First aid manual 2012

If the choking adult or child becomes unconscious, place them on their back. Perform CPR, with these additions:. If the air does not enter freely, reposition their head and try again. Remove any obstructions you can see, but do not blindly sweep your finger in their mouth. Continue the sequence of attempting to breathe, chest compressions and looking for and removing any visible objects from the mouth or throat until the object is removed, qualified help arrives or the decision is made to stop CPR.

If CPR is stopped, the rescuers will need support to help them to come to terms with their experience. When the object is expelled, the patient will feel tired, relieved and possibly embarrassed. They may burst into tears. They have just undergone a life-threatening experience and may need to talk about this with a sympathetic listener. Lay the infant face down over your arm. Rest their body on your thigh with their head lower than their trunk.

Avoid excessive force. Then turn them face up, keeping their head lower than their trunk. Give five chest thrusts, just below the nipple line, the same as for CPR chest compressions, but slower. Look in their mouth, and hook out any visible foreign body with your finger. Repeat the sequence of five back blows, five chest thrusts and checking the airway until the object is dislodged or the infant becomes unresponsive. Support their head by clasping both sides of their jaw, 5 blows. Remember with infants to tilt the head back only slightly to avoid kinking and blocking the windpipe.

If air does not enter freely, gently reposition the head and try again up to five times. If a patient has been unconscious, they should be evacuated, even if they have regained consciousness and appear to have fully recovered. Usually, after having time to rest and recover, a patient who did not lose consciousness is able to continue the activity they were doing before. Be aware that swelling of the airway may occur later, if the airway was sufficiently irritated.

Watch for signs of breathing difficulty and for signs of shock see chapter 6 , which may indicate internal bleeding. If these signs occur, arrange an urgent evacuation. If you are alone, with a fully obstructed airway, you should try to dislodge the obstruction yourself. Try coughing. If that fails, you could try falling forwards onto a solid object, such as the back of a chair, a pack or a log.

Your chest sternum should hit the object with enough force to compress your chest. You may need to try several times.

This chapter covers breathing emergencies arising from chest injuries, carbon monoxide CO poisoning and hyperventilation.

Severe allergic reaction anaphylaxis is covered in chapter 6 and existing medical conditions asthma are covered in chapter Breathing emergencies can be caused by injuries, medical conditions or severe allergic reactions. They can range from the immediately life-threatening, needing CPR, to the possibly life-threatening, needing urgent attention to prevent the situation from becoming worse. Inadequate breathing less than six breaths per minute requires CPR.

A person experiencing breathing difficulty respiratory distress will exhibit some or all of the following symptoms:. CO poisoning is the largest cause of deaths related to camping appliances in New Zealand. CO is formed by incomplete burning of gaseous or liquid fuels or by appliance malfunction.

CO poisoning occurs when stoves and lamps are used in poorly ventilated areas, for example, huts, tents, snow caves or vehicles. CO is particularly dangerous because it is colourless, odourless and tasteless.

People are unaware they are inhaling the gas and being poisoned. NOTE CO poisoning can be avoided by ensuring you keep cooking appliances in good condition and use them in well-ventilated areas. When cooking, open hut windows or tent flies. Either ventilate the area to remove the CO or remove the patient from the area. Once the patient has been removed from the source of the poison, make them comfortable.

Sitting, rather than lying down, will let more air into the lungs. There is nothing that can be done in the field to quickly remove CO from the body. In mild cases of CO inhalation, the patient will recover over time without any specific treatment. Oxygen, if available, should be administered at percent. See chapter 16 for information on other poisons. Hyperventilation, or over-breathing, lowers the level of carbon dioxide CO2 in the blood. It can be caused by:. Breathing into a bag or their hands will help them to regain the correct CO2 balance.

Some people hyperventilate at the top of an abseil site, crossing a three-wire bridge, rock climbing for the first time or doing any activity that makes them feel nervous. Once they have been reassured and treated, they are usually fine.

However, as some serious medical conditions such as a severe allergic reaction, a heart attack or internal bleeding look like hyperventilation, make sure you get a detailed history. If you are unsure if hyperventilation is the problem, have the patient evacuated.

Flail chest occurs only with a high impact injury to the chest, such as a heavy fall against rock, which causes two or more ribs to break in two or more places.

This creates a floating segment of ribcage, which moves in a different direction from the rest of the chest. As the patient inhales, the segment is pulled in, and as they exhale, the segment is pushed out.

As well as being very painful, the lung under the broken segment is unable to fill with air, causing serious breathing problems respiratory distress. This stabilises the flail segment.

Extend tape to both sides of the chest, but not right around, as this may cause breathing difficulty. Sitting up expands the chest, which allows more air into the lungs. If the patient is required to move, the injury may worsen and the pain may increase.

Keep the patient quiet and rested, and if it is necessary to move them any distance, consider using a stretcher. Spontaneous pneumothorax occurs when a weak spot on the surface of the lung ruptures, causing air to leak out. This is not always related to exercise or injury and can occur at rest. This most commonly happens to tall, slim males who are younger than 40 years old, sometimes with a family history of the condition.

If the pressure continues to build, the lung may fully collapse. The pressure can, in the late stage, cause the windpipe to be pushed towards the unaffected side of the chest, affecting the heart and the good lung.

A person with a closed chest injury will exhibit the signs of respiratory distress see page 52 and may have:.

Lean them towards the injured side, to help them breathe and keep blood and other matter in the chest away from the uninjured side. Arrange an urgent evacuation. Moving a patient may make their injury and pain worse.

Signs of this are swollen spongy skin and a crackling sound when the area is pushed due to the trapped air. This condition can progress to compress the airway, so an urgent evacuation is needed. Air is sucked into the chest cavity through the wound when the patient inhales. Air may also escape from a damaged lung. Note: If the wound is difficult to assess, treat it as a penetrating wound see page Finding out how the accident happened will help you assess the wound for example, a wound caused by a heavy fall on an ice axe would suggest penetration.

In managing an open chest injury, the aim is to stop air being sucked into the chest cavity while allowing air to escape from the chest cavity to reduce pressure. Suitable dressings include gauze dressing still in its plastic wrapper, survival blanket foil, petroleum jellyimpregnated gauze held in place with a pressure dressing, or strong plastic. DO NOT use cling film — it is not strong enough and can be sucked into the wound.

Ensure the dressing is large enough that it will not be sucked into the wound. It should be larger than the wound by about 5cm on all sides. Tape the dressing into place on three sides, leaving the fourth side open.

This creates a flap valve, which prevents air being sucked into the chest cavity when the patient inhales, but allows air to escape on exhalation. If the patient is conscious, position them in a semi-sitting position, with their legs straight and their upper body leaning back slightly and well supported.

Lean them towards the injured side to assist breathing and help keep blood and other matter in the chest away from the uninjured side. If the patient is unconscious, position them in the recovery position with the injured side down. It creates its own seal and removing it can cause more damage.

Chest injuries with damage to a lung need urgent medical treatment. Remember patient assessment and management. The circulatory system consists of the heart, the blood vessels and the blood. The average adult heart pumps 6L of blood per minute through the blood vessels, ensuring that all organs and cells of the body receive a constant supply of oxygen.

Note: Capillary refill refers to how quickly blood returns to fingernails or toenails. If the nail remains white, circulation is not effective. This chapter covers circulation emergencies caused by shock, anaphylaxis, heart disorders, severe bleeding and major crush injuries. No part of the body can exist for long without oxygen. Organs such as the brain and heart require a constant supply of oxygenated blood, and loss of oxygen may affect their ability to function normally.

Hypovolaemic low volume shock: Blood or fluid loss, caused by damage to the blood vessels, allows blood to escape from the circulatory system. This results in less oxygen being circulated to the vital organs. Fluid is also lost from the circulatory system in the case of burns, dehydration and diarrhoea. Septic shock septicaemia : In some bacterial infections, toxins are released by the bacteria into the bloodstream, causing the blood vessels to widen dilate.

Blood vessel walls are damaged and become leaky, so blood is lost into the tissues. Circulation becomes inadequate due to decreased pressure and volume. Any patient with an infection showing signs of shock needs to be treated for shock and evacuated urgently. Neurogenic shock: This occurs as a result of a brain injury interfering with the nerves that maintain the muscle tone of the blood vessels.

The vessels relax and dilate, so the blood pools, causing the blood pressure to drop. The treatment for brain injuries is covered in chapter 8. Patients with neurogenic shock should be evacuated urgently. Spinal shock: An injury to the spinal cord can paralyse the muscles of the blood vessels, causing the blood vessels to dilate. The treatment for spinal cord injuries is outlined on page Any patient with a spinal cord injury needs to be urgently evacuated.

Anaphylactic shock: This is a severe allergic reaction. Blood vessels dilate and leak, causing the blood pressure to drop. See separate treatment for anaphylactic shock on page Cardiogenic shock: Damage to the heart, caused by a heart attack or high impact accident, means it can no longer pump effectively enough to ensure adequate circulation to the vital organs. Fainting Vasovagal event : A sudden momentary widening of the blood vessels and slowing of the heart rate caused by the vagus nerve cause a temporary reduction of blood supply to the brain.

This type of shock is not serious, as it can be treated quickly and easily. The treatment for fainting is outlined on page In all of the above examples, the result of shock is the same. Shock is a serious condition that needs to be recognised and managed quickly. A patient with severe shock needs medical treatment urgently. A malfunction of any part of the circulatory system can cause shock.

Blood is drawn from the surface of the skin and the digestive system to the core of the body, to divert oxygen to the vital organs. If the level of shock increases, the brain loses the ability to compensate and the patient will exhibit some or all of the following signs and symptoms:. How quickly these signs and symptoms appear will depend on the cause.

A person suffering a heart attack or major injury will usually show signs of shock very quickly, while symptoms of shock may take hours to appear in a patient with a slow internal bleed. A fit, healthy person may not show signs of shock for some time after an accident. Initially, a fit body can compensate for even a significant loss of blood. In all significant injuries, the patient should be treated for shock, particularly in the outdoor environment. The later signs and symptoms of shock are more serious, and evacuation will usually be necessary.

In managing shock, the aim is to keep blood circulating through the vital organs:. Make sure both legs are completely supported. Do not place hot water bottles at the feet, as this will draw blood away from the core of the body. If the digestive system is not functioning, the fluid cannot be absorbed and the patient may vomit.

If the patient is very thirsty, you can moisten their lips. If the patient is fully conscious and alert, and their condition is not deteriorating, give them small sips of water. DO NOT give them alcohol as it causes the blood vessels to dilate, which will increase the level of shock.

DO NOT allow the patient to smoke. As detailed on page 64, any patients with septic shock, neurogenic shock or spinal shock should be evacuated. Anaphylactic shock also called anaphylaxis is a severe allergic reaction to any substance that the body recognises as foreign an allergen , for example, insect venom, food, medication or pollen. Chemicals released into the bloodstream in response to the allergen cause the blood vessels to dilate, leading to a drop in blood pressure.

Blood vessels can leak fluid, leading to a further drop in blood pressure and flushed skin. Fluid released into the skin causes hives. Fluid released into the upper airway can cause swelling of the throat, mouth and tongue. It can also cause asthma. The onset of anaphylactic shock can begin seconds or minutes after encountering the allergen, or can progress over 24 hours. If the reaction is going to be severe, the onset of symptoms will be rapid. The reaction will probably peak after 10—40 minutes.

Adrenaline should be given to anyone with signs of anaphylaxis. Adrenaline is usually carried as an auto-injector. Junior versions of both can be prescribed to children younger than five years old. Some organisations will carry autoinjectors in their first aid kits. This action plan can be downloaded from www.

The alternative to auto-injectors is adrenaline in ampoules. These are inexpensive, but the adrenaline must be drawn up into a syringe before injecting. Before administering adrenaline, a first-aider should be trained in how to recognise the symptoms of anaphylaxis and how to give adrenaline. Online e-training in auto-injector use is available at www. If in doubt, follow the action plan instructions for using the adrenaline auto-injector. People who know they are at risk of anaphylaxis usually carry adrenaline and an individualised action plan with instructions.

If someone in your group is at risk, make sure you are familiar with their action plan. However, not everyone who has an anaphylactic reaction has a history of them. Someone who has had only mild reactions to stings in the past may experience a full-body reaction and go into anaphylactic shock. If in doubt, administer adrenaline. It must be used quickly, so do not wait until the patient stops breathing.

Recognise the signs and act. Even though the patient may appear to recover after the adrenaline, they may need further medical treatment, including oxygen, intravenous fluids and more adrenaline. When the vagus nerve is stimulated, the blood vessels widen suddenly and the heart rate slows, resulting in decreased oxygen to the brain. If the patient is looking pale, or feeling dizzy or light-headed, lay them down flat and raise their legs. DO NOT tell them to put their head between their legs as this makes it difficult to breathe, and if they collapse from this position, they may land on their head.

Get all the details to help determine the cause. If it was a momentary loss of oxygen to the brain, the patient should feel better quickly. Place them in the recovery position and treat as for an unconscious patient. Knowing the cause will help to prevent a recurrence. Angina occurs in people with coronary arteries narrowed by plaque. These arteries supply blood to the heart muscle. Angina pain is triggered by exercise, stress or cold because the narrowed arteries are unable to supply sufficient oxygen to meet the increased demands of the heart.

Usually the patient will tell you if they suffer from angina and will carry medication. A person experiencing an angina attack will exhibit some or all of the following signs and symptoms:.

Repeat as necessary. Change trip plans if necessary to avoid triggering another attack with strenuous exercise, stress or cold. A heart attack myocardial infarction or coronary thrombosis occurs when a coronary artery becomes completely blocked or is severely narrowed, resulting in the death of a portion of the heart muscle. A person experiencing a heart attack will exhibit some or all of the following signs and symptoms:.

Figure 6. The damaged area is called an infarct. Remember to place support under the thighs. If they are short of breath, sit them up. If necessary, carry them to a safer, more suitable location. Note: Patients will sometimes dismiss the pain as indigestion. If in doubt, treat as a heart attack. The main danger with a heart attack is that the heart may stop cardiac arrest.

This is possible at any stage but is more likely in the first 72 hours following the onset of pain. It is important to take all practical measures to rest the heart as much as possible while waiting for evacuation. Do not give anti-inflammatory medication, such as ibuprofen Nurofen or diclofenac Voltaren.

This may happen if the heart has been weakened by previous heart attacks. If untreated, shock and death may follow. If not, place half a mg Aspirin tablet under their tongue to be dissolved in the mouth, or give them half a mg tablet dissolved in water.

In this position, the chest is expanded and it is easier to breathe because more air can enter the lungs. This will help to retain some fluid in the legs and away from the lungs.

Without treatment, heart failure is likely to become progressively worse. The patient will become increasingly breathless and agitated, and may lose consciousness as the lungs fill with fluid. A thrombosis is clotting of the blood within a blood vessel. Surface clots are quite common, but a deep thrombosis is of concern because it has the potential to move around the body and lodge somewhere else for example, in the lungs or heart.

Prolonged immobilisation can result in deep-vein thrombosis in the legs, such as in the calf. Signs include pain, tenderness, warmth and swelling in the affected limb. When a blood clot thrombus breaks off and travels through the bloodstream, it can lodge in the vessels of a vital organ.

A pulmonary embolism is when the blood clot lodges in the lung. This damages the lung tissue, so breathing can become painful and oxygen transfer is affected with serious consequences. It can lead to cardiac arrest. Cuts from sharp objects, blows from blunt objects, falls or broken bone ends can damage blood vessels. A torn major blood vessel with severe blood loss is immediately life-threatening. A person who has experienced severe blood loss will exhibit the signs and symptoms of shock.

In assessing the injury, expose the wound and look for impaled, embedded objects. Try to describe and record the amount of blood lost, for example, a cupful, a litre or a square metre. This can be difficult as blood spreads over non-absorbent surfaces and soaks into clothing. Save any evidence of blood loss, such as soaked clothing.

Protect yourself by using surgical gloves, cling film or plastic bags. Wash your hands thoroughly after treating a wounded patient. Your first priority is to stop the blood loss. Place a pad such as a T-shirt or bandana over the wound and press down firmly. Imagine the blood vessel is a straw — the pressure you apply should be enough to seal the straw.

If no dressings are available, use their hand or yours, if they are unable to assist. Maintain firm pressure until a clot forms. This can take 5—15 minutes. Reassure the patient and lay them down with any bleeding limbs elevated above the heart. Remove rings and jewellery from affected limbs, as swelling may occur. If the first dressing becomes soaked with blood, do not remove it. This will disturb the clotting process.

Place another dressing pad on top. If bleeding continues after a second dressing is applied, do not use another on top. Pressure on the wound gets less effective as the number of dressings increases. Carefully remove the dressings, check the wound and start again with a new dressing.

After 5 minutes, slowly release pressure this is the time to put on a dressing if you did not have one initially. If the bleeding resumes, reapply direct, firm pressure for 15 minutes. Once bleeding has stopped and a clot has formed, apply a compression firm bandage over the dressing to hold it in place and maintain some pressure. Check the fingers or toes of an affected limb for circulation every 10 minutes. If the circulation is affected:.

In most cases, bleeding from a limb wound can be controlled by a combination of applying direct pressure and elevating the affected limb. Indirect pressure can be used for controlling bleeding of a limb but not bleeding of the torso.

If direct pressure alone is not effective, apply pressure to pressure points. These points are parts of the body where arteries lie close to the skin and against the bone. You are able to feel a pulse at these points. Pressure applied to an artery compresses it against the bone and can slow or stop the flow of blood in that artery, reducing the bleeding at the injury site.

Use this method in conjunction with direct pressure. Do not maintain pressure for more than 10 minutes, as loss of circulation to a limb may cause permanent damage. After 10 minutes, release the pressure point for 10 seconds, while maintaining direct pressure over the wound, allowing normal circulation to resume. If the wound is still bleeding, reapply indirect pressure, and release again after another 10 minutes.

Place 2 or 3 fingers on the temple side of the face between the top of the ear and the eyebrow. Place 2 or 3 fingers behind the knee, midline and slightly to the outer side, just below the bend. Lay the patient down with the limb bent at the knee. You can feel this artery pulsing in the groin. Press it against the bone using your thumbs, fist or heel of hand. Tourniquets Use tourniquets as a last resort only when the combination of direct and indirect pressure does not stop the bleeding of an injured limb.

Wrap the tie around the limb several times, as close to the injury as possible, between the wound and the heart. Tie a knot and place a stick or something similar, such as a tent peg into the knot. Twist the stick, tightening the tie until the bleeding stops. Leave the tourniquet released for 30 seconds, using direct pressure to control the bleeding. If direct pressure controls the bleeding, remove the tourniquet completely.

Continue with direct pressure. Tighten the tourniquet again to completely cut off the circulation. After another 30 seconds, loosen the tourniquet to allow some circulation and removal of toxic substances. Tighten again after 30 seconds. Repeat this pattern of loosening then tightening every 30 seconds for 5 minutes. Write down the times that the tourniquet was applied and released and give them to the rescue personnel.

This is a last resort treatment. Tourniquets are only applied when bleeding is excessive and uncontrollable by direct and indirect pressure. If you use a tourniquet, assume that the patient will lose the limb. The major problems with a tourniquet are that it completely cuts off circulation to the affected limb and causes a build-up of toxins in the limb. Any patient who has lost a considerable amount of blood will need to be evacuated.

The urgency of evacuation will depend on the degree of shock and the size of the wound. Infection is a risk. While waiting for evacuation, treat the patient for shock and keep them warm.

Handle them gently so as not to disturb the wound. Do not remove the dressings, as this disturbance could restart the bleeding. Give the patient pain relief and sips of fluid if they are fully conscious. If the patient is unconscious, place them in the recovery position and monitor their vital signs. Internal bleeding should be considered if the patient has had a significant fall or has been struck by a blunt object such as a rock.

Obtaining all the details about the accident or injury will help you determine if internal bleeding is likely. Internal bleeding may result from a medical condition such as a perforated stomach ulcer or from a serious injury. Internal bleeding may present no visible signs, but a lethal amount of blood can be lost from the circulation system into surrounding tissues. Often, by the time the signs of shock are apparent, the situation is serious.

A person with internal bleeding will exhibit the general signs and symptoms of shock. Other signs that may indicate internal bleeding include:.

A previous history of abdominal problems, such as a stomach ulcer, may indicate that internal bleeding is the result of a medical condition. Leaning them towards the injured lung will help them breathe, as it keeps blood from collecting in the uninjured lung and creates space for it to function properly. If the patient becomes unconscious, place them in the recovery position with the damaged lung downwards.

Internal bleeding can usually only be managed in the operating theatre. Giving the patient pain relief and sips of fluid may help keep them comfortable. Food should definitely be withheld if an intestinal injury is suspected. In the outdoors, crush injuries can be caused by rockslides, avalanches or falling trees. They can involve serious damage to internal organs and body tissue, and can cause fractures. If a significant area of the body, such as both lower limbs, has been crushed for longer than 1 hour, all circulation to the legs will have been cut off for that length of time.

Toxins will have built up in the affected limbs. These toxins can cause serious problems or death when released suddenly into the circulatory system. One option is to apply a tourniquet above the crushed area only if the area is a limb just before removing the crushing object. Apply the tourniquet for 5 minutes, then release for 5 minutes, then repeat, following the steps on page This allows a gradual release of the toxins.

If the crushing object has been in place for more than 1 hour, request specialist medical personnel to come to the scene and administer the appropriate intravenous fluids and medications to counteract the toxins, and to give oxygen. Keep the patient in the shock position, with their head and body lying flat. If their injuries permit, elevate their legs. Monitor their vital signs.

Is the patient alert, do they respond to voice or pain, or are they unresponsive? The treatment is the same for all three levels of unconsciousness: whether the patient responds to voice V , responds to pain P or is unresponsive U. See page 22 for details about the AVPU scale. Causes of unconsciousness include head injury, choking, stroke, epilepsy, diabetes, meningitis or other infections, alcohol or drug abuse, heat stroke or hypothermia.

Are they completely unresponsive or do they respond to voice or pain? Look for medical ID bracelets and necklaces on the wrists, ankles and neck.

Note: It is easier to do a full head-to-toe examination while the patient is lying on their back. Never leave an unconscious patient unattended on their back. The normal reflexes that protect the airway of a conscious person will fail. An unconscious person cannot cough, swallow or gag and:. Frequently check that the patient is breathing by listening for gurgling noises in the throat and watching for vomit in the mouth.

Because the patient cannot gag, you will not hear the usual gagging vomiting noises — the stomach contents will just flow up. The person who is checking the breathing should be kneeling at the side of the patient that best allows for ease and speed of turning, and use of gravity. They need to be ready to do an emergency rollover see page Offer constant reassurance. Do not allow anything negative to be said within earshot. Contact lenses move with blinking and are lubricated by tears to prevent harm to the cornea of the eye.

This action is lost with unconsciousness, so an unconscious patient may need to have the lenses removed. Different types of contact lenses require different methods of removal and storage. Discuss these methods with the lens wearers in the party. When a person is unconscious their dentures can fall back and block the airway. Only remove the dentures if you cannot constantly monitor the patient.

It is impractical to remain kneeling beside the patient for extended periods. For the position to be effective, the patient needs to:. Have insulation and a sleeping bag ready. Clear away any stones or twigs that will dig into your patient. Place insulation on top of a groundsheet for the patient to roll onto. This will protect the patient from the cold ground and make it easier to move them later if needed. Use clothing as a small pillow to support their head before and after you move them.

With the patient lying on their back, place their hand on the side closest to you, palm up, under their buttock. Support their neck and head with one hand and push down on their knee with the other, rolling the patient towards you. Act quickly as rolling over their arm will be uncomfortable for the patient.

Position their uppermost arm at a right angle to their body, bending the elbow so the hand points towards the face. Trees, rocks and sloping, uneven ground may cause difficulties. In difficult terrain, you may want to practice positioning an uninjured party member first. If the patient is in the recovery position for an extended period, parts of the body pressing on the ground may develop pressure sores. A slight change in position every couple of hours will help to relieve pressure on these areas.

If possible, the patient should be turned to the recovery position on the other side. Hold the head by supporting the bony part of the chin in your hand, ensuring that the spine is neutral. If the patient is on their back, and you hear or see any vomit, you must turn them quickly regardless of their injuries, to allow the vomit to flow away and not choke them. Two methods are:. This method requires slightly less strength and decreases the chance of you getting splashed with vomit. If the patient has a neck or spinal injury, the head must be supported during the emergency rollover, even if a neck brace is in place.

Sometimes you will need to keep the patient on their back, for example, when doing a patient assessment, or if you suspect they have spinal injuries. While they are on their back, use the head-lift, chin-tilt method or the jawthrust technique if you suspect a neck or spinal injury to keep the tongue off their airway. As the patient comes over onto your knees, keep supporting their head, always keeping their spine as neutral as possible.

Recognise the risk to the neck and spine, but remember your priority is to clear the airway quickly, otherwise the patient will not survive. Practise these manoeuvres at home so you will be able to do them quickly and confidently in the field. Anyone who is or was unconscious, even very briefly, needs to be assessed and treated by a doctor. Arrange for prompt evacuation. Check often, and wash and dry the area if necessary.

All head injuries should be considered serious. They are often difficult to assess. A person with a significant head injury can initially appear to be symptom-free but can deteriorate quickly over time.

Decreasing levels of consciousness indicate a worsening injury. Symptoms relate to the pressure building up inside the skull as bruised brain tissue swells, blood clots enlarge or bleeding occurs. Patients with a closed head injury can deteriorate over time.

The brain can be damaged by fragments of broken bone or an object penetrating the skull. Symptoms relate to the damage caused by the initial injury, and the situation may be relatively stable.

The skull, vertebrae and cerebrospinal fluid all act to protect the brain and spinal cord. Concussion occurs when the brain is shaken, for example, by a blow to the head or when a patient lands heavily from a height.

Concussion causes a temporary decrease in brain function, ranging from momentary confusion to brief loss of consciousness. Wake them to check and record their level of consciousness every 15 minutes for the first 2 hours.

Extend the interval if their level of consciousness remains stable. A patient who has been unconscious, even for a short time, should be evacuated. If the patient appears to have recovered, and the journey is straightforward, it may be appropriate to allow the patient to walk with assistance.

Compression occurs when a head injury bruises the brain or damages blood vessels in the skull. A build-up of pressure within the skull compresses the brain. Place them in the recovery position see page 85 with the head slightly higher than the rest of the body.

Extend the interval if the level of consciousness remains stable. Take care to ensure the patient is kept as warm and comfortable as possible. The patient may be incontinent, or they may be retaining urine and need assistance in getting to an upright position to urinate. Prolonged urine retention can lead to permanent damage to the bladder.

A person with an open head injury will have a damaged skull and will exhibit the signs and symptoms of a compression injury see page It takes considerable force to penetrate the skull, so you should suspect brain injury, a broken neck and other spinal damage. DO NOT apply direct pressure. Cover the wound with sterile bandages.

Care as for compression injury see page To explain the exact site of injury to a limb, describe it as either upper limb above or below the elbow or lower limb above or below the knee. The arm shoulder to elbow The forearm elbow to wrist The thigh hip to knee The leg knee to ankle.

The bones in the adult skeleton protect the vital organs and give the body shape and rigidity. Bone is very strong living tissue supplied with blood vessels and nerves, with a central core called the marrow. Joints, where bones meet, can be moveable such as the knee or fixed such as the skull. Ligaments attach bone to bone. Tendons attach muscle to bone. Bones are moved by contraction and relaxation of muscles. A fracture is a break, crack or chip in a bone, caused by direct force when the bone is fractured at the point of impact or indirect force where the fracture occurs away from the point of impact due to force being transferred through the body.

The skin wound is caused by either the fractured bone penetrating the skin from the inside or the object causing the fracture for example, a rock or axe penetrating from the outside.

Note: In considering treatment, it is the complication that is important rather than the fracture. In fractures of long bones, muscle spasms around the fracture site can pull the fractured bone ends together, causing them to override. The overriding increases pain and can cause soft tissue, artery and nerve damage. It can be difficult to tell whether or not a bone has been fractured. Always err on the side of caution. It is better to immobilise a sprain than to fail to immobilise a fracture.

In an urban environment, you should not move the broken limb or apply a splint. Simply keep the patient still and contact emergency services. Assess circulation, sensation and movement in fingers or toes before you immobilise a fracture.

Compromised circulation is a sign of a more serious injury. Damage to circulation and nerves can result in permanent damage or eventual loss of the limb. Pack all natural hollows, such as behind the knee, with padding.

Check circulation regularly. For lower limb fractures, support the knee — elevating the lower leg without knee support is uncomfortable.

Traction can greatly reduce pain, by preventing muscle spasm from driving broken bone ends any further into the surrounding soft tissue. You may want to do a trial run on an uninjured party member first, to ensure that the traction can be maintained.

Once you have discovered a fracture, do not move the patient until it has been splinted. Where practical, take your time to carefully improvise a splint that will be comfortable and effective. Work out what materials you need and have them in place before you start. Ensuring an adequate blood supply When a fractured limb is out of its usual alignment, the blood supply to the limb can be affected because blood vessels have been damaged, twisted or kinked.

This is a serious emergency. The limb may be permanently damaged if deprived of blood supply for more than 2 hours. The following are indications of compromised circulation in the fractured limb. If the limb is twisted and the circulation impaired, you should straighten the limb in an attempt to restore the blood supply.

This can be painful but will result in far less pain afterwards. Note: Stop repositioning the limb if this process causes the patient a significant increase in pain or there is resistance that prevents the limb from moving. If you need to stop, immobilise the fracture as it is. If it is impaired, loosen and reapply splints.

If this is unsuccessful, traction and realign the limb. A fractured skull can be caused by a direct blow or by indirect force. When a patient lands heavily on their feet, force can be transmitted up the body and fracture the base of the skull.

Injuries to underlying tissue can result in life-threatening bleeding. Be careful not to probe any wound or fracture as you may cause further damage to the brain. To control bleeding, apply gentle pressure around any wound, rather than directly on it. Cover the ear with a clean pad, to help prevent infection. If the patient is unconscious, place them in the recovery position with the discharging ear or nostril downwards. It takes significant direct force to fracture the jaw, because the lower jaw is very strong.

A patient with a fractured jaw may also have head and neck injuries see chapter 8. Saliva and vomit need to be able to drain away. The bones vertebrae in the spine protect the spinal cord. The spinal cord is the nervous connection between the brain and the rest of the body. A broken vertebra can easily damage or cut the cord. The extent and location of a spinal injury will determine whether the patient might be paralysed from the neck, chest or waist down.

The neck is the most vulnerable part of the spine because it contains the smallest vertebrae with the greatest range of movement.

It is difficult to assess a spinal injury in the outdoors. Only an X-ray can give a definite answer. If you are uncertain, it is better to err on the side of caution. Any numbness, tingling, or loss of movement or sensation can indicate spinal cord damage. Swelling may also cause these sensations, and they may not necessarily be permanent.

Only examine the spine if you can do so without aggravating a possible spinal injury or it is necessary to deal with major bleeding. Never assume that because the patient has sensation and movement, and can wiggle their fingers and toes, their spine is not fractured. A vertebra can break without damaging the spinal cord. Most spinal damage occurs at the time of the accident, but poor handling can make it worse. Use the jaw-thrust method to open the airway of an unconscious patient with a spinal injury.

The aim of managing a spinal injury is to prevent any damage, or further damage, to the spinal cord. Make sure the patient is kept warm. Insulate the patient from cold ground to prevent hypothermia, a significantly increased risk in patients with spinal injuries. Use a log roll see page to get insulation beneath the patient while keeping the spine neutral. Imagine the patient standing up, with a straight back and their eyes and nose facing straight ahead — that is the neutral position.

If the patient is lying flat on their back with the head on the ground, the neck is not in the neutral position, it is tilted slightly backwards. Place your hands on either side of the head and face, with your fingers under the jaw to support and control the airway. If the patient is lying down: Kneel behind the patient. Place your hands under the head and the nape of the neck, supporting either side of the head.

The improvised collar needs to be pliable enough to go around the neck but rigid enough to support the jaw. It needs to be shaped to fit snugly under the jawbone and held firmly in place without restricting breathing. Use the resources you have, for example, closed cell foam, pack waist belt, clothing, sleeping bag or tent fly. Tie the collar in place. If they are wearing a medical ID necklace, wrap it around their wrist.

Hold the head steady by:. Remember that the only truly effective collars are custom made and adjustable, as carried by rescue teams. You can never rely on improvised collars to be effective. They provide support only for still patients. Even if your improvised collar looks effective, it is essential to support the head by holding it at all times when the patient is being moved. Immobilising the spine Ideally a patient is only moved by using a rigid backboard, carried by most rescue teams.

However, you may need to move the patient to safer ground, onto insulation or onto a backboard. The aim is to roll the patient as a log, keeping the head and spine as neutral as possible. When the patient is on their side, the fifth person can examine the back for injuries and push the insulation or improvised stretcher into place. The person at the head gives the command to lower, and everyone slowly rolls the patient on to their back and into the middle of the insulation or improvised stretcher.

The lift method needs six people. This method can be used if the backboard, insulation or stretcher is too thick or rigid to do the log roll. The aim is to lift the patient approximately 20cm off the ground, again keeping the head and spine straight, while the backboard, insulation or stretcher is placed underneath them. Two people kneel on each side of the patient and place their hands over them, to determine exactly where their hands will be see figure 9.

They gently and slowly slide their hands as far under the patient as possible, careful not to jostle them. On the command of the first person, the others lift the patient slowly and evenly, then lower them onto the backboard, stretcher or insulation that is positioned underneath.

Urine retention leading to permanent damage of the bladder is a problem in spinal injuries, as is incontinence, especially when there is no feeling below the waist. Help the patient to urinate and inform rescue crew if the patient has not urinated. If you are waiting for an extended time before moving a patient, ensure paralysed body parts do not become damaged by being left in the same position too long. Turn patients every two hours to avoid pressure sores. Remember that a backboard is designed to transport a patient.

Ideally, paralysed patients should not be on them for more than two hours. If a paralysed patient is no longer being transported, or is likely to be waiting for more than an hour before further transport with emergency services, you may move them from the backboard to a more comfortable surface for example, a mattress in a hut.

This should be done by log rolling them off the backboard see page This is less important for patients who are not paralysed, as pressure sores are much less of an issue because they can shift themselves regularly. Continue to monitor and record vital signs. The collarbone is commonly fractured by indirect force when a person falls onto an outstretched hand or their shoulder.

A sling will make the patient feel more supported and comfortable. Improvise by folding up the bottom of a jacket or shirt and securing it as a sling.

Bandaging the arm to the body may make the patient a little more comfortable. This suggests multiple broken ribs see page 55 for more information. If a flail segment is suspected, see page See page 58 for information on managing a sucking chest wound. Ensure the waist strap is taking all the weight of the pack.

In particular, if the elbow joint is fractured, splint it in the position found. There is danger that if the elbow is moved, blood vessels and nerves could be damaged. The patient may be able to walk out. If their circulation is affected, prompt evacuation is required. A fractured arm can be tied to the torso as a means of splinting, if the patient is not required to walk.

This method is generally uncomfortable if used for long periods, and even small movements in the torso can cause further pain. If in doubt, treat as a fracture. Paul Small's Ownd. First aid manual pdf Reassure the person. If the person has a history of heart disease and takes a prescribed medication to relieve chest pain e. This manual meets the first aid training needs of individual service members. Because medical personnel will not always be readily available, the nonmedical service members must rely heavily on their own skills and knowledge of life-sustaining.

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