oxygen, and the red is when there is lots of oxygen in the blood. It is important to understand that the heart along with the rest of the cardiovascular system is responsible for transporting oxygen and nutrients which keeps the cells in the body alive. In ventricular fibrillation, the heart muscles do not pump effectively, which means that blood is not being effectively transported throughout the body – in particular the brain. The brain is of significant importance in this context because cells in the brain can last only a few minutes without oxygen before they start to die. This means if successful CPR and defibrillation does not take part very soon after the casualty’s heart no longer is functioning, the casualty may very well suffer permanent brain damage, or worse, may not survive. This is explained in more detail in the ‘Chain of Survival’ section a bit later.
Blood supply to the heart
It has been mentioned that cells in the body require oxygen and nutrients to properly function as well as to survive. The heart muscles themselves are no exception. Even though the heart pumps blood throughout the body, the muscles that pump the blood also need oxygen and nutrients to be able to properly function. The heart muscles are known as the myocardium (myo - muscles, cardium – heart). The circulation to the myocardium is termed the coronary circulation, and is composed of:
In some circumstances, the blood supply to the heart can become compromised due to pathology. A build up of fatty plaque in the walls of the coronary arteries known as atherosclerosis can cause a decrease of blood supply to the heart and lead to cardiac problems such as angina or even a heart attack. An embolus (a piece of material such as a clot that breaks off from one part of the circulatory system and gets lodged in another part) can also cause a sudden blockage to an artery supplying the heart. When the circulation to the heart becomes compromised in these ways, the heart is unable to function as per normal and this can cause a variety of cardiac problems.
How does the heart pump?
Now that we have covered some basic anatomy of the heart, let’s look at how the heart actually works.
Within the heart wall there are cells that act as a pacemaker to the heart, called autorhythmic cells. These cells set the beat of the heart, and in doing so generate an action potential of electronic impulses that they then transmit to nodes and bundles located at specific points in the heart. These impulses cause contraction of the heart muscles at different points causing the cardiac cycle. The main nodes and bundle locations are shown below:
The Chain Of Survival
Cardiac arrest can happen at any-time, at any place. Over 75% of all cardiac arrests happen outside a hospital, and of that – only 5% will survive.
“Survival of cardiac arrest depends on a series of critical interventions. If one of these critical actions is neglected or delayed, survival is unlikely. The American Heart Association has used the term Chain of Survival to describe this sequence.”
(Emergency Cardiac Care Committee and Subcommittees. American Heart Association.)
When a person is unconscious and not breathing, they will need more than basic first aid. Early access means calling for an ambulance or medical assistance as soon as possible. By calling 000 / 112 you can tell the operator what sort of emergency you are reporting:
When calling for assistance you need to be clear on your information. Give specific details as to your location, the nature of the emergency, and follow all their instructions. When the area is difficult to find, allocate a person to meet with the emergency services personnel.
The 2 most vital anatomical systems in our body are the Cardiovascular System and the Respiratory System. If these systems fail for only a short time, then the body cannot function normally, and death can quickly result. Cardio-respiratory arrest (also known as cardiac arrest) is a condition that is caused by both the Cardiovascular and Respiratory Systems stopping abruptly. This is a life threatening condition!
Cardio-respiratory arrest can be triggered by:
Statistics show that our brain cells begin to die in as little as 3-4 minutes without oxygen. Brain cells do not regenerate, hence the longer CPR is delayed, the more chance the casualty may suffer permanent brain damage, and the less chance they will survive.
Early CPR within the first 3-4 minutes can help improve the chances of survival greatly.
Automated External Defibrillators (AEDs) are portable computerised devices that provide an electrical charge to “jump-start” the heart. These portable devices have built in computers and sensors that will check for a heart rate once placed on the casualty’s chest and determine if defibrillation is required. Voice prompts are then given to the user to follow, to streamline the defibrillation process
Access to Early Defibrillation is the single most important step in this cycle. Every minute where early defibrillation is delayed reduces the person’s chances of survival by 10%. This is why it is so important to call 000 / 112 if a heart attack is suspected, as if the casualty is in ventricular fibrillation, a defibrillator is necessary to reverse this process and ‘reboot’ the heart back into its normal cycle.
Early Advanced Care
Early advanced care means the sooner a paramedic can attend, the greater the chance is that the causality can be stabilised. As such, it is important that you call 000 as soon as possible. The sooner you contact emergency services, the sooner a paramedic will be on the scene, which dramatically increases the casualties’ chance of survival.
Basic Life Support Chart
Casualty who is NOT breathing and NOT conscious.
The Australian Resuscitation Council recommends using the following acronym when caring for the unconscious – D R S A B C D
As you will see, this process is very similar to providing care to Caring for the unconscious. Infact, you will find that the some of the words are the same
Note: same for breathing and non-breathing casualties
Over the page you will see DRSABCD for unconscious, non-breathing casualties.
Basic Life Support
(Full DRS ABCD)
D - Danger
This step is the same when both caring for a breathing or non-breathing casuality.
If danger is present you need to make a logical decision as to whether it is safe to continue or not. Sometimes dangers can be removed, or the casualty may be able to be moved away from the danger. However, some dangers may present a great risk to yourself and others, and sometimes the best thing you can do is call 000 / 112 and enlist professional assistance to deal with the situation.
R - Response
This step is the same when both caring for a breathing or non-breathing causality.
Check conscious state, speak in a calm positive manner, identify yourself and ask if you can help. Always approach a casualty with caution, feet first. If there is no response and it is safe to do so, implement TALK and TOUCH.
S - Send For Help
This step is the same when both caring for a breathing or non-breathing causality.
Once you have determined the casualty is unconscious, you should next immediately send for help. Yell out for assistance! If there are any bystanders, instruct them to call 000 / 112. If you are alone and have access to a phone, call 000 / 112 and clearly explain the situation.
Remember, early access, early CPR, early defibrillation and early advanced care all maximise the chance of a casualty’s survival. The earlier paramedics are notified and attend, the better the chance the casualty will survive.
A - Airway
Open casualty's mouth and check for signs that the airway may be blocked. By using the ‘Pistol Grip’ you can lift the jaw forwards without putting pressure on the casualty’s neck. If the casualty has anything obstructing their airways, you will need to turn the casualty into the Recovery Position and use 2 fingers to scoop out any foreign objects, fluid or vomit.
If the airways appear clear, then you do not need to move the casualty at this point, you can proceed onto checking Breathing and Signs of Life.
B - Breathing
Get very close to the casualty, placing your ear just above their mouth. Can you feel breathing on your cheek? Can you hear breathing? By looking towards the casualty’s feet and placing a hand on their abdomen you will also be able to check for chest movement. If the casualty is breathing, they should be turned into the Recovery Position.
C - CPR
This step is only to be applied to a non-breathing casualty.
Compressions are the first part of CPR used in conjunction with rescue breathing to circulate the oxygen that has been exhaled into the casualty’s mouth around the body.
Compressions are performed as follows:
Our recommended method is to sing Twinkle Twinkle Little Star to assist in achieving the correct speed of compressions. You compress on every syllable, and when you sing the work SKY – you look up to the casualty’s face and perform 2 rescue breaths
Fractured Ribs –This is a common consequence of CPR, however this is acceptable given that the alternative to CPR is likely death of the casualty.
First aider change-over – When possible, it is recommended that first aiders change every 2 minutes (5 cycles) to prevent fatigue and also to help ensure that the depth and speed of compressions in maintained. If this is performed, it is important to minimise interruptions to compressions
CPR – Rescue Breath methods
Perform 2 rescue breaths after 30 compressions using one of the following methods.
Mouth to Mask involves the first aider using a CPR mask for providing rescue breaths. The first aider exhales through a 1-way valve through the mask into the casualty’s mouth. The valve prevents air from returning into the first aider’s mouth and therefore prevents contact with potentially infectious fluids such as saliva, blood or vomit. Head tilt is still required to open up the casualty’s airways and full head tilt for adults should be used if there is no suspected cervical injury.
Mouth to Mouth is the recommended form of rescue breathing when a mask is not available. The following steps should be taken to correctly provide mouth to mouth:
Mouth to Nose can be used if preferred by the first aider. For infants, an adaptation of mouth to mouth is for the first aider to cover the infant’s mouth and nose with their own mouth instead of attempting to pinch the infant’s nose. If providing mouth to nose on adults, the same method as mouth to mouth is used, except instead of blocking the nose, the first aider should ensure the casualty’s mouth is closed when exhaling into the casualty’s nose (this involves sealing the mouth by pushing the casualty’s lips together with your thumb).
Blocked Airway - If the casualty’s chest does not rise during rescue breathing, check that:
Vomiting and Regurgitation – It should be noted that about one in four casualties will regurgitate whilst having CPR performed on them, especially when drowning is the cause of unconsciousness. This is because when unconscious, the casualty’s muscles are totally relaxed, including the valve that stops regurgitation above the stomach.
If the casualty does vomit or regurgitate during CPR, turn them into the recovery position and clear the airways using the 2 finger scoop method. If they are still not breathing once the obstruction is cleared from the airway, place them on their back again and re- commence CPR.
Although full CPR is recommended, in the event that you are unwilling or unable to perform rescue breaths, you should continue performing CPR using chest compressions only. Remember – any attempt is better than no attempt!
CPR – Considerations in Children
DRSABCD is identical for children and adults. The main differences between child and adult CPR are as follows:
D - Defibrillation
This step is only to be applied to an unresponsive and non- breathing casualty.
A defibrillator is a very useful and effective device and can play a great part in saving a person's life.
AED (Automated External Defibrillators) are portable devices that can be used effectively with minimal training, as all the current model units are designed not to function unless the unit cannot detect a normal heart beat.
AED use is not restricted to trained personnel – any first aider can use an AED. Time is a key factor when using an AED. For casualties suffering from VF (ventricular fibrillation), for every minute defibrillation is delayed, there is approximately a 10% reduction in survival rate.
AED units can accurately identify the casualty’s cardiac rhythm as ‘shockable’ or ‘non-shockable’.
What is an Automated External Defibrillator (AED)?
An AED is a portable, electronic device that enables users to successfully diagnose and treat casualties who are suffering from the potentially life threatening condition of ventricular fibrillation (loss of rhythmic heart contractions, resulting in an inability of the heart to effectively pump blood).
The device achieves this by being able to undertake several functions:
Detecting Electrical Activity Within The Heart
Normally, the action potential that generates muscle contractions begins in the sinoatrial (SA) node and then travels throughout the atrial muscles to contract the atria. The timing of the impulses are incredibly designed to allow just enough time for atrial contraction to finish before the action potential reaches the muscles of the ventricles for ventricular contraction. The SA node typically sets a heart rate of 90-100 beats per minute, and works in conjunction with autonomic and chemical regulation to maintain an adequate heart rate to meet the requirements of the body’s cells. The impulses that conduct through the heart to contract the heart muscles generate a tiny current which can be picked up by detectors placed on the chest as part of either an electrocardiograph (ECG) unit or an AED unit. These impulses can be recorded and analysed to determine if the heart is working correctly – as any disruption to the normal rhythmic cycle of impulses can be picked up from the ECG wave.
A normal ECG wave
Although quite simple in appearance, subtle variations in the ECG wave can be caused by a variety of pathologies and problems. Some examples are:
Precise timing of impulses is required for the heart to function optimally. In ventricular fibrillation, the heart loses this rhythmic, well-timed series of impulses and the heart muscles go into a spasm. This muscular spasm of the myocardium means that the heart is no longer effectively pumping blood throughout the body which can rapidly result in death. The only way to stop this in the majority of cases is by defibrillation, such as with the use of an AED unit. Note the difference in the normal ECG wave above to that of a casualty who is in ventricular fibrillation as shown below:
An AED unit incorporates a tiny microprocessor that can interpret this data to find that there is a loss of the normal pattern of electronic activity within the heart, and that the casualty requires defibrillation.
How to use an AED
Time is critical! For every minute defibrillation is delayed, the survival rate for victims in cardiac arrest due to VF is reduced by approximately 10%.
Once it is determined that the casualty is unconscious and not breathing after having a suspected heart attack, then after calling 000 the following steps should be taken to correctly use an AED as soon as one is available:
AED For Children
Standard adult AED pads are suitable for persons 8 years and older. For children between 1 and 8 years old, paediatric pads should be used when available. If these are not available, then standard adult AED pads can be used.
Pads placement is the same as for adult AED. If using adult pads on smaller children (i.e. 1-5), one pad may need to be placed in the centre of the chest, and the other on the postero-lateral chest (casualty’s left side towards their back).
Make sure the pads do not touch each other. If the pads are too large for the child there is a risk of charge arcing. If the pads are too large then use an antero-posterior placement (first pad placed on the front of chest, slightly to the left of centre if possible; the second pad to be placed between the shoulder blades on the back of the child).
Adult Placement vs. Child Placement
As noted above, child pad placement is the same as for adult AED. Although time is of the essence, it is important to stay calm and take care to look for and select paediatric pads where available, as well as selecting paediatric / child settings if available on the AED unit.
If using adult pads on smaller children (i.e. 1-5), one pad may need to be placed in the centre of the chest, and the other on the postero-lateral chest (see below):
AED - Additional Information:
Post Incident Debriefing
Once you have provided CPR to a casualty, and handed over responsibility to the paramedics, it is suggested that you undergo a debriefing. Talk through your actions with your manager, other first aiders, psychologists, family or friends. Take time to calm down and reflect on your actions - don’t go straight back to work.
The following reactions are normal, and help people come to terms with a critical incident
Physical reactions - Disturbed sleep, Nausea, Nightmares, Restlessness, Headaches, Excessive alertness and being easily startled.
Cognitive reactions - Poor concentration, Poor attention and memory, Visual images of the event, Intrusive thoughts, Disorientation or Confusion.
Emotional reactions – Fear, Numbness and detachment, Avoidance, Depression, Guilt, Oversensitivity. Anxiety and panic, Withdrawal and tearfulness.
Tips to recover from Trauma
Seek professional help
Traumatic stress can cause very strong reactions in some people. You should seek professional help if you:
Psychological impact on children
Whether the child is the casualty or a witness to the event, it is important to be mindful of the potential impact exposure to emergency situations can have. There are many considerations which should be emphasised, including the immediate post-incident needs, emotional outcomes and stress / grief of the child and their family. Careful, age- appropriate explanations and communication is vital to alleviate anxiety and to help achieve compliance during a critical situation.
Professional guidance and advice should be sought for all children who have witnessed or been involved in traumatic / life-threatening events. In particular, care givers should be aware of and observing for signs of emotional distress, including but not limited to withdrawal, sadness, anger, loneliness, loss of appetite, difficulty sleeping, irritability, or any significant changes to demeanour / personality. Any persons involved in the care of the child (including teachers, babysitters, minders, etc) should be aware of the child’s experience and be instructed to inform the primary care giver(s) of any concerns.
Provide Basic Emergency Life Support
Choking Adult or Child
In first aid, choking is defined as a mechanical obstruction of the airways by a foreign object such as food. Choking can lead to unconsciousness or even cardiopulmonary arrest if the obstruction is severe enough. The quick recognition and proper management of a casualty who is choking is of key importance. Children 4 years and under are most at risk of choking, and statistically food and toy parts make up the highest number of deaths. These can include toys with small parts, balloons or inappropriate food items left in reach of children.
When a person’s airway becomes blocked, permanent damage and even death from asphyxiation can result. Brain damage can begin just four minutes after the organ has been deprived of oxygen. If the casualty is able to cough and talk, then this is not considered serious choking. Serious or true choking occurs when the object is firmly lodged in the casualty’s throat and they are unable to cough effectively.
The danger signs of choking are:
As previously mentioned, children 4 and under are at the highest risk of choking related injuries or death. Some statistics demonstrate that the reflex action of infants placing items in their mouths account for as much as 60% of choking deaths. Hence infants should be carefully supervised at all times to ensure they do not find small items or food pieces that can be picked up and placed in their mouths.
Choking occurs when food or other small objects become lodged in a child’s throat or airway (trachea), which prevents oxygen from getting to the lungs and brain. Food is among the objects most likely to cause choking in a child.
Children who begin to choke typically cannot breathe, cry or make noise. As choking persists, a child’s face may become initially red, then turn blue as the body runs out of oxygen. If the child’s airway is not cleared, loss of consciousness will follow. As like adults, brain damage can begin just four minutes after the organ has been deprived of oxygen.
The danger signs of true choking are the same for adults, children and infants
IF OBJECT ISN’T FREE AFTER 5 BLOWS
IF THE INFANT LOSES CONSCIOUSNESS or if the child becomes unresponsive, stops breathing, or turns blue:
Shock is a life threatening condition that occurs when the body is not getting enough blood flow. All organs need blood to perform, and if they are not getting sufficient blood they cannot function normally. Shock can damage multiple organs, and requires immediate medical treatment, as it can get worse very rapidly. There are many specific types of shock including:
The signs and symptoms will vary slightly with the specific types of shock, although it is not important for a first-aider to identify what kind of shock a casualty is in. What is most important is for a first aider to recognise the signs and symptoms of a casualty going into shock so that they can assist the casualty and call 000 / 112 when appropriate.
Shock may be caused by any of the following:
Symptoms may include:
Bleeding is a very common condition requiring first aid. Bleeding, also termed haemorrhage, occurs when there is a rupture of blood vessels causing a loss of blood. Bleeding can be very minor to life threatening depending on which vessels have been damaged.
In small, superficial wounds, capillaries (which are the smallest vessels) may be damaged causing a slow, oozing of the blood from the wound. This is not considered serious and is easy to control – attention should be paid to reducing the risk of infection by washing hands before assisting and using sterile wound dressings (i.e. bandaids).
Sometimes with deeper wounds, veins (which carry blood back to the heart) may be damaged. As these are larger vessels than capillaries they carry more blood, hence a more steady flow of dark blood will be seen. This may require firm pressure to control.
In the most serious bleeds, arteries (which carry fast flowing blood from the heart) are damaged. An arterial bleed will typically be very fast, bright red and can result in a great loss of blood if not controlled. If damage occurs to the major arteries such as the aorta or femoral arteries, immediate attention is required to prevent death from blood loss.
Bleeding can also be external or internal.
External bleeding means there is damage to the vessels and skin, and the blood is leaking outside the body. This is generally easy to see, however this can be hidden beneath clothing and should be checked for during your DRSABCD check.
Internal bleeding is the same process as external bleeding, the only difference being the blood is leaking INSIDE the body, hence this can be very difficult to detect unless specifically looking for it. When checking for bleeding during your DRSABCD check, you should always include palpation of the casualty’s abdomen and thighs so that any internal bleeding can hopefully be detected early.
First Aid measures should include stopping the bleeding, using sterile, hygienic measures to reduce the risk of infection where possible and watching for signs of shock.
For minor bleeding (cuts, scrapes, etc) apply pressure with a dressing for about 30 seconds. Clean the wound if necessary, and cover with a sterile or clean dressing.
First aid of serious bleeds should follow 3 basic steps as listed below. By remembering the colour of blood (RED) you can remember these easy steps:
R – Rest. Any movement of the injured body part can potentially increase the bleeding and make it harder to control. The body part should be kept still until bleeding is controlled.
E – Elevation. By elevating the body part, gravity will make if more difficult for blood to reach the wound, reducing the amount of bleeding. If the injury is to the casualty’s abdomen or chest, then these areas cannot be elevated.
D – Direct Pressure. This step is by far the most important and involves using an absorbent material, ideally a dressing such as sterile gauze. If you do not have this, then a clean towel, a piece of clothing or even just your hand can be used if the bleeding is severe and there is nothing else available.
Once the pressure is applied on the wound, a pressure bandage can be used to maintain the pressure by wrapping it firmly around the wound and dressing. If the dressing becomes soaked with blood, it is better is to leave the first dressing on, and to apply another dressing firmly on top of the first.
If however, major bleeding continues it may be necessary to remove the pad(s) to ensure that a specific bleeding point has not been missed. The aim is to press over a small area to achieve greater pressure over the bleeding point. For this reason an unsuccessful pressure dressing may be removed to allow a more direct pressure pad and dressing on the bleeding location.
To apply a pressure bandage to the limb:
Bleeding (Embedded Objects)
SIGNS AND SYMPTOMS OF INTERNAL BLEEDING
First aid for internal bleeding is limited as any serious internal bleed will likely require surgical intervention. If the internal bleed is minor, such as some bruising, then cold packs can be applied to the area to reduce the swelling and relieve pain. If you suspect more severe internal bleeding, carefully monitor the casualty and call 000 / 112 immediately. Checking for internal bleeding should be routinely performed during your DRSABCD checklist if the casualty is unconscious and breathing. Be aware that the casualty may go into shock. If they are unconscious and breathing then they should be placed in the recovery position and kept under close supervision until assistance arrives.
Bleeding (from Head)
If the casualty is bleeding from the head after a trauma, a first aider should not apply firm direct pressure on the wound if there is a risk of a skull fracture. If the skull feels ‘spongy’ or you are not sure, then indirect pressure can be applied by wrapping a bandage around the head with minimal risk of causing brain injury by pushing a fractured skull into the brain.
Ear – Bleeding from the ear is a sign of internal bleeding within the skull. Medical aid should be sought for all situations where this occurs.
Nose – Bleeding from the nose is fairly common and normally not serious, unless bleeding continues for more than 20 minutes.
Tooth – The dislodgement of teeth is common, especially among children or sports.
Treatment (dislodged tooth)
Treatment (chipped tooth)
Amputation is the removal of any part of the body, either by surgery, disease or traumatic event. Amputation accidents around the home or workplace normally involve a finger or a toe. More serious amputations include legs or arms and can occur in workplaces using industrial equipment.
First Aid in the event of amputation of a body part involves firstly controlling the bleeding and looking after the casualty, finding the amputated part and transporting the casualty to hospital or calling 000 / 112
Partial amputation is where a limb has been severely damaged, but is still partially attached to the body.
Wrap or cover the injured area with a sterile dressing or clean cloth. Apply direct pressure to reduce the bleeding if necessary. Remember not to cut off blood flow to the area by compressing the area too tightly. Gently splint the injured area to prevent movement or further damage. Transport the casualty to medical assistance or call 000 / 112.
It is estimated that at least 2 million Australians have asthma. Up to 16% of children are estimated to have asthma in Australia. Latest statistics show that 318 Australians died of Asthma in 2005. The majority of people with asthma do not have an action plan and many do not carry their reliever medication with them.
People with asthma have very sensitive airways. An Asthma attack is caused by spasm or narrowing of the bronchioles (air passages) in the lungs. During an episode, air passages become narrowed by muscle spasm, swelling of mucous membranes and increased mucous production. Although the exact cause of asthma is still relatively unknown, exposure to certain toxins, such as smoking during pregnancy is linked with the disease.
Muscle Spasm:The layer of muscle surrounding each bronchiole constricts or tightens, causing the air passage to become narrower.
Inflammation:The lining of each passage, being very sensitive becomes inflamed and swollen.
Excess Mucus:More than usual amounts of mucus are produced in each bronchiole that contributes to the narrowing of the airways
These may cause coughing (varied) noisy, wheezy breathing (not always), tiredness, difficulty speaking, chest tightness, and shortness of breath or rapid breathing. The victim may become very distressed because of difficulty in breathing.
How to assess a: Mild Asthma attack
How to assess a: Moderate Asthma attack
How to assess a: Severe Asthma Attack (Dial 000)
Asthma Medication - Relievers - works within minutes
Treatment: Using Your Puffer (4 X 4 X 4)
Step 1-Sit the person upright, reassure them and attempt to keep them calm.
Step 2Without delay shake a blue reliever puffer and give 4 separate puffs through a spacer (if available). Use 1 puff at a time and ask the person to take 4 breaths from the spacer after each puff.
Step 3Wait 4 minutes. If there is no improvement repeat step 2. If there is still no improvement after another 4 minutes, or you are concerned at any time, call an ambulance immediately (Dial 000), and repeat step 2 until ambulance arrives or the casualty is breathing normally.
Using an inhaler
Using inhaler with spacer (preferred)
Risk Factors include:
Signs and Symptoms of a Heart Attack
Angina is a symptom of a condition called myocardial ischemia. Basically put, this means that the heart muscles are receiving inadequate blood flow and hence inadequate oxygen for the amount of work the heart is doing at a particular time. This is due to disease of the coronary arteries called atherosclerosis (fatty deposits causing hardening and narrowing of the artery lumen)
This means that when the casualty starts exercising, they will develop symptoms very similar to that of a heart attack. The big difference however, is once the casualty is instructed to rest and their heart rate decreases, the symptoms will subside and disappear.
Unstable angina is a more severe form of this condition and occurs when the disease process is so pronounced that symptoms become less predictable and can occur during minimal exertion or even at rest. Casualty’s suffering this form should seek medical advice immediately as this is a warning that a heart attack may occur soon.
Angina is a warning sign that the casualty is at risk of potential cardiac arrest. You should strongly advise the casualty to seek medical advice regarding their heart if they are not already under the care of a general practitioner or cardiologist.
Signs and Symptoms
Anaphylaxis is the most severe form of an allergic reaction. It is an acute, systemic type 1 hypersensitivity reaction. This reaction is a medical emergency, and without prompt medical intervention, the casualty’s condition can quickly deteriorate to even respiratory arrest or death. It is caused when a casualty is exposed to a substance that they are severely allergic to – this substance is known as an allergen.
It is worthwhile noting that intolerance to a certain food is not an allergic reaction – for example, some people may experience diarrhoea or abdominal pain from dairy products, chocolate, food additives or certain meats. They may also experience allergic-type reactions such as rapid breathing, tightness in the chest or throat, breathing problems or even a rash. It may be difficult to differentiate between intolerance and an allergy, so medical diagnosis should be sought for clarification – an allergen can be diagnosed with a skin-prick test or blood (RAST) test.
There are no specific risk factors that will identify an individual as being hypersensitive to certain common allergens. Generally the only way to identify such an allergen is by exposure to it – such as a severe reaction to peanuts when first introduced. It is estimated that up to 3% of the population are hypersensitive to some form of allergen. Recent statistics place Australia as having an anaphylaxis rate of approximately 1 in 500 to 1 in 5000 per year – similar to that of the United States and United Kingdom.
Anaphylaxis may induce a skin rash on the chest, neck and extremities
Common Causes of Anaphylaxis
Where does it happen?
Anaphylactic food reactions as can be seen from the chart occur most commonly in the family home. A recent Australian survey reported that >90% of these food reactions occur in preschool age children. Although the ratio of incidence is most common in preschoolers, the risk of death is greatest among teenagers. This is thought to be because they have less parental supervision, and can result from poor decision making or forgetfulness such as leaving their EpiPen at home when they have a known hypersensitivity.
It only takes minute amounts of an allergen to cause anaphylaxis, and exposure can occur several ways:
Signs and Symptoms
Initial signs (these can be used as warning signs to get help)
Soon after hives develop, more serious symptoms may occur, including
The signs and symptoms of anaphylaxis can vary greatly, and a casualty can even experience different symptoms from the same allergen. It is hence very important to be aware of the different signs and symptoms that can accompany an anaphylactic reaction. It is also important to note that food allergies can take time to manifest, the average being between 25-35 minutes after ingestion. Reactions have been recorded anywhere between 10 minutes to 6 hours after ingestion. Stings can cause an almost immediate reaction to around 12 minutes. Drug-induced anaphylaxis takes on average 5 minutes to start causing symptoms.
The best way to treat a known hypersensitivity is strict avoidance of the allergen. This means reading labels and even involving a dietician and doctor to go over the foods that can and can’t be eaten. People with a known hypersensitivity, especially to peanuts should be especially wary of foods where the ingredients are not known. Regular review with a family doctor should be undertaken to monitor for changes to hypersensitivity – some food hypersensitivities can resolve over time if the body has time to recover from the problem.
If the casualty has a known hypersensitivity and is experiencing severe symptoms, then the best treatment is the use of an EpiPen® IMMEDIATELY. A definite indication for this is if the casualty has a known previous anaphylactic response to the allergen. There are different colour Epipens ® for adults and children
Adults = Yellow
Children = Green
An Epipen ® is NOT indicated on a casualty who has no previous anaphylactic reaction and is experiencing
General first aid for mild anaphylactic symptoms after exposure to an allergen consists of:
What is an Epipen®?
An EpiPen is a small, hand-held auto-injector for intramuscular-use that administers adrenaline for the emergency treatment of anaphylaxis. Adrenaline (epinephrine) is a fast-acting hormone that is produced naturally by the adrenal glands in the body.
Adrenaline works very fast in countering the effects of an anaphylactic response by:
Adrenaline is injected through an EpiPen into the fleshy part of the casualty’s thigh.
There are a few reasons why it should be injected in this position:
Adrenaline doses range from 0.05ml in infants less than 1 year old, to 0.5ml 13 years and older – that is a ratio of 10x, which is why there are different Epipens ® for adults and children.
Side effects of adrenaline can include:
Important information about EpiPens®:
Important information regarding administration of Adrenaline:
How to use an EpiPen®
After administration, place the pen back into the container. Always call an ambulance if an EpiPen® has been required. Follow basic first aid techniques, and note the time the EpiPen® was given, and KEEP CASUALTY lying down for at least 30 minutes. For victims with severe anaphylaxis, if symptoms are not relieved by the initial dose after 5 minutes, administer second dose.
Recent statistics found that only 27% of people with an EpiPen® actually used it during an anaphylactic attack. This is due to several reasons:
Prevention is always better than cure.
PROVIDE FIRST AID
Altered Conscious States
There are a large number of conditions that can lead to acute disruption of a casualty’s cognitive function. These range from a direct blow to the head, to drug or alcohol abuse, to low blood sugar caused by diabetes. Depending on the condition, some states will resolve fairly easily and require minimal intervention. It is however critical to realize that some conditions can deteriorate very quickly and calling 000 / 112 immediately may be the best thing you can do for the casualty.
In the following section, we aim to outline some of the basic principles in recognising an altered conscious state, as well as what indications signify the need for immediate medical assistance.
The Human Brain
The human brain is a uniquely complex and powerful organ. At any one time, the brain is registering sensations such as eyesight, hearing & smell, computing and filtering data and sending appropriate responses. It is controlling our conscious thought, movement & actions as well as our unconscious thought, emotions and memories. It is also controlling the vital aspects of our bodies that keep us alive, such as regulating body temperature, heartbeat & respiration.
In basic terms, the brain can be divided into 4 main parts:
The cerebrum is the largest part of the human brain and is associated with higher function such as conscious thought, intellect and action. It is divided typically into 4 sections called lobes.
The cerebellum or literally ‘little brain’, is predominantly responsible for coordination of movement, balance and posture. The Brain Stem is responsible for the vital life functions such as heartbeat, breathing, blood pressure etc.
Cerebrospinal Fluid (CSF)
Cerebrospinal fluid nourishes the brain and spinal cord, as well as protecting it from chemical or mechanical injury. It circulates through the subarachnoid space and through cavities called ventricles. The fluid act as a shock-absorbing agent which prevents the delicate brain tissue from being damaged though contact against the skull. The chemical environment of the CSF is optimal for neural signalling. It regulates this environment as even the smallest change in this consistency can drastically affect brain function. CSF also acts as the medium for exchange of nutrients and waste between the blood and brain tissue.
How to Recognise an Altered Conscious State
There are many simple reactions and responses that we do that we can take for granted, such as our eyes following someone as they walk into the room, or turning our head when we hear someone speak. When a casualty has a condition or injury that affects the brain, these responses can be delayed or non-existent. There are several different methods for quantifying the extent of change to a person’s conscious state, such as the AVPU System and the Glasgow Coma Scale (GCS).
The AVPU System
This is loosely based on the GCS, however it is simplified so a quick, effective and quantifiable assessment of a person’s conscious state can be performed and relayed to medical personnel. The AVPU stands for:
A - Alert - If you walk into the room and the casualty sees you and follows (tracks) you with their eyes, then they are basically alert.
V - Verbal - The casualty does not respond to your presence, but will respond to your verbal commands – i.e. their eyes open when you speak to them
P - Pain - The casualty does not respond to your verbal commands, but will respond to pain stimuli, such as a sternal rub or pinching them in the fleshy part of their arm next to the armpit.
U - Unresponsive - This means nothing you do gets a response, in other words, they are unconscious.
What to do if they are not alert
In terms of the AVPU scale, a persistent AVPU of anything below A is reason enough to call an ambulance. In situations like this, you should not to leave the casualty for any reason except for a danger to yourself being present. Their conscious state can become worse very quickly. If the casualty becomes unconscious at any stage, then you should follow DRSABCD. If they are breathing, then place them into the recovery position and call an ambulance. If they stop breathing at any stage, then begin CPR.
Levels of Alertness
Another way to assess the extent of injury to the brain is the 1-4 Alert Scale. This is used in many Emergency Services Protocols and refers to how many alert attributes the casualty exhibits. The alert attributes are:
TIME - (Does the casualty know what the time is? What the date is? The year?)
PERSON - (Does the casualty remember their own name?)
PLACE - (Does the casualty know where they are?)
EVENT - (Does the casualty know how they got here? What they are doing here?)
If the casualty is alert and answering all of the above questions successfully, then they are alert and orientated, and it is fairly safe to assume they are not mentally compromised.
CAUSES OF ALTERED CONSCIOUSNESS
There is a popular mneumonic that encompasses the possible reasons for a casualty’s altered conscious state, AEIOU-TIPS.
Important: If a casualty has an unexplained change in conscious state, then an ambulance should be called immediately. If the casualty has had a stroke, then time is critical. Delayed medical assistance can have a large impact on the extent of damage caused by the stroke.
SPECIFIC CAUSES OF ALTERED CONSIOUSNESS
Now that we have covered how to recognise and assess the extent of an altered mental status, we will cover some of the more common causes for an altered mental status in first aid, and what intervention we can do to improve the outcome for the casualty.
ALCOHOL POISONING AND ILLICIT DRUG USE
This is perhaps the most common cause of altered conscious state that you might encounter. Alcohol impairs judgement, vision, speech, coordination, reflexes, balance and cognitive function. At a blood alcohol level as low as 0.3%, the brain’s ability to control respiration, heart rate and blood pressure can be compromised, which can lead to a loss of consciousness, or even death. Although the effects of alcohol can commonly be seen as comical, they can be just as serious as any of the causes of altered conscious state on the AEIOU-TIPS mnemonic. It is important to recognise this and treat an acute, alcohol-related change in conscious state promptly and responsibly.
If you see a decline in a person’s AVPU scale, even to V, then you should treat this as seriously as when the cause is not known. The old ‘let them sleep it off’ way of dealing with alcohol abuse can have serious consequences, as you cannot monitor a person’s AVPU scale when they are asleep, and therefore cannot determine if they are in acute alcohol poisoning. If this is the case, and they are asleep, unsupervised, it is possible for them to go into respiratory arrest and then death if not properly managed. If someone ‘passes out’ or loses consciousness after over-indulging, then this is the equivalent of U on the AVPU scale, and the person’s brain has been severely compromised. An ambulance should be called at this stage, and the casualty should not be left unattended.
Management of Acute Alcohol / Drug Poisoning
If the Casualty Becomes Unconscious
UNDER THE INFLUENCE – DRUGS AND ALCOHOL
Alcohol presents a very common cause for altered mental status, and as already discussed, can be very serious and even life-threatening if not properly managed. It not only has direct effects on the body as it travels to the brain and other organs, but impairs judgement which prevents a person from logically assessing a situation and acting in a rational manner.
Alcohol and drugs have been clearly linked in studies to an increase in the likelihood of injury of death from accidents or violent behaviour, and the impact on the road toll is well documented. A person under the influence of drugs or alcohol has problems recognising danger – as like the rest of the brain, the part that is responsible for comprehending and appreciating this is functioning at an impaired level.
Studies have also shown that those under the influence have difficulties reading facial expressions, lose control of their emotions and have cognitive impairment. It should also be noted that using any combination of alcohol of drugs can cause extreme effects and a much higher risk of injury or death. In short, someone under the influence has a decreased ability to:
Some common types of drugs:
This is one of the most frequently used illicit drugs in society, and has similar effects as stimulants, depressants and hallucinogens. Short term effects include:
This is a very strong stimulant to the central nervous system, and is very addictive. It can be taken via injection, smoking or snorting. Short term effects include:
This is taken as a capsule or tablet. This affects the serotonin system, which plays a large role in regulating mood, sleep, aggression and sensitivity to pain, and as such can affect all of these. Other short term effects include:
This is a synthetic hallucinogen that is found in tablet, capsule or liquid form (added to paper, sugar cubes etc). Effects can last for over 12hours, and include:
There are many types of projectile objects that can cause injury – from glass or shrapnel, to knives if thrown, to bullet wounds. If a projectile object becomes embedded in the skin, you should follow the first aid principles of embedded objects. This involves forming a donut bandage to secure the object (reducing any movement that can potentially cause more injury and damage) and assist in reducing the bleeding by providing indirect pressure to the area. Remember – NEVER attempt to remove an embedded object. If the object is large and deep, the casualty will likely require surgery to remove it. The main thing is to reduce bleeding, keep the object secure and keep the casualty calm until the ambulance arrives.
Bullet wounds provide a potentially more serious and complicated injury, as they are not embedded in the skin and hence they cannot be secured, but rather will likely enter completely into the body. Bullet wounds cause three types of damage:
There are many other complications from bullet wounds, such as the risk of infection or even bullet embolism, where the bullet enters a vein and travels through the cardiovascular system, lodging somewhere and causing a blockage.
The first thing to do is call 000. Not only is an ambulance needed, but police intervention is necessary. If there are weapons being fired, you must take care of your own safety – remember, you cannot assist anyone if you get injured.
Follow DRSABCD – if the casualty stops breathing, then immediately start CPR. If the casualty is breathing, concentrate on controlling the bleeding. Depending on the location, you should take further steps:
Chest wound: Seal the wound with an airtight material, such as plastic. This will help prevent air being ‘sucked’ into the wound and causing a lung to collapse. Seal 3 sides of the covering with tape, but leave the 4th side free so air can escape back out of the wound. If the casualty complains of increased shortness of breath or difficulty breathing, then remove this.
Abdomen: Use direct pressure to control the bleeding, and try to keep the casualty as calm as possible. Damage to internal organs can be very serious, and calling 000 immediately is the best plan to follow. Without proper medical personnel and equipment, there is not much else you can do.
Limbs: Again, use direct pressure on the wound. If possible, raise the part to reduce blood flow to the area. The use of a tourniquet is not recommended first aid treatment, and should only ever be used if all other methods of stopping the bleeding has failed and as a last resort.
Demonstrating appropriate treatment of a casualty
Determining appropriate treatment of a casualty is heavily reliant upon a good assessment of the situation and the casualty themselves. When arriving at a scene where there is one or multiple casualties, a visual survey is the first key in determining what response is necessary, for example:
Many of these questions can be answered by a short visual assessment of the casualty and their surroundings. Following this, more information is generally needed, which can come from talking to the casualty and asking questions to assess what the problem is, or talking with others to get an idea what has occurred. If the casualty is unconscious, always follow DRSABCD – this is a highly recommended method of assessing a casualty because it covers all of the most important aspects of assessing a casualty’s well-being in a logical and easy to remember order.
If the casualty is conscious, follow a logical progression of questioning and assessment to determine what has occurred. If they appear confused, vague or in any way mentally impaired, then ask them the level of alertness questions:
If they cannot answer any of these, there is a risk that for some reason their brain is not functioning normally and there are many causes for this, from intoxication and overdose, to seizures or head trauma. By piecing the puzzle together from what you have seen and what information you can ascertain from the casualty and any witnesses, you can hopefully narrow down the cause or even determine exactly why they are in the state they are.
If the casualty can answer all of these and is cooperative, then generally they can indicate what has occurred and how they are injured. If the casualty is not cooperative then this can make assessment difficult. If the casualty is being violent, remember the safety of yourself and others is the number one priority.
Generally speaking, by undertaking a good visual assessment and verbal questioning you can almost always form a good idea of what is occurring. From there, it is simply a matter of putting your first aid skills to use to determine the best course of action, for example:
Remember, good communication is key. Be calm and collected – take a moment to absorb what is occurring and respond accordingly and not only will this help you act in a more rational manner, but will reassure the casualty and others that you have the situation in control. Further reassuring the casualty that you have the situation in control and they are in good hands will also help keep the situation in control and assist in gaining trust. It is also important to be assertive – demonstrate that you know what you are doing and are confident in your own abilities and people will respond positively. It is a skill that requires practice, but the ability to communicate instructions assertively without being aggressive is the key to getting a positive and helpful response from the casualty any bystanders present.
Chemical exposure (OLEORESIN SPRAY) Capsicum spray
Capsicum spray is used routinely in crowd control, self-defence and in arrests. It has become increasingly popular as a law enforcement weapon of choice as it can diffuse a potentially violent situation and prevent injury to law enforcement officers or the public.
Capsicum spray is an extract of hot peppers consisting of capsaicin and derivatives. It is a lachrymatory agent – meaning that it is designed to irritate the eyes to cause tears and pain. It acts within seconds of being sprayed in a person’s face to cause stinging, tearing and blepharospasm (uncontrolled muscle spasm) – causing the eyes to shut.
It also has an effect on the respiratory system – causing bronchoconstriction and coughing as well as mucous secretion, shortness of breath and laryngeal paralysis (causing the inability to speak). The effects can last for up to 30 to 40 minutes.
People with certain conditions may be at an increased risk of developing more severe symptoms, those conditions include:
More severe respiratory effects may include pulmonary effects or even asphyxia due to bronchospasm.
This is a condition that occurs when a person’s position causes their breathing to be restricted and can be potentially fatal if they are in such a position for any length of time. Positional asphyxia occurs commonly in small infants who find themselves in a position where their airways are restricted and are unable to reposition themselves.
This can occur in adults also either by an accident where they become stuck in a difficult position, or more commonly during restraint by police officers, security guards or even health care staff if not carefully performed.
During restraint, pressure should not be applied to the neck. Pressure here, particularly near the carotid sinus can disturb the nervous controls to the heart and can lead to respiratory or cardiac arrest. People who are at higher risk include those with:
The most common positions where this can occur is with the person forced prone or with their head forced towards the knees.
If the person complains of or demonstrates any of the following:
If any of these signs occur, the person’s restraint should be released if this is an option, or at the very least, immediately modified, allowing them to breathe efficiently.
It should be remembered that an intoxicated or drug affected person is more likely to need restraining, but they are also more likely to suffer from positional asphyxia if an incorrect restraint is applied. Another important note is that a person can be struggling until the moment before they lose consciousness – just because they are shouting or yelling, doesn’t mean they are able to breathe effectively.
What to do if they lose consciousness
Fainting is a temporary loss of consciousness, otherwise called syncope. It is generally caused by a temporary reduction in the blood supply to the brain. It can be caused by a variety of factors such as:
Before fainting, the casualty may feel light-headed, nauseous or dizzy, and may appear pale and clammy.
Management of Fainting
If a casualty is light-headed, and appears near a faint, the best thing to do is to lie them down on their back, and raise their legs, increasing the blood supply to the brain. If the casualty refuses to lie down, offer for them to sit with their head between their legs – although this is not as effective as lying down, it is still better than falling from a standing position. Keep close to the casualty in case they collapse from the sitting position. Remember also to protect your back – if the casualty is falling, do not attempt to keep them upright, but rather guide them gently down onto the ground. Once on the ground they can be placed in the recovery position.
If they lose consciousness, follow DRSABCD. Fainting usually only lasts from a few seconds to a minute or two, and the casualty may even have a slight seizure. Proper placement into the recovery position will assist recovery. Once conscious, encourage the casualty to lie down until they feel better, then very gradually moving back into an upright position to reduce the risk of fainting again.
Recovery Position – Adults and Children
A stroke, or otherwise called a cerebrovascular accident (CVA) is an acute disruption to the blood supply within the brain. A stroke is a medical emergency, and without prompt medical intervention, there can be substantial neurological damage or even death. There are several classifications of strokes, although from a first aid perspective these are purely academic, as all have similar symptoms and all require immediate intervention. The main factor in determining the symptoms is the site of the injury.
Types of Stroke
This is by far the most common cause of stroke. In ischemic stroke, a blood vessel becomes either partially or totally blocked by either a blood clot or debris. Depending on the size and location of the vessel, the effected area can be only a small part of the brain, or can extend to a very large area, becoming potentially fatal
This occurs when a blood vessel ruptures and bleeds into the brain. Not only does this cause blood to be diverted from where it is needed, but the haemorrhaged blood disrupts the delicate chemical balance in the brain causing damage. As bleeding continues, the blood has nowhere to go, and intracranial pressure builds up causing further damage to the brain.
The most well known symptom of a stroke is one-sided weakness or numbness, and is generally on the opposite side of the body as the stroke (depending on which part of the brain is affected). The symptoms of a stroke are dependant on which part of the brain is affected, and include the following:
How to Pick an Early Stroke
If a person notices any of the above symptoms (Can be different combinations of symptoms depending on the site involved), then there are 3 basic tasks you can get the casualty to perform
Difficulty performing any of these tasks may indicate an early stroke. If this is the case, prompt transportation to a hospital is necessary by either car or calling 000 / 112. With early diagnosis and intervention, the severity of the stroke can be drastically reduced, and the casualty’s outcome can be improved.
Another way to remember strokes is that you should act FAST.
F – Facial drooping or weakness, generally 1-sided
A – Arm numbness or weakness, again 1-sided
S – Slurred speech, or difficulty talking or understanding
T – Time to call 000. Time is critical – the faster the casualty is properly diagnosed and treated, the much higher their chance at survival and less risk of permanent brain damage.
The only management that can be achieved is to call 000 / 112 immediately if a stroke is suspected and to keep the casualty comfortable until the ambulance arrives. Do not leave the casualty unattended, as their condition may become worse very quickly. If the casualty becomes unconscious, follow DRSABCD. If the casualty stops breathing, begin CPR.
A seizure is a sudden interruption to the brain’s normal function, when an abnormal level of electrical activity of the neurons takes place. They can manifest as an alteration in mental state, tremors, convulsions or psychiatric symptoms. Epilepsy is the term given to describe a condition where someone is predisposed to recurrent, unprovoked seizures; however anyone can have a seizure given the circumstances, not just people with epilepsy.
Causes of Seizures other than Epilepsy
Types of Seizures
In partial seizures, the increased brain activity begins in or involves one part of the brain. The experienced seizure can vary greatly depending on the location within the brain. If simple, the seizure may be as small as a twitching of a limb or part thereof, or if complex may lead to confusion, memory loss and possible unconsciousness.
The most recognised type of generalised seizure is the tonic-clonic convulsive seizure (previously referred to as grand mal). The casualty may become rigid and fall, or may cry out or bite their tongue initially. Breathing can become laboured and the casualty may become incontinent. After a generalised seizure, the casualty will most likely feel lethargic and confused, and may have a headache and need to rest.
Most Important is to stay calm. Look at the time to see how long the seizure lasts for – the length is important as prolonged seizures longer than 5 minutes are a medical emergency and you will need to call an ambulance (unless they have a known history of long seizures). Move any bystanders away from the area, and move any objects out of the way which could injury the casualty. DO NOT ATTEMPT TO RESTRAIN THE CASUALTY, AND DO NOT ATTEMPT TO PUT ANYTHING IN THEIR MOUTH. If possible you can place something soft underneath their head and loosen any tight clothing. Be prepared to assist the casualty once the seizure stops.
Once the seizure has stopped, follow DRSABCD. If unconscious and breathing, roll the casualty into the recovery position. Wipe away any excess saliva with a tissue and check their airways to make sure there is nothing blocking them such as food or dentures etc. If the casualty has become incontinent, try and be sensitive to their embarrassment, and deal with this discreetly by covering them with a jacket or towel. Do not give them anything to eat or drink until they have fully recovered. They will likely be very tired, so let them rest it off, and stay with them for assurance
A convulsive seizure can be frightening, especially if you have not witnessed one before, and it can be very difficult to keep your wits about you. During the early phase of a seizure, it is not uncommon for the casualty to stop breathing temporarily and turn slightly blue. This looks especially frightening, but will subside once normal breathing continues later on. If the casualty has injured themselves during the seizure, attend their injuries once it has finished.
You need to contact medical assistance if:
Approximately 1 in every 30 children will experience a febrile convulsion, which is caused by a sudden increase in the child’s body temperature, usually due to a fever from a viral or bacterial infection. The most common age group affected is between 6 months and 6 years. Although very frightening for parents, febrile convulsions do not cause brain damage and generally are not harmful to the child. Even very long convulsions lasting up to an hour almost never cause harm. It is important to stay calm, follow the above steps and reassure the child.
Management of febrile convulsions is the same as above. If the convulsions stop in less than 5 minutes then you should see your family doctor. If the child was very unwell prior to the convulsion, then you should see your doctor immediately (it is ok to drive the child as long as there is an accompanying adult to care for them during transport).
DO NOT put the child in a bath to cool them down as this can be extremely dangerous
Diabetes Mellitus is a metabolic disorder in which there is a higher than normal amount of sugar found within the blood (hyperglycemia). There are three main types – Type 1, Type 2 and gestational, all of which have similar symptoms but vary in the underlying cause. Type 1 is generally due to destruction of pancreatic beta cells which produce insulin. Type 2 involves resistance to insulin of body tissue. Gestational diabetes is not well understood, but its underlying cause is thought to be due to some abnormal interaction between foetal requirements and maternal metabolic controls.
How to Recognise a Hypoglycaemic Attack (Low blood sugar)
There are many symptoms that can be associated with low blood sugar; the following is a shortlist of the more common ones:
First thing to do if a hypoglycaemic attack is suspected is to offer the casualty sugar. This ideally should be something that can be absorbed quickly such as jelly beans, soft drink (not diet) etc. You will be surprised how quickly this sugar will stabilise the casualty’s condition. Once the casualty is feeling better, suggest a small meal (e.g. sandwich and milk), as this will help stabilize their blood sugar over a longer period of time. Further medical assistance should be sought in the case of uncontrolled diabetes.
If the casualty becomes unconscious, follow DRSABCD. Seek medical aid urgently. DO NOT attempt to feed an unconscious casualty sweet food by mouth, as this will only cause a significant risk to their airways and likely cause them to choke.
Hyperglycaemia (High blood sugar)
High blood sugar occurs generally in people with undiagnosed diabetes. The effect is a build up of toxins in the blood called ketoacidosis. This has a slow onset; however it can lead to unconsciousness if not managed.
The most common symptoms of undiagnosed diabetes are excessive thirst, excessive urination, and also an increased appetite.
Prolonged high blood glucose also alters the shape of the lens in the eye, and hence blurred vision can also be a symptom of undiagnosed diabetes. When ketoacidosis is present, the smell of acetone may be found to be present in the casualty’s breath (this is a very sweet smell) as well as rapid, deep breathing, nausea, vomiting, abdominal pain and a state of altered consciousness.
If the casualty presents with symptoms suggesting ketoacidosis, then a medical opinion should be advised immediately. Ketoacidosis is a medical emergency and prompt diagnosis and treatment is the only way to relieve the casualty’s symptoms.
If the casualty is unconscious, then follow DRSABCD and call 000 / 112 for an ambulance.
Head injuries are a common cause of hospitalisation, especially in children. These can occur from motor vehicle accidents, a fall or assault to an occupational accident or sporting injury. Regardless of the cause, head injuries can be serious and need to be properly assessed to ensure there is no underlying injury such as a concussion or haematoma. In the event of a serious head injury, the first aider should assess for signs of concussion such as by following the AVPU scale and asking the casualty relevant questions to ascertain their mental awareness. If the casualty becomes unconscious, DRSABCD should be followed, and bleeding from the skull should be controlled. If bleeding occurs from the ear, then the casualty should be placed in the recovery position with the effected side down, to allow blood to drain out of the skull. Any significant head trauma should be referred onto further medical aid to fully assess and monitor the casualty.
What to look out for
If someone sustains a blunt trauma to the head such as in the above circumstances, then they need to be assessed for an underlying injury. If the casualty experiences any of the following, then this can be an indication of a serious injury and an ambulance should be contacted ASAP.
If you notice any of the above, an ambulance should be contacted immediately. A serious head injury should not be taken lightly, even if the casualty insists they are fine. Even people without any noticeable signs or symptoms require close observation 12-24 hours after the event to ensure there is no delayed onset of symptoms.
Any bleeding from the head should be controlled, being careful not to place pressure onto the skull if a fracture is suspected. If the skull feels ‘spongy’, then DO NOT place any direct pressure, but rather use pads and indirect pressure to control bleeding. The casualty should be closely monitored, and an ambulance called immediately. If the casualty becomes unconscious, then follow DRSABCD.
If the casualty has a haematoma (brain bruise), concussion or an internal bleed as a result of the trauma, then they can rapidly deteriorate to unconsciousness, and permanent disability or even death can be a possibility if not treated promptly.
Spinal injuries should be suspected for all trauma victims. Recent evidence suggests that the risk of causing further injury due to pre-hospital first aid is less than initially thought, however caution is still strongly recommended when moving a victim with a suspected spinal injury.
Spinal injuries can occur in the neck (cervical spine), back of the chest (thoracic spine), lower back (lumbar spine) or a combination of these areas. The higher the injury the high the danger, additionally cervical injuries are the most common accounting for more than half of all spinal injuries.
The most common causes of spinal injuries are:
These can be difficult to detect, particularly if the victim is unconscious
If a spinal injury is suspected, call 000 immediately, reassure the victim and tell them to remain still (do not physically restrain the victim). Keep the victim comfortable until help arrives. If the victim is in danger (e.g. in water or on the road), their immediate safety is first priority and they should be moved carefully if they are at risk of further injury. Care should be taken when moving victims to minimise movement of the spine.
If the casualty is unconscious, management of airways takes precedence over any potential spinal injury. Follow DRSABCD. If you do need to adjust the victim’s airways, use techniques which minimise movement of the cervical spine (neck).
If it is not necessary to move the victim, then they should be managed and stabilised until paramedics arrive. If the victim does need to be moved (i.e. they are in acute danger), care should be taken to ensure the alignment of the spine is maintained.
Methods of Spinal Immobilisation
One first aider positions themselves above the head of the casualty, looking down towards the casualty’s feet. From this position, the first aider can support the victim’s head by locking their own elbows for stabilisation and holding onto the sides of the victim’s head. Gently raising and placing padding under the head 2cm off the ground (in a supine position) can assist in keeping the neck in a neutral position.
Example of cervical injury management using cervical collar. Note paramedic to the right in the picture performing in-line stabilisation to prevent further injury.
As can be seen above, these are used by trained personnel to stabilise a victim’s neck. These should only be fitted by trained personnel as they need to be correctly sized and fitted.
If a child is involved in a motor vehicle accident whilst in a child seat / capsule, they should ideally not be taken out of this unless they are in danger or unconscious. If it is possible to remove the infant seat / capsule with the child in it this is preferred. Reassure the child and attempt to keep them calm and still until assessed by a paramedic.
Tips when moving an unconscious casualty with a suspected spinal injury
The number 1 tip is to not move the casualty unless necessary (i.e. if they are conscious and the area is safe, instruct them to lie still and call 000). If it is necessary to move the casualty, the following should be followed:
Crush injuries occur through a crushing force causing injury to a victim such as from vehicle entrapment, industrial incidents or a falling heavy object. Crushing injury to the head, neck, chest or abdomen can quickly lead to death from internal bleeding, respiratory failure or heart failure.
Comminuted fracture of the tibia and fibula following crush injury to lower leg from an industrial injury (trapped by forklift)
There are many types of causes of abdominal injury. Basic first aid principles should be followed depending on the type and cause of the injury, for example:
Basically the best thing a first aider can do is to recognise a serious abdominal trauma and contact 000. The casualty should be monitored and if they become unconscious follow DRSABCD. Control any bleeding using light-moderate pressure (avoid placing firm pressure on the abdomen unless required to stop serious bleeding). Keep the casualty comfortable and warm and await assistance.
Locations of some major abdominal organs:
A Poison is any substance that causes injury, illness or death. In terms of risk, it is estimated that up to 80% of all poisonings occur in the home, particularly in the kitchen or bathroom. Hence the old saying of ‘precaution is better than cure’ is very relevant. Some tips to reduce the risk of this occurring in your household are as follows:
Poisons can enter the body several ways, the most common being ingested (through the mouth). They can also enter the body by being inhaled, such as car or chlorine fumes. The third way is they can be absorbed through the skin, such as weedkiller or occupational chemicals. Most pharmaceuticals which are relatively safe when taken normally are poisonous in overdose.
These can be very variable, as they depend on the nature of the poison.
The first step is to identify the suspected poison and ensure that it is not a danger to yourself or others.
If safe to do so, attempt to separate the casualty from the substance
Once separated from the poison, contact the Poisons Information Centre on 131126. This is a 24 hour national hotline, and operators can instruct you on what to do. They will need to know what type of poison is involved, and approximately how much has been ingested/inhaled. Some poisons have specific antidotes – if possible, attempt to identify the poison (i.e. check for any nearby containers or bottles) as this will significantly assist diagnosis and treatment.
You will need to:
If the casualty is unconscious following poisoning, then you should follow DRSABCD. Particular emphasis should be on the danger risk – ensure that there are no fumes or spilt chemicals that can pose a risk to yourself or others. If necessary, remove the casualty from the source of the exposure if safe to do so
Before commencing resuscitation, remove any obvious contamination from around the casualty’s mouth. If available, a self-inflating bag-valve mask should be used. Mouth-to- mouth should be avoided if inhaled poison is suspected (i.e. cyanide or organophosphate poisoning).
Call 000 / 112 for an ambulance and if there is a large spill involved, you will need to also alert the operator so the fire brigade can decontaminate the area effectively.
Normal body temperature is between 36 - 37.5 degrees Celsius. In normal circumstances, this remains fairly constant regardless of the temperature of our environment through a process called thermoregulation. The body has mechanisms that allow this temperature to be maintained such as:
In extreme heat or cold, the body’s mechanisms can be insufficient to combat the difference in temperature, and subsequently the body’s core temperature can fall outside of the normal range. When this occurs, conditions such as hypothermia (body temperature falls too low) or hyperthermia (body temperature is too high) can set in. The following is a list of temperature variation effects.
EFFECTS OF BODY TEMPERATURE VARIATION
Overexposure in the sun is a very common cause of injury due to excessive heat. When the temperature is too high for the body’s cooling mechanisms to sufficiently cope, the body becomes stressed, and injury occurs. Heat cramps, heat exhaustion and heat stroke are three specific stages that the body undergoes during this time. The body’s sweating mechanism causes a loss of water from the body, as well as the heat itself causing fluid to evaporate. This leads to dehydration if fluids aren’t maintained when in a hot climate.
Heat cramps can be extremely painful, and can occur anywhere in the body such as the arms, legs, back and abdomen. Dehydration or excessive exercise can exacerbate the problem. Generally, a casualty will present with signs of heat exhaustion as well as the cramps. Management involves predominantly treating the heat exhaustion, by:
Heat exhaustion occurs as the casualty’s body temperature increases, and can lead to heat stroke. Heat exhaustion can occur very quickly, especially if the casualty has been over-exerting themselves such as working or exercising in the heat. Signs to look out for include:
Treatment is as above. Again, remember to encourage small sips of water initially – the casualty will be very thirsty and the temptation is to offer fluids as quickly as they can drink them. This can cause more harm than good if vomiting occurs.
Heat stroke is a medical emergency, as it occurs generally when the body temperature has reached 40 degrees or above. Symptoms include:
Management is as above, and includes moving the casualty to a cool area, introducing fluids slowly, using water or a damp towel to help cool them. Heat stroke is a medical emergency, and in addition to these steps, the following steps should be taken:
Some Useful differences between Heat Exhaustion and Heat Stroke are as follows:
Remember to keep safe in the sun
It does not have to be freezing for cold exposure to develop. Wind and moisture such as during humid weather or in the rain can also both rapidly decrease the body’s temperature. Particularly young or old people can be more susceptible to the cold, as can people in poor physical shape. It is important to be able to recognize the symptoms of hypothermia, particularly the changes that occur as the body’s temperature decreases.
Management of mild hypothermia includes moving the casualty to a warmer location, giving them a hot drink, removing any wet clothing and encouraging physical activity to increase body temperature. Heat packs or hot water bottles can also be used to assist this process.
Management of severe hypothermia is to attempt to warm the casualty’s body temperature as quickly as possible, and contact urgent medical aid. This is a medical emergency, and should be treated as such.
There are many causes of acute ineffective breathing, including:
In any situation where a casualty is unconscious and not breathing effectively, follow DRSABCD and perform CPR.
Specific treatments for conditions causing respiratory distress:
There are specific treatments for the following causes of respiratory distress (Please refer to the appropriate sections in this text for first aid directions for these causes of respiratory distress):
Drowning is the process of experiencing respiratory impairment from immersion in liquid. Treatment of a casualty who has been rescued from drowning and is unconscious involves following DRSABCD. The very first step is to place the casualty on their side during the checking / assessment stages of DRSABCD, including checking for breathing (if possible). If the casualty is unconscious and not breathing, then lay the casualty on their back and commence CPR.
Specific problems relating to treatment of drowning casualty
Swimming ability of rescuer
It is critical to ensure that you do not overestimate your own abilities when attempting to save a casualty who is drowning. Unnecessary drownings occur each year due to people attempting rescues beyond their capabilities.
Ideally, the casualty should be removed from the water as soon as possible for treatment. If this is not possible, then expired air resuscitation (EAR) may be attempted by a trained rescuer with appropriate floatation devices
Vomiting / regurgitation
This is a possibility whenever CPR is performed, however due to inhalation of water during drowning; it is much more likely to occur in this situation. Laying the casualty on their side during initial assessment will assist in reducing this risk during CPR. If the casualty does vomit / regurgitate during CPR, immediately roll them onto their side, clear the airways, reassess DRSABCD and continue CPR if necessary.
THE MUSCULOSKELETAL SYSTEM
The musculoskeletal system is a term used to describe the bones, as well as the adjoining ligaments, tendons and muscles. The following introduction section should be read to get an overview of the names and locations of different bones; however you are not expected to demonstrate a complete knowledge of all the bones listed. It is recommended for your own benefit that you become well acquainted with the following section, as it will assist you in understanding medical terminology, and give you a greater knowledge base as a first-aider in which to understand and communicate effectively.
The skeleton can be divided into 2 main parts – the axial and appendicular skeleton. The axial skeleton refers to the spine (vertebrae), skull and ribs. The appendicular skeleton refers to the bones of the upper and lower limbs as well as the pelvic girdle.
Upper Limb Bones
Medically, the term arm refers to the part of your arm that lies between your shoulder and elbow. The bone in the arm is called the humerus. The length of your arm below your elbow is actually termed the forearm, which includes the radius (the bone on the thumb side of the arm) and ulna (the bone on the side of your little finger). The bones in the wrist are called carpal bones (there are 8). In the hand, the next group of bones which are between your wrist and fingers are called the metacarpals. The fingers (as well as toes) are referred to as digits, and the bones in the digits are called phalanges (singular = phalanx).
Lower Limb Bones
The part of the leg that lies between your hip and knee is called the thigh, and the bone commonly known as the ‘thigh-bone’ is called the femur. It can be confusing to note that whilst the term arm refers to the ‘upper’ part of your arm, the term leg medically refers to the part of the leg between your knee and ankle. The leg contains the tibia (the bone on the inside of your leg) and the fibula (the bone on the outside). The correct term for the kneecap is the patella. The main bone in the ankle which connects to the leg is called the talus. Your heel bone is called the calcaneum. The bones in the part of the foot closest to the ankle are called tarsals, the longer bones of the forefoot are called metatarsals, and the toes are digits with the toe bones being called phalanges (Note the foot terminology is very similar to the hand).
The bones of the skeleton have 4 main functions:
The following is a brief list outlining some of the specific medical terms relating to different commonly known names for bones. Again, you do not need to memorize this list, but it is recommended that you read through it so you recognise these terms.
The levels of the spine are referred to by their area and level, such as C5, or L2. C5 refers to the 5th cervical vertebra. L2 refers to the 2nd lumbar vertebra. The disc spaces are named according to the levels they lie between, for example C7/T1 is the disc between the 7th cervical vertebra and the 1st thoracic vertebra.
Ever heard this? “Phew, they told me I had a fracture – I was sure I had broken it”
A fracture is the medical term used to describe any break in the cortical surface of a bone. If should be clarified that a break and a fracture are the same thing – a break is not worse than a fracture as is sometimes thought, but rather it is the non-medical equivalent term to fracture. A fracture (or break) can be as small as a tiny chip off a bone, to a complete fracture in which the bone fragments separate and the limb appears deformed. Fractures can occur through a variety of mechanisms, such as a direct blow to a bone (like in a motor vehicle accident or being punched in the face), or indirectly, such as when someone falls forward onto their hand, but in doing so fractures their clavicle due to the force of the fall travelling up the arm to the weakest point. The force does not have to be due to a direct blow - a severe twisting motion or muscular contraction can cause excessive force on a bone or joint and also cause a fracture.
Types of Fractures
The severity of a fracture depends on the force of the trauma and the flexibility and strength of the bone. A simple trip on a crack in the sidewalk concrete can cause an elderly lady with osteoporosis to severely fracture her hip (most commonly the femoral neck). A young, healthy person would most likely get up and walk away uninjured from the same trauma, with only some embarrassment. Obviously as the force of the trauma becomes greater, so does the risk and severity of the fracture.
Another common misconception is that if you can move the injured limb, it can’t be broken. This is incorrect, as you can still have almost full use of a limb with a small fracture. Generally there is some degree of loss or difficulty in moving a fractured bone, but the lack of this does not exclude a fracture.
There are numerous different medical classifications of fractures, however in a first-aid sense, there are 3 main types that you should be aware of are:
A closed fracture refers to a break with no penetration through the skin. This is the simplest type of fracture.
If there is penetration of the bone through the skin (e.g. a bone sticking out of a casualty’s arm) then this is an open fracture. These fractures have a greatly increased chance of infection to both the wound and the bone.
A complicated fracture refers to any fracture that has caused additional complications to organs. A fractured rib can be a simple closed fracture, but if it punctures the lung or an abdominal organ such as the spleen, then this becomes complicated as there are secondary injuries which can be extremely severe.
How to pick a fracture
It can be very difficult to distinguish between a bad sprain and a fracture. If there is any doubt, then treat the injury as if it is fractured. Clinical diagnosis can be hindered by excessive swelling, and the use of x-rays or other diagnostic imaging modalities like CT or MRI may be necessary to definitively diagnose a fracture. There are however some signs and symptoms to look out for. Not all of these listed are specific to fractures, but a combination of the following may indicate a fracture
It can be very difficult to judge the extent of an injury based purely on the level of pain indicated by the casualty. In some cases, a person can walk away with a fractured ankle, whereas in other cases a casualty may be hysterical in pain with no significant damage to the part. In any event, if a fracture is suspected, then prompt, correct first aid can prevent further injury and assist healing, as well as help reduce pain by immobilisation.
First aid of a suspected fracture involves 3 basic principles.
Immobilisation is essential when treating a suspected fracture. This can be done using many methods, and depends on the location of the injury, the materials on hand and the casualty themselves. Immobilisation can be achieved by using a splint, such as a length of wood, or a sling, or even by having the casualty hold their own arm or hand. Movement of a fracture can cause significant damage, such as injury to blood vessels, nerves or abdominal organs, which can potentially cause irreversible damage to the limb. Not only this, but movement of a fracture can further displace it, and mean much more difficult treatment – even surgery.
Elevation of the part cannot always be achieved, but when possible is useful in reducing blood flow to the injured area, and hence reducing bleeding and swelling.
Fractures can be extremely painful, and can put a casualty into shock due to the injury itself and the pain. You should assess the casualty using a holistic approach, by which refers to the casualty’s general condition and their state of mind. You may need to lie the casualty down and call an ambulance if they are in significant pain and going into shock. In this situation, you should do your best to calm the casualty down and ensure that the injured part is well stabilised to reduce further pain.
If a fracture is left untreated for any significant length of time, then there is a risk that it can start to set in an incorrect position and cause possible chronic pain and possible disability of the part. Depending on the severity of the fracture, an orthopaedic opinion may be necessary. A prompt medical opinion will ensure that the fracture is properly diagnosed and treated effectively to optimise healing of the bone.
There are numerous considerations that affect the length of time a fracture takes to heal. These include the severity and nature of the fracture, the location, general health of the casualty etc. In general terms, it takes approximately 5 weeks or so for the bone to fuse. Even after 5 weeks, the bone is still weakened, and care should be taken not to put too much pressure on the part. It may be another month or two before the bone and the adjoining muscles regains most of their strength. Rehabilitation may be necessary to assist the strengthening of the muscles, which may include specific exercises. Care should be taken not to try and put too much pressure on the bone too early.
Tips for First Aid:
SPRAINS & STRAINS
A sprain is an injury to ligaments, caused by a very sudden overstretching of a joint. There are 4 degrees of a sprain, ranging from a minor tear to a complete rupture. Diagnosis can be achieved through ultrasound or optimally by MRI.
A strain refers to an injury to a muscle and/or adjoining tendons. The mechanism of injury and diagnosis tools are similar to that of a sprain. As you can see below, the symptoms are also quite similar.
A sprain or strain usually occurs during sporting activities; however it can occur even while getting out of bed. If a tendon or ligament that is stiff for any reason has a sudden, strong stretching force applied to it, it may overstretch or tear. The most common causes include rolled ankles, whiplash (this is a sprain and strain), falling onto an outstretched hand or a sudden twisting action of the knee.
Rest. - Resting the injured part will encourage healing and prevent further injury. It can be difficult to convince someone to keep off their injured ankle, but it should be stressed that resting the part for a few days can drastically improve healing time in the long term.
Ice. - Apply for 20 minutes maximum at a time. Never apply ice directly to the skin, but rather wrap it in a towel or t-shirt. The ice will cause blood vessels to constrict and hence help reduce the swelling to the area
Compression. - A crepe bandage should be applied moderately tight to help reduce the swelling. Be careful not to apply too tight, as this can cut off the blood supply excessively. Assess to ensure there is no numbness or tingling of the limb, and that it is not excessively painful.
Elevation. - This again helps to reduce swelling by firstly making it more difficult for blood to travel to the part, and secondly helping fluids to drain away from the injured area.
In addition to the RICE routine, there are also factors that can hinder healing or even cause further injury. The following should be avoided, as they can cause HARM:
Heat. - This has the opposite effect to cold as it causes blood vessels to dilate, which increases swelling. Heat should not be applied for the first 48 hours following an injury
Alcohol. - This also causes dilation of blood vessels, and hence increases the swelling of the injured area.
Running/Exercise. - Just like bones, ligaments and tendons need time to heal and recover their strength. Attempting physical activity involving the part too early can not only delay the healing time, but re-injure or further injure the part.
Massage. - Although this can be beneficial for longstanding ailments, it should not be performed to the injured part in the first 48 hours following the injury. Massage will increase blood flow to the area.
A dislocation involves the bones of a joint being displaced from their normal position. Generally, this is caused by a sudden trauma directly to a joint such as the shoulder or finger joints. As the bones move out of position, the attached ligaments are also overstretched and hence a strain can also commonly accompany a dislocation. Some people are prone to dislocations, however in most situations; they are caused by a moderate to severe trauma.
A casualty with a dislocation will present with the symptoms of a strain (see previous section), but will also have a deformity of a joint, and loss of movement.
A first-aider should NEVER attempt to re-position the joint – some GP’s won’t even attempt this. A trained, experienced emergency specialist will utilise x- rays to characterise a dislocation, and then use specific techniques to minimise the dislocation. These steps minimise the chance of causing further injury while reducing the dislocation.
BITES AND STINGS
Bites and stings from certain creatures can be potentially dangerous, and Australia has no shortage of such creatures. There are many different varieties of snakes, spiders and jellyfish which carry venom that can cause pain and swelling, and in extreme cases, death (most commonly through neurotoxic muscle paralysis causing breathing failure). Other insect bites can be potentially fatal when a person is allergic to the insect, such as with bee stings.
It can be difficult when faced with a situation to remember how to specifically treat each individual sting or bite. It may be difficult to identify a snake bite as they are not always accompanied by the common ‘vampire / fang mark’ and may be a single mark or a scratch only. The following basic principles should be studied carefully as they apply to most bites and stings.
Snake Bites – First Aid:
Statistically, only 1 in 20 snake bites require emergency treatment, however if in doubt, an ambulance should be contacted and a medical opinion should be obtained.
Symptoms that would indicate the need to call an ambulance immediately include:
Occasionally, a casualty may not even know they have been stung. If you are in a high-risk area for snake bites, such as the bush and the casualty complains of any of the above symptoms, a snake bite should be suspected and investigated. Sometimes, it can be only a scratch or laceration over a leg or arm. There will also be probable local swelling and redness. The bite site most of the time will have no pain. You should take care to firstly rest the casualty, and reassure them as best as possible while you investigate for a possible snake bite. If found, follow the pressure-immobilisation approach ASAP and attempt to get emergency medical assistance.
Of the numerous species of spiders found in Australia, only two are capable of causing death – the funnel web (including their related atrax species) and the red back spiders. It can be difficult to identify a funnel-web, so any bite from a big, black spider should be considered potentially dangerous. The last confirmed death caused by a spider bite occurred in 1979, hence with current-day anti-venoms, spider bites can be easily treated successfully. Both the funnel web and red-back spiders have specific anti-venoms available, and are administered by emergency staff when there are signs of a life- threatening bite.
Funnel Web (or suspected funnel web)
Single stings from a bee, ant or wasp whilst painful, generally do not cause serious injury unless the victim is allergic to the sting. If symptoms of anaphylaxis occur, then this is a medical emergency and should be treated accordingly (see section on anaphylaxis).
Most stings should be treated as per the RICE method with a cold compress. Bees have a unique sting, as they leave their barb behind. Trying to pull it out will cause move venom to be injected into the casualty, hence you should use a fingernail to scratch out the barb using a sideways motion, then treat using the RICE method. Follow DRSABCD
COMMON CREATURES THAT CAUSE BITES AND STINGS:
Pressure-Immobilisation Technique Summary:
Recommended for the following bites and stings:
Not recommended for:
The do not list:
The skin is a waterproof cover designed to protect the body's cells from damage, drying out, infection and from temperature changes. It is liberally supplied with special nerve endings that transmit sensations of touch, temperature and pain. Sweat glands open onto its surface, and sebaceous glands provide a protective oily substance for the skin.
THE EPIDERMIS LAYER
This is outermost layer of the skin and is especially thick on the palms of the hands and the soles of the feet. There are no blood vessels in the epidermis but its deepest layer is supplied with lymph fluid
DERMIS OR CORIUM LAYER
The dermis is a tough, elastic layer containing white fibrous tissue interlaced with yellow elastic fibres.
Many structures are embedded in the dermis including:
HYPODERMIS OR SUBCUTANEOUS SKIN LAYER
This is the deepest skin layer. It connects or binds the dermis above it to the underlying organs. This layer is mainly composed of loose fibrous connective tissue and fat (adipose) cells interlaced with blood vessels. Females have a hypodermis that is generally about 8% thicker than in males. The functions of the hypodermis include storing of lipids, insulation, cushioning of the body and temperature regulation (Van De Graff and Fox, 1986).
The sebaceous glands are the oil secreting glands that help lubricate the hair shaft and outermost layer of the skin. A certain amount of oil on the skin is necessary to keep it soft and pliable. This natural oil on the skin also helps to give skin its water resistance
THE LYMPHATIC SYSTEM
The lymphatic System is a network of vessels, nodes, ducts and organs that produce and transport lymph fluid. The lymphatic system plays a large part in the following:
The lymphatic system does not have a pump like the circulatory system, but rather utilizes muscle movement in order to transport fluids.
The lymphatic system is predominantly responsible also for the transportation of venom from snake bites, which is why it is critical to keep the casualty as still as possible and immobilise the bitten limb. Muscle contractions cause increased lymph movement and hence help spread the venom. An interesting side point is that the lymph nodes become enlarged when the body is fighting an infection. Other causes of lymphadenopathy (increased lymph nodes) include some medications, rheumatoid arthritis, TB, metastatic cancer or even Hep B. Occasionally if your doctor is not sure what is causing enlarged lymph nodes, an ultrasound, or biopsy can assist the diagnosis.
To distinguish a minor burn from a serious burn, the first step is to determine the degree and the extent of damage to body tissues. The three classifications of superficial, partial thickness and full thickness burns will help you determine emergency care:
Superficial (First-degree) burn
The least serious burns are those in which only the outer layer of skin (epidermis) is burned. The skin is usually red, with swelling and pain sometimes present. The inner layer of skin hasn't been burned through. Treat a superficial burn as a minor burn unless it involves substantial portions of the hands, feet, face, groin or buttocks, or a major joint.
Partial Thickness (Second-degree) burn
When the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is termed a partial-thickness burn. Blisters develop and the skin takes on an intensely reddened, splotchy appearance. Partial-thickness burns produce severe pain and swelling.
If the partial-thickness burn is no larger than 2 to 3 inches in diameter, treat it as a minor burn. If the burned area is larger or if the burn is on the hands, feet, face, groin or buttocks, or over a major joint, get medical help immediately.
For minor burns, including partial-thickness burns limited to an area no larger than 2 to 3 inches in diameter, take the following action:
Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may be a different color from the surrounding skin. Watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek medical help. Avoid re-injuring or tanning if the burns are less than a year old — doing so may cause more extensive pigmentation changes. Use sunscreen on the area for at least a year.
Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin. Don't break blisters. Broken blisters are vulnerable to infection.
Full Thickness (Third-degree) burn
The most serious burns are painless and involve all layers of the skin. Fat, muscle and even bone may be affected. Areas may be charred black or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning or other toxic effects may occur if smoke inhalation accompanies the burn.
For major burns, dial 000 or call for emergency medical assistance. Until an emergency unit arrives, follow these steps:
Burns are body tissue injuries caused by contact with dry heat and/or wet heat. When a burn occurs, the heat destroys the epidermis (top layer of skin). If the burn progresses, the dermis (second layer) is injured or destroyed. Burns break the skin and can cause infection, fluid loss and loss of temperature control. Deep burns can damage muscle, tissue and bone.
Burns are classified by the source, such as heat, cold, chemical, electricity, or radiation. They are also classified by depth.
The more painful a burn, generally the less serious it is
Treatment for a Burn:
Always monitor a burn victim for signs and symptoms of shock, notify emergency assistance. Clean and Cool burn area taking appropriate precautions; apply a sterile, non stick dressing.
Clean the area. USE WATER ONLY – Do not use lotions, creams or antiseptics on a fresh burn. If there are tiny foreign bodies on the wound site such as gravel, then use water to flush these out.
Coolthe area. Use cool, running water over the site of the wound for up to 20 minutes.
Cover the area with a sterile, non-stick bandage. If this is not available, then use a clean, lint-free material such as a pillow case or sheet
In addition C - Clear Fluids should be drunk slowly to keep fluid levels stable. Remember that serious burns can cause a great loss of body fluids and lead to shock, so it is important to keep the casualty well hydrated.
When To Refer For Medical Aid
The full extent of a burn can be difficult to tell initially, and hence it can be hard to say whether it is necessary to seek medical aid or just treat using basic first aid. The following require medical aid:
REMOVE: - JEWELLERY, BELTS, BUCKLES, CHAINS, ANYTHING THAT HOLDS HEAT (IF SAFE TO DO SO)
RULE OF 9 CHARTS
Medical professionals use charts like these, to assess percentage of body area affected by burns. The chard divides the body surface into areas equating to 9% each. They then use this calculation to determine the total body surface that has been injured. As the proportions of adults and children differ, professionals may use the Lund-Browder chart (below) to more accurately determine the extent of the burn
SPECIFC TYPES OF BURNS
Electrical burns are caused by contact with electricity such as electrical devices or lightning strikes. Electrical burns are often associated with other injuries such as cardiac and respiratory system problems. Treatment is to follow DRSABCD – firstly isolate any power supply contacting the casualty without coming into contact with the casualty. If it is unsafe to proceed, then call 000 – do not attempt to move a casualty who is in contact with a live electrical source.
Once the power is isolated, continue DRSABCD. If the casualty is unconscious and not breathing, perform CPR. If the casualty is conscious and stable, then the burn can be treated but the casualty should be referred for medical assessmen
Thermal burns include flame, scald, inhalation and direct heat contact. Immediately run cool tap water over the burn for at least 20 minutes.
The most potentially dangerous of thermal burns is an inhalation burn. This should be suspected if the casualty has been trapped for a period of time with hot / toxic gas or fumes. The casualty may cough up sputum with black particles, have a hoarse voice and / or breathing difficulties. Symptoms may be delayed, so if an inhalation burn is suspected, call 000 and follow DRSABCD.
Avoid contact with any chemical burn or contaminated material, such as with proper use of PPE. If the MSDS is available, then refer to this or contact the Poisons Information Centre (131126) for advice. Immediately run cool tap water over the area for at least 20 minutes and contact 000. For powder chemicals, safely brush the powder from the skin. If the chemical has entered the eye, flush the effected eye thoroughly with water for at least 20 minutes and contact 000.
There are many different recommendations depending on the type, location and severity of the wound as to what treatment is preferred. In this section, the aim is to provide a general overview into the subject of wound management and to provide basic wound management principles and directions. Any chronic or serious wound should be managed under medical advice.
Basic Tools of Wound Care
A dressing refers to the material that is placed directly over the wound. It is preferably sterile to reduce the chance of infection, and a material that will not readily stick to the wound and cause difficulty removing. The main aim is to provide a fairly sterile environment for wound healing to occur, and to assist in reducing the risk of infection.
A Pad is an absorbent material placed over the dressing. It assists in controlling bleeding and absorbing any pus or fluids that may seep from the wound.
A Bandage is placed over the pad, and can be used for compression to reduce bleeding, and to keep the pad in place.
How To Clean A Minor Wound
Certain wounds are at a high risk of infection, and require further medical assessment and supervision. These include:
Signs of Infection
If the casualty experiences any of the following signs in their wound, then a medical opinion should be advised as infection is likely
General Self-Care of wounds includes:
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