DEBRE BIRHAN UNIVERSITY

institute of medicine and health

science
First aid and Accident
prevention for midwifery
Students
Compiled by wondimeneh s.(BSC N)
1

Red cross and red crescent

emblem

Dislocation

Strain

Shock

Seizure

Poisoning

HeartAttack

First Aid

Burns

CPR

Insulin Shock

Bandages

CVA
3

Unit I. Introduction

Learning Objectives
After completing this unit, student will able to:

Define first aid

Mention the aim of first aid

Describe the value of first aid training for health professionals

Describe the responsibilities of a first aider

Brain storming

Have you ever heard about red cross and

red crescents?

Discuss the rational of learning fist aid?

What are fears to giving fist aid care?

List some of emergency drug and

material?

First aid

First aid is an initial(immediate) help given to a person

in case of sudden injury or sickness till he/she gets
medical help.

First aid is the immediate or emergency assistance

given on the scene to sick or injured person before
professional medical care
First aid is

- A matter of common sense

- Application of mind
- Swift/rapid/ response
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aim/purpose/ of first aid

To preserve life
- To prevent injury
- To alleviate pain
- To prepare the victims for
medical aid
-

Values of first aid training

Boot of population growth

Increasing use of technological products in home & work

place
Raise the prevalence of accidents
(Every body is at risk for accident)

E.g. Car accident, falling with a bite of chew, machine

cut, etc

Contd

Any first aider who is equipped with

principle of first aid management

Why? To save life

When? At any time when injury occurs

Where? Any where or place

To whom it is applied? To all who needs to

be helped

Characteristic of a first aider

Must be a good observant

Resourceful: use material at hand to prevent further

damage.

Tactful

Dexterous- that she/he may handle a causality without

causing unnecessary pain and use appliances efficiently.

Explicit-give clear instruction.

Persevering-continue the effort until recovery of the

victim.

Discriminating- prioritizing the casualties depend on the

severity.

Sympathetic- humanity

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General Principles of First aid care

Obtain qualified assistance as soon as possible

Report all information obtained to proper
authorities
Avoid unnecessary movement of the victim
Reassure the victim
If the victim is unconscious or vomiting, do not
give him or her anything to eat or drink

Protect the victim from cold or chilling, but avoid

overheating the victim

Remain calm and avoid panic

Evalauate situation thoroughly

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con

Work quickly, but in an organized and efficient manner

Do not make a diagnosis or discuss the victims

condition with observers at the scene

It is essential to maintain confidentiality and protect

the victims right to privacy while providing treatment

Make every attempt to avoid further injury

Have a reason for anything you do

Treatment you provide will vary depending on type of

injury or illness, environment, others present,
equipment or supplies on hand, and availability of
medical help

PROVIDE ONLY THE TREATMENT THAT YOU ARE

QUALIFIED TO PROVIDE

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Casualty Assessment

History of the case

Signs (objective evidence, vital signs)

Symptoms (sensations that a person feels and

describes)

Keep the casualty lying down, head level with the

body, until you determine the extent and
seriousness of the illness or injury.
The Conscious Casualty

Ask where the injury or pain is located and

examine that area first

Ask if anything else is wrong and make sure there 13

are no injuries that are masked by pain, numbness

The Unconscious Casualty

Primary examination

- Severe external bleeding?

- Unconsciousness?

- Breathing?

- Circulation (pulse)?

Give first aid for life-threatening

conditions in all victims before conducting
a secondary examination
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con

Secondary examination

Look: for bleeding, skin colour and

condition,

Listen: for patient responses or sounds

Feel: (very gently) for deformity,

texture, swelling,or temperature

Smell: the patients breath and other

odours to form an impression of other
problems the patient may have
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Priorities in First Aid Multiple Injuries

The highest priority

- Asphyxia and breathing difficulties

- Severe bleeding

- Unconsciousness

- Shock

- Other immediate life-threatening medical

emergencies

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Priorities in First Aid Multiple

Injuries

Next in priority

- Burns

- Fractures

- Back injuries

The lowest priority

- Minor fractures

- Minor bleeding

- Behavioural problems

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The scope of first aid

treatment

Assessing the situation

Diagnosing the problems

Giving immediate treatment

Referring of the causality to higher health institutions

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First Aider responsibility

. Assessment of the situation ( DR-ABCD)
- Danger: Ensure for no treat in & around the scene
- Responsiveness : Level of consciousness
: Call for help & position the victim
: Conscious---Take history
: Take Sign & Symptoms
- Airway - Open & clear the airway
I

- Use head-tilt/chin-lift technique

- Breathing: using LLF approach
Look at the chest
Listen for air movement
For 5-10 seconds
Feel with your cheek
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First Aider responsibility--- Circulation:

Check the Carotid/Brachial/ pulse

- Check for bleeding , shock, & fractures

- Check for burns
- Check for possible head injury

II. Diagnosis ( but prioritize the problem)

III. Take immediate action
- Reassure the victim
IV. Arrange transportation for medical aid
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When to Get Help

It is vital for rescuers to get help as quickly as possible

When more than one rescuer is available,one should

start resuscitation while another rescuer goes for help

Alone rescuer will have to decide:

If the victim is an adult, and the cause unconsciousness

is not trauma (injury) or drowning, the rescuer should
assume that the victim has a heart problem and go for
help immediately when unresponsiveness is established
or after the absence of breathing

If the likely cause of unconsciousness is trauma (injury)

or drowning or if the victim is an infant or child, the
rescuer should perform resuscitation for about one
minute before going for help
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Infection prevention and

Patient Safety

Patient safety is a discipline in the health

care sector that applies safety science
methods toward the goal of achieving a
trustworthy system of health care
delivery. HAI is defined as:

an infection acquired in hospital by a patient

who was admitted for a reason other than that
infection.

an infection occurring in a patient in a hospital

or other health-care facility in whom the
infection was not present or incubating at the
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time of admission.

Impact of health care

associated infection
HAI can:

Increase patients suffering.

Lead to permanent disability.

Lead to death.

Prolong hospital stay.

Increase need for a higher level of care.

Increase the costs to patients and

hospitals.
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Main Sources of Infection

Person to person via hands of health-care

providers, patients, and visitors

Personal clothing and equipment (e.g.

Stethoscopes, flashlights etc.)

Environmental contamination

Airborne transmission

Hospital staff who are carriers

Rare common-source outbreaks

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Main Routes for infections

Urinary tract infections (UTI)

Catheter-associated UTIs are the most

frequent, accounting for about 35% of all HAI.

Surgical infections: about 20% of all HAI

Bloodstream infections associated with

the use of an intravascular device: about
15% of all HAI

Pneumonia associated with ventilators:

about15% of HAI
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Ways to Prevent HAI

1.

Maintain cleanliness of the hospital.

2.

Personal attention to handwashing before and

after every contact with a patient or object.

3.

Use personal protective equipment whenever

indicated.

4.

Use and dispose of sharps safely.

Which Requires health care providers who have:

Knowledge of common infections and their vectors

An attitude of cooperation and commitment

Skills necessary to provide safe care

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con

before contact with each and every

patient:

clean hands before touching a patient

clean hands before an aseptic task

after contact with each and every

patient:

clean hands after any risk of exposure to

body fluids

clean hands after actual patient contact

clean hands after contact with patient

surroundings

27

First Aid Follow-up Care

After immediate first aid is given:

Call emergency services if someone else has not

already done so Monitor the casualties
continuously

Keep the casualty comfortable and warm enough

to maintain normal body temperature

Do not give the casualty anything to eat or drink

because it may cause vomiting, and because of
the possible need for surgery

Protect and shelter the casualty while awaiting

the arrival of medical aid
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con.

Safeguard the casualty`s personal

belongings

Assist in the evacuation of the casualty by

ambulance

Ensure that casualties who do not require

medical aid are placed in the care of
friend or relatives

Make notes of the names of the casualties

and bystanders and record the first aid
given

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Examples of first aid care

Preventing severe blood loss

Helping the child to maintain breathing

Diluting or removing poisons from the childs body

Preventing shock

Treating burns properly

Immobilizing head and back injuries

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Unit II. Respiratory emergency

Learning objectives
1. Define respiratory emergency
2. Discuss different causes of respiratory failure
3. Demonstrate artificial respiration
4. Describe first aid measures for obstructed airway (Choking )in conscious and
unconscious victims.
5. Demonstrate the procedure of external cardiac massage (CPR)

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Common definition

Respiratory arrest.

Cardiac arrest.

Stroke;the blood supply to the part of the brain is

blocked.

Clinical death,heart and breathing have stoped.

Heart attack;sudden sever instance of abnormal heart

function.

Brain death;

Biological death.all system become cease.

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Respiratory Emergencies
Definition

Respiratory emergency
- Respiratory emergency is one in which

normal breathing stops or in which

breathing is reduced so that oxygen intake
is insufficient to support life.
Apnea or difficulty in breathing
Respiratory distress- An abnormal condition
where breathing is labored, noisy, irregular, or
unusually fast or slow, or a combination of these
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Causes of respiratory failure

1. Anatomical Obstruction

Roll back of the tongue, Asthma, Croup, Anaphylaxis, Diphtheria, Poisons,

Laryngeal spasm Constriction of air passage
2. Mechanical Obstruction
Choking of food, Aspiration with vomits, Accumulation of mucus, saliva or blood in
the throat --- Lodge the respiratory tract

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cont,d3. Air depleted of Oxygen or containing toxic gases

Ex. CO poisoning, Explosion hazard (suffocation)

4.

Other causes

- Stroke, drowning, shock, excess alcohol, heart disease, lung disease, etc

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General information

The air contains 21 % Oxygen

The air that we breath out contains 16-18 % of Oxygen

The average person may die in 6 minutes or less if his oxygen supply is cut off

Recovery from Resp. failure is usually rapid except in case of CO poisoning, over
dosage of drugs or electrical shock

So it is important to give artificial respiration until the victims begins to breath

by himself

36

Artificial Respiration
= A procedure for making air to flow into and out of a persons lungs when victims
natural breathing is inadequate or ceases.
= Rescue Breathing
Methods of administering artificial respiration
A.

Mouth to Mouth Method (Kiss of life)

A. Head tilt/ Chin lift technique or
B. Jaw thrust technique (if u suspect spinal injury)

B. Mouth to Nose Method (wound, Jaw fracture , vomitus around

mouth,maxiofacial fracture ,,,etc)
C. Cardiopulmonary resuscitation CPR.( when there is no breath & pulse)

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artificial respiration

artificial respiration is the act of assisting

or stimulating respiration, a metabolic
process referring to the overall exchange
of gases in the body by pulmonary
ventilation, external respiration, and
internal respiration.

The efficiency of artificial respiration can

be greatly increased by the simultaneous
use of oxygen therapy. The amount of
oxygen available to the patient in mouth
to mouth is around 16%. So may enhance
up to 41%.

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A. Mouth to Mouth Method

- Place your hand on his forehead, and pinch his
nostrils together with the thumb and index finger

With your other hand, keep your fingertips on the

bony part of the lower jaw near the chin and lift

Take a deep breath and place your mouth (in an

airtight seal) around the casualtys mouth

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Mouth to Mouth Method-- Blow

2 full breaths into the

casualtys mouth (1 breath at least
Q. 5 seconds), taking a breath of
fresh air each time before you blow.

After

giving two slow breaths, which

cause the chest to rise, attempt to
locate a pulse on the casualty.
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Mouth to Mouth Method----

A. Head tilt/ Chin lift technique

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Check carotid pulse

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Mouth to Mouth Method---(a) If signs of circulation are present and a pulse is

found and the casualty is breathingSTOP; allow
the casualty to breathe on his own. If possible,
keep him warm and in recovery position.
(b) If a pulse is found and the casualty is not
breathing, continue rescue breathing.
(c) If a pulse is not found, perform CPR as soon as
possible.
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Use mouth-to-nose
ventilation when

You cant open the victims mouth

The victims mouth is so large that you cant seal it off

with your mouth

The victim has no teeth, which interferes with the

formation of a good seal

The victim has mouth injuries

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Choking /obstructed air way/

Airway obstruction, which includes choking,

suffocation, and strangulation, prevents oxygen
from entering the lungs and brain.

Partially obstructed airway either with good air or

poor air exchange.

Fully obstructed air way.

When small piece of food or foreign body may be

inhaled in to the windpipe when eating in which
some times help is needed.
N.B. Do not try to hook the foreign body out with
your fingers. This is likely to push it further down.45

chocking hazards:

incident of chocking
FOOD-60%
NONFOOD-31%
Not Reported-9%

coins

small balls

marbles

small toy parts

safety pins

jewelry

pen caps
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Signs of complete
airway obstruction are

Inability to speak, groan, cough, or cry

out (the victim of a heart attack or other
emergency will be able to at least
whisper)

Absence of breath sounds

Labored use of muscles required in

breathing flared nostrils, strained neck
and facial muscles

Progressive restlessness, anxiety, and

confusion

Unresponsiveness

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First aid Manoeuvres for Choking

- Back blows

- Abdominal thrusts (Heimlich manoeuvre)

- Finger sweep to remove any solid

foreign body seen in the mouth

- Chest thrusts

- Ventilations

The restoration of breathing takes

precedence over all other measures
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Obstructed Airway ( Adult & Child) Conscious victim

A. Abdominal thrust (or Heimlich maneuver best

technique) is the manual thrust with the hands
centered between the waist and the rib cage.
B. The chest thrust (the hands are centered in the
middle of the breastbone) is used only for an
individual in the advanced stages of pregnancy,
in the markedly obese casualty, or if there is a
significant abdominal wound.
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Obstructed Airway ( Adult & Child)

Conscious victim--- Abdominal

thrusts are used on victims with severe

airway obstructions.

Before

attempting abdominal thrusts, ask the

victim Are you choking?

If

the victim can reply verbally, you should not

interfere, but encourage the victim to cough.

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Abdominal thrusts -procedure

Stand

behind the casualty and wrap your arms

around his waist.

Make

a fist with one hand and grasp it with the

other
Press

the fists into the abdomen with a quick

backward and upward thrust

Continue

performing abdominal thrusts until the

obstruction is expelled or the casualty becomes
unresponsive ( perform mouth to mouth breath)
51

Picture that shows abdominal

thrust/helimach manover/

52

Obstructed Airway ( Infant)

Instead

of abdominal thrusts, alternate 5

chest thrusts with 5 back blows:

Hold the infant with the head in your

hand, and the spine along your forearm
and the head below the rest of the body

53

Obstructed Airway ( Infant)-- Switch the infant to your other

forearm, so their chest is now
against the arm
Perform 5 back blows, keeping the
infants head below the rest of the
body
Continue until the obstruction is
cleared, or the infant goes
unconscious

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Obstructed airway unconscious victim

Call

for help, position the casualty on his back

,open the airway, perform a finger sweep, and
attempt rescue breathing

Perform

4-5 rapid back blows

If

still unable to ventilate the casualty, perform 6

to 10 manual (abdominal or chest) thrusts.

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Abdominal thrusts

A. Kneel astride the casualtys thighs

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Abdominal thrust--B. Place the heel of one hand against

the casualtys abdomen (in the
midline slightly above the navel but
well below the tip of the
breastbone).
Place your other hand on top of the
first one. Point your fingers toward
the casualtys head.
57

Abdominal thrusts--C. Press into the casualtys abdomen with a quick,

forward and upward thrust. You can use your body weight to
perform the maneuver. Deliver each thrust quickly and
distinctly.
D. Repeat the sequence of abdominal thrusts, finger
sweep, and rescue breathing (attempt to ventilate) as long as
necessary to remove the object from the obstructed
airway.
E. If the casualtys chest rises, proceed to feeling for
pulse.
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First -Approach --- DR-ABCD

Airway---

open & clear

Breathing---

Look, Listen, Feel & Perform = 5-10 sec

If no breathing, give 2 rescue breaths for Adults

-- Give 5 rescue breaths for Child & infants
Attempt to locate a pulse on the casualty after 2
rescue breaths
Circulation

If there is no breathing & sign of circulation, perform

CPR
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Prevention of chocking

supervise young children when they are

eating,

Keep small items that are a choking

hazard out of children's reach.

Check toys regularly for damage.

Never let children run, play, or walk with

food in their mouths.

Do not talk and drink while eating

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Questions/Comments

61

CPR
Cardio-Pulmonary Resuscitation
The aim of heart message is to press the heart between the breast
bone (sternum) and the back bone (spine) thus literally squeezing
blood out of it.

CPR combines rescue breathing and chest

compressions.
Rescue breathing provides oxygen to the
person's lungs.
Chest compressions keep oxygen-rich blood
flowing until the heartbeat and breathing can be
restored.
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Causes of respirtory arrest

Electric shock

Drowning

Suffocation

Inhalation of poisonous gases

Head injuries

Seizures

Airway obstruction

Stroke

Drug overdose

Heart problems

Allergy reactions

63

Cause of circulatory arrest

1 .Cardiac

Ischemic heart disease (myocardial infarction,

stenocardia)

Arrhythmias of different origin and character

Electrolytic disorders

Valvular disease

Cardiac tamponade

Pulmonary artery thromboembolism

Ruptured aneurysm of aorta

64

Con
2. Extra cardiac

airway obstruction

acute respiratory failure

shock

reflector cardiac arrest

embolisms of different origin

drug overdose

electrocution

poisoning

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Con..

What type of situation might cause

avictim to need CPR.

Heart attack

Epilpsey

Accident

Suffocation

chocking

Drowing

Over exposure to cold temp.

66

Con
Purpose

To squeeze blood manually out of the heart for victims

with cardiac arrest

To provide oxygenated blood to the brain and heart

To restore blood circulation

As basic life support

To minimize the occurrence of panic

For early dx and detection of symptom.

67

Indications

Respiratory Arrest: - Respiratory arrest refers to the

absence of breathing.

Cardiac Arrest: When the heart stops, there is no pulse.

Precaution

The CPR Must begins within 4-6 minutes of collapse if not;

the brain is sensitive to hypoxia and will sustain irreversible
damage after 4-6 minutes of no oxygen.

The cause of cardiac arrest is important BUT do not delay

CPR to obtain history

Relative Contraindications

Ribs fractured

Burn of sternum( full thickness )

68

Equipments
No special equipments are needed at emergency
situation- just hands and mouth & step by step
procedure.
At hospital level ( Ambu bag , firm board, stethoscope ,
spatula , )

69

Adult CPR procedure

1. Check the Scene or Assessment of the Situation
(Always Present if it is out of Health Centers)

Make

sure it is safe for you to

help.
Don't

become another victim

and assess the environment
to know the cause of the
problem
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Con
Lay

the patient on a firm flat surface

Kneel close to his side, at right
angles to him and along side his
chest.
Press the lower third of his breast
bone sharply with the heels of your
hands, using pressure from your
shoulders.
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Con
2. Check the Victim or Assessment of unresponsiveness

Tap or gently shake the victim and shout Are you ok.
To elicit a response a painful stimulus can be applied
such as:

Pinching

the earlobe,

Pressing

over the eyelid and

observing for grimacing.
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Con..

73

Con
3. Call for Help or Activate EMS

Rescuer who is alone should alter sequence of rescue

based on most likely cause.

Sudden witnessed collapse (likely VF) arrest activates

EMS (Emergency medical service), do CPR.

Hypoxic arrest (i.e., suffocation give 5 cycles of CPR

(about 2 minutes) before alerting EMS.

If there is no response, Call ***** and return to the victim.

In most locations the emergency dispatcher can assist
you with CPR instructions

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4. Positioning the victim

Place the victim first on His/ Her back on hard surface. If the
victim is lying face down, turn or roll the victim as unit,
supporting the head and neck

5. Airway

Open the airway by the head tilt / chin lift maneuver for all
victims and Remove foreign body. We might also assess the
breathing status of the victim

Health care personnel use:

Head tilt- chin lift

Jaw thrust in trauma patient

75

Con

76

Breathing

Assessment of breathlessness and carotid pulse (5-10 second)

Place your ear just one inch above the mouth and the nose of the
victim and perform the following simultaneously: Use

LOOK: for the chest to rise and fall

LISTEN: for air escaping during exhalation

FEEL: for the flow of air on your cheek

NB: Count the number

1001,1002,1003,1004,1005,1006,1007,1008,1009,1010 to be
sure you are checking for 10 seconds because 1001 represents 1
second, and 1002 represents 2, and continue others like this.
77

Con..

78

Con..

Simultaneously assess the presence of pulses

Assessment

of pulselessness (5-10 second)

:check pulse at carotid artery which is the
most common and most reliable.

While

maintaining the head tilt with one

hand, locate the victims Adams apple
(thyroid cartilage) with two or three fingers
of the other hand. Slide your fingers into
the groove between the Adams apple and
the muscle on the side nearest you where
the carotid pulse can be felt
79

Con..

If breathing is not present, begin rescue breathing by

giving two slow breaths: pinch nose and cover the
mouth with yours and blow until you see the chest rise.
Give 2 breaths.

Time:

Each breath should take 1.5 sec to 2 sec and watch for
chest rise and allow time for exhalation (3-3.5 sec).

Volume:

Sufficient volume

No large volume or forceful breathing.

80

Circulation
If pulse is not definitely felt within 10 seconds, proceed
with chest compression.

Provides 30% (or less) of normal circulation.

To locate the landmark for external chest compression

The technique of costal margin that is as follows:

A. Run your index and middle fingers up the lower margin

of the rib cage and locate the sternal notch with your
middle finger. The index finger is place next to the
middle finger on the lower and of the sternum.

81

Con..
B. The heel of the other hand (the one nearest the victims
head) is placed on the lower half of the sternum, and
the other hand is placed on the top of the hand on the
sternum so that the hands are parallel.
C. Your fingers may be either extended or interlaced but
must be kept off the chest.
D. Lock your elbows into position, the arms are
straightened and shoulders directly over the victims
sternum. Keep the heel of your hand lightly in contact
with the chest during the relaxation phase of chest
compression to maintain correct hand position.

82

Con..

83

Con..

Push hard- push fast: equal compression and relaxation

allowing recoil of chest wall.

Chest compression ventilation 30: 2, for 5 cycles (2

minutes rate of 100 per minute.

Depth of 1.5 to 2 inches for adults

84

Con

Count compression in English in the sequence of:

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,1

9,20, and 1,2,3,4,5,6,7,8,9,1= for 1st cycle

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,1

9,20, and 1,2,3,4,5,6,7,8,9,2= for 2nd cycle

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,1

9,20, and 1,2,3,4,5,6,7,8,9,3= for 3rd cycle

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,1

9,20, and 1,2,3,4,5,6,7,8,9,4= for 4th cycle

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,1

9,20, and 1,2,3,4,5,6,7,8,9,5= for 5th cycle

85

Reassessment
After 5 cycles of compressions and 6 cycle of ventilations
(30:2), check for return of carotid pulse/ and spontaneous
breathing
According to the findings (after 2 minutes):

There is pulse place in the recovery position, monitor vital

signs until EMS arrives.

There is pulse but no breathing: continue rescue breathing

every 5- 6 seconds (10-12 breaths). Recheck pulse every 2
minutes.

No pulse or breathing continues CPR 30:2. Until provider

arrives

Repeat A B- C to 5 cycle of compression and 6 cycles of

breathing. (150:12)
86

CPR Procedure--Do

not bend your arms at the

elbows.
After five complete cycles (about
2mins) check for carotid pulse for 10
seconds
If you are succeeding the pupils of
the patients eyes will begin to get
smaller.
87

Con..

88

Chest
Compression:
rescue breath
ratio

Chest
Depression

Age (Yrs)

Hand

Adult > 8

30: 2

1.5 2 inches

Child 1-8

30:2

1- 1.5 inches

Infants < 1

30: 2

0.5- 1 inches

(2
fingers)

89

Drugs used in CPR

Atropine can be injected bolus, max 3 mg to block

vagal tone, which plays significant role in some cases of
cardiac arrest
Adrenaline large doses have been withdrawn from the
algorithm. The recommended dose is 1 mg in each 3-5
min.
Vasopresine in some cases 40 U can replace
adrenaline
Amiodarone - should be included in algorithm
Lidocaine should be used only in ventricular
fibrillationa

90

Complications of CPR

Broken ribs
Check and correct your hand position

Gastric distention

Caused by too much air blown too fast and too forcefully into
stomach

Regurgitation : pressure on stomach during thrust.

rib fractures, sternal fractures, bleeding in the anterior

mediastinum, heart contusion, hemopericardium, upper
airway complications,

damage to the abdominal viscus - lacerations of the liver

and spleen, fat emboli, pulmonary complications pneumothorax, hemothorax, lung contusin.
91

When to stop CPR

Victim

is revived
Exhaustion
Scene become unsafe
Trained helper arrives if
the victim's heart starts
beating
92

The five fears of rescue

Lawsuit:

legal issue.
Fear of uncertainty
Fear of disease
Fear of hurting or killing
Unsafe scene ( chemicals, fires,
guns, knifes ,etc)
93

Good Samaritan law ,proverb.

Law that protects rescuers from prosecution or civil

lawsuit,unless their actions constitute willful
misconduct and negligence.

Acting in good faith by being prudent and responsible in

their rescue efforts.

94

unit III.wound and control bleeding

Learning objective
1. Define wound
2. Classify different types of wound
3. Identify common causes of wound
4. Give first aid measures for different types of wounds
5. Apply first aid measures to stop severe bleeding
6. Explain the preventive measures of contamination and
infection of wounds

95

Brain storming

What does mean pressure sore ?

Discuss factors affecting wound healing?

Mention technique of suturing and its purpose?

Describe goals of wound care?

96

Wound
A wound is a break in the continuity of the tissue of the
body either internal or external.

The skin is the bodys largest organ and

is the primary defense against infection.
It is a disruption in the integrity of body
tissue

Common Causes of Wounds

Accidents, falls and handling of sharp objects, tools,
machinery and weapons.
97

Mechanism of injure
Wounds are caused by different type of force

Shear force:result from sharp object.

Low energy,minimal cell damage , result in straight edge
,little contamination, heals with goods result

Comperssive force:-result from blunt object impacting

the skin at right angle.
Complex laceration, ragged edges,prone to infection,

Tensile force ; result triangular wound,produced

flap,prone to infection.

98

Classification of wounds
A. by status of skin integrity

open
involves a break in skin integrity or mucous membrane

closed

involves no break in skin integrity or mucous membrane,

involves injury to underlying tissues with out a break in the
skin or mucous membrane
B.by severity of injury

superficial

involves only the epidermal layer of skin

penetrating
involves penetration of the epidermal and dermal layers

99

C.Based on Causes of Wound

Intentional wounds occur during treatment or therapy.

These wounds are usually made under aseptic

conditions.

Examples include
venipunctures.

surgical

incisions

and

Unintentional wounds are unanticipated and are often

the result of trauma or an accident.

These wounds are created in an unsterile environment

and therefore pose a greater risk of infection.
100

D .Based on Cleanliness of Wound /by degree

of contamination/

This classification according to its contamination by bacteria

and risk for infection

clean wounds are intentional wounds that were created

under conditions in which no inflammation was encountered .

Clean-contaminated wounds are intentional wounds that

were created by entry into the alimentary, respiratory,
genitourinary, or oro-pharyngeal tract under controlled
conditions.

101

Con,,,,,

Contaminated wounds are open, traumatic wounds or

intentional

wounds in which there was a major break in

aseptic technique, spillage from the gastrointestinal tract, or
incision into infected urinary or biliary tracts.

These wounds have acute non-purulent inflammation present.

Dirty and infected wounds; are traumatic wounds with

retained dead tissue or intentional wounds created in situations
where purulent drainage was present.

102

E .by Thickness of Skin Loss/depth/

superficial
partial-thickness
involves only the epidermal and dermal layers of skin

full-thickness

involves the epidermal and dermal layers of skin,

subcutaneous tissue

deep wound
The thickness classification system is based on the depth of the
wound and is used for wounds whose etiology is other than
pressure wounds such as skin tears, donor sites, vascular
ulcers, surgical wounds, or burns.
103

F .The RYB Wound Classification

System/colour /

Red wounds are the color of normal

granulation tissue and are in the proliferative
phase of wound repair.

These wounds need to be protected and kept

moist and clean.

104

Con,,,,

Yellow wounds have either fibrinous slough or

purulent exudate from bacteria.

These wounds need to be cleansed of the

purulent exudate, and nonviable slough needs to
be removed.

Black wounds contain necrotic tissue (eschar).

Eschar may be either black, gray, brown, or tan

These wounds need debridement, which is the removal of

nonviable necrotic tissue.

The rule for treatment is to treat the worst color first.

105

Physiology of Wound
Healing

Defensive (Inflammatory) Phase :-The defensive phase

occurs immediately after injury and lasts about 3 to 4 days.

The major events that occur in this phase are hemostasis and
inflammation.

Hemostasis or cessation of bleeding, occurs by

vasoconstriction of large blood vessels in the affected area.
Activation of the clotting cascade results in the formation
of fibrin and a fibrinous meshwork, which entraps platelets
and other cells.

Inflammation is the bodys defensive adaptation to tissue

injury and involves both vascular and cellular responses.

During the vascular response, tissue injury and activation of

plasma protein systems stimulate the release of various
chemical mediators, such as histamine (from mast cells),

106

Con,,,,

Reconstructive (Proliferative) Phase :-The

reconstructive phase begins on the third or fourth day after
injury and lasts for 2 to 3 weeks.

This phase contains the process of collagen deposition,

angiogenesis, granulation tissue development, and wound
contraction.

Fibroblasts, normally found in connective

tissue, migrate into the wound because of
various cellular mediators.

Collagen is the most abundant protein in the

body and is material of tissue repair.
107

Angiogenesis

(formation of new blood

Con.
Wound contraction is the final step of the
reconstructive phase of wound healing.

Contraction is noticeable 6 to 12 days after injury

and is necessary for closure of all wounds.

The edges of the wound are drawn together

by the action of myofibroblasts, specialized
cells that contain bundles of parallel fibers in
their cytoplasm.
These myofibroblasts bridge across a wound
and then contract to pull the wound closed.

108

Con..
Maturation

Phase :Maturation, the final stage of

healing, begins about the twenty-first day and
may continue for up to 2 years or more,
depending on the depth and extent of the wound.

-During

this phase, the scar tissue is remodeled

(reshaped or reconstructed by collagen deposition
and lysis and debridement of wound edges).

Capillaries

eventually disappear, leaving an

avascular scar (a scar that is white because it lacks
a blood supply).
109

Types of Healing
Primary

intention healing occurs in

wounds that have minimal tissue loss
and edges that are well approximated
(closed).

If

there are no complications, such as

infection, necrosis, or abnormal scar
formation, wound healing occurs with
minimal granulation tissue and scarring.
110

Con,,,,
Secondary intention healing is seen in wounds with
extensive tissue loss and wounds in which the edges can
not be approximated. The wound is left open, and
granulation tissue gradually fills in the deficit.
Repair time is longer, tissue replacement and scarring
are greater, and the susceptibility to infection is
increased because of the lack of an epidermal barrier to
microorganisms

Tertiary intention healing:- also known as

delayed or secondary closure, is indicated
when primary closure of a wound is
undesirable.
Suturing of the wound is delayed until the

111

Factors Affecting Wound

Healing
1.

Hemorrhage

2.

Infection

3.

Age

4.

Nutrition

5.

Oxygenation

6.

Smoking

7.

Drug therapy

8.

Diabetes mellitus

112

the main aim when dealing

with wound care

To treat and prevent shock

Facilitate hemostasis

TO protect the wound from

contamination and infection

To prevent complication

Obtain medical attention

Decrease tissue loss

Minimize scar formation

113

Basic wound care

In

evaluating the casualty for location, type, and

size of the wound or injury, cut or tear his
clothing and carefully expose the entire area of
the wound.
This

procedure is necessary to avoid further

contamination.
Clothing stuck to the wound should be left in place to
avoid further injury.
DO NOT touch the wound; keep it as clean as possible.
DO

NOT REMOVE protective clothing in a

chemical environment.
Apply

dressings over the protective clothing.

114

Con.

To cleanse a wound, wash your hands thoroughly with

soap and water.

Wash in and around the wound to remove bacteria and

other foreign materials (wash the wound from inside to
outer side.

Rinse the wound thoroughly by flushing with clean water.

Blot the wound, dry with a sterile gauze pad or clean

cloth.

Apply a dry bandage or clean dressing and secure it

firmly in place.
115

Bleeding

Bleeding (hemorrhage) is the escape of blood from

capillaries, veins, and arteries.

Capillaries are very small blood vessels that carry blood

to all parts of the body.

Veins are blood vessels that carry blood to the heart.

Arteries are large blood vessels that carry blood away

from the heart.

Bleeding can occur inside the body (internal), outside

the body (external) or both.

116

con.

There are three types of bleeding.

Capillary bleeding is slow, the blood "oozes" from the

(wound) cut.

Venous bleeding is dark red or maroon, the blood flows in a

steady stream.

Arterial bleeding is bright red, the blood "spurts" from the

wound.

Arterial bleeding is life threatening and difficult to

control.

117

G.by descriptive qualities

Abrasion

A.
: A scraping or
scratching. Generally quite superficial,
and affecting only the surface layers of
the epidermis. No internal organs, nerves,
or blood vessels other than capillaries,
are affected. This may be the result of a
fall, or of sliding (friction) against rough
surfaces. The road rash often suffered by
falling motorcyclists is an example of this
type of wound

A. Abrased (scraped) Wounds

A graze
118

B.Incised Wounds(inscion)

Incision: Straight edges to the wound margins,

as if sliced with a knife. These can vary in size, and
may be caused by a variety of objects, including a
scalpel, a knife, any piece of straight, sharp metal,
or a piece of glass

B.

A clean surgical wound

119

CON..
incised wound

C .contusion

involves a blow from a blunt object resulting in

swelling, discoloration, bruising, and/or eccymosis

120

D.Lacerations

Laceration: Jagged edges to the wound

margins, more closely resembling a tear
than a slice. The direction of the wound is
random rather than straight, and it may
have multiple branches

C. Irregular wound caused by blunt impact to

soft tissue
121

E.Punctured wound
Puncture: Sharp object penetrates the tissue and
travels inward, but does not move laterally in any
direction from the point of entry.Such wounds can
be misleading, as they may appear quite small on
surface examination, but extend quite deeply into
the body, even damaging nerves, blood vessels, or
internal organs.

D. Caused by an object penetrated the skin and

underlying layers, such as a nail, needle or knife
122

F. Avulsions
Avulsion: A full thickness laceration-type
wound, often semi-circular in shape. This
creates a flap which, when lifted, exposes
the deeper tissues to view, or extrudes
them from the wound itself. Avulsions often
occur in mechanical accidents involving
fingers (sometimes referred to as
degloving), or, more seriously, may affect
the orbit of the eye or the abdominal cavity,
exposing the internal viscera. Avulsions are
difficult to repair, and no avulsion should
ever be considered a minor injury

It results when tissue is forcibly separated or torn

off the victims body. An avulsed body part may be
reattached to a victims body by a surgeon
123

Signs of internal bleeding

1. Anxiety and restlessness.

2. Excessive thirst (polydipsia).

3. Nausea and vomiting.

4. Cool, moist, and pale skin (cold and clammy).

5. Rapid breathing (tachypnea).

6. Rapid, weak pulse (tachycardia).

7. Bruising or discoloration at site of injury (contusion).

124

control bleeding

Physical
Direct pressure
epinephrine
ligation

thermal
cautery

Physiological
if it is refractory
use of tourniquet for external bleeding
125

control bleeding

There are four methods to control bleeding:

Direct pressure

Elevation

Indirect pressure

Use of a tourniquet.

Immediate and effective direct pressure to the wound may

reduce the need for a tourniquet application. This is an
important benefit as tourniquet applications are to be
avoided and used only as a last resort.

126

RX for External bleeding

Mnemonic RED
R = Rest
In all cases, the less movement the wound undergoes, the easier the healing process will be, so rest
is advised.
E = Elevation ( elevate above the level of the heart)
D = Direct pressure/Dressing/

RX For internal bleeding

Monitor

ABCs
Lay on side if appropriate (expect vomiting)
Treat for shock
Raise

legs 8-12 inches

Cover victim

Bruises: Ice, ace wrap, elevate

127

Indirect pressure

In cases of severe bleeding when direct pressure and

elevation are not controlling the bleeding, indirect
pressure must be used.

Bleeding from an artery can be controlled by applying

pressure to the appropriate pressure point.

Pressure points are areas of the body where the blood

flow can be controlled by pressing the artery against an
underlying bone.

Pressure is applied with the fingers, thumb, or heel of

the hand.

128

Elevation

Direct pressure is usually enough to stop most

minor bleeds, but for larger bleeds, it may be
necessary to elevate the wound above the level of
the heart. This decreases the blood flow to the
affected area, slowing the blood flow, and assisting
clotting.
129

First Aid for Severe Bleeding

Direct Pressure
130

Pressure on the Supplying

Artery

131

Tourniquet

The use of a tourniquet is dangerous and the tourniquet

should be used only for a severe life threatening
hemorrhage that can not be controlled by other means.

A tourniquet should not be applied over a joint or

wound, and must not be covered up by any bandage or
clothing.

132

Prevention of contamination
and
infection
Safe Guards

Do not remove or disturb the cloth pad initially placed on the wound.

Do not try to cleanse the wound, since the victim requires medical care.

Watch for signs of shock before and during transportation.

Immobilize the injured area.

Adjust the victim in a lying position so that the affected limb can be
elevated.

133

Removal of Foreign Objects

Visual inspection

Imaging with plain radiograpy

If there is something deeply embedded in the wound,

do not remove it.

Dressing the Wound

Take Infection control measure

134

sign /symptom of infection

Swelling of the affected part

Redness of the affected part.

A sensation of heat

Throbbing pain

Fever

Pus formation

Swelling of lymph nodes depending on the affected sites.

Red streaks leading from the wound (sign of spreading of

infection through the lymphatic circulation).
135

Emergency Care for Infection

Keep the victim lying down and quiet, and immobilize the entire infected
area.

Elevate the affected body part if possible.

Apply heat to the area with hot water bottle or placing warm, moist
towels or clothes over the wound.

Do not delay efforts to get medical care for the victim.

136

THANKS FOR YOUR

ATTENNTION

137

Bites
A. Human Bite

Dangerous than other animal bites b/se it is heavily contaminated

bacteria & viruses

Wash the wound thoroughly with soap and water (for 5 minutes), flush the
bitten area but do not scrub ,then dry & cover the wound

Stop bleeding by applying pressure

Refer ( for TAT, antibiotic, wound care, etc)

138

B.
Animal Bite
There is no known cure for rabies in human beings or animals once

symptoms develop.

A bite on the face or neck should receive immediate medical attention,

because of the proximity to brain.

Keep the animal under observation if possible.

139

First Aid Measures

Apply bandage 2-4 inches above the bite

Wash the wound thoroughly with soap and water (for 5 minutes), flush the bitten
area but do not scrub ,then dry & cover the wound.

Immobilize the bitten area & keep it lower than the heart.

Cold application to minimize swelling & discomfort

Refer the victim to health institution for medical attention( dressing ,TAT, Anti
rabies & antibiotic ,etc)

Some animals need to be captured, confined & observed for rabies

140

Unit IV. Dressings and Bandages

Learning Objectives:1. Define dressing and bandaging.
2. Describe the purposes of dressing and bandaging.
3. Identify the general principles of bandaging.
4. Perform different applications of bandages.
5. Describe different kinds of first aid kits and supplies.

141

Dressings and Bandages

Requirements:

Sterile, meaning that any microorganisms and spores on

the dressing have been killed

Aseptic, meaning that it is free of bacteria

Held in place with a bandage tightly enough to control

bleeding but not so tightly that it stops blood
circulation

Soft, thick, and compressible so that it

provides
even pressure over the entire
surface of the
wound.

142

Dressing

Dressings are sterile/clean/ pads or compresses used to

cover wounds.

Any of various materials used for

covering and protecting a wound
Wound dressing is process of covering
wound or applying sterile protective
covering using aseptic technique

143

Purpose of Dressings

To assist in the control of bleeding

To absorb blood and wound secretion

To relieve pain

To promote wound healing by primary intention .

To assess the healing process

To protect the wound from mechanical trauma .
To prevent contamination from bodily discharge.

144

Con,,,,

To Keep the wound moist and therefore

enhance epithelialization

To Keep the wound clean

To keep locally applied drugs in position

To keep edges of the wound together by

immobilization

Provide physical, psychological, and

aesthetic comfort

Remove necrotic tissue

Prevent, eliminate, or control infection

145

The selection of wound

dressing is based on

Location ,size and type of wound

Amount of exudates

Whether wound required

debridement

Frequency of dressing change ,easy

or difficulty.
Cost

Condition of wound bed

146

Dressing selection

Dressing selection should be simple and

promote moist wound healing

Avoid complex combinations of dressings

which may be expensive and ineffective.

Do not be taken in by expensive dressings.

Ensure that they are safe and research
based.

Wounds need to be reassessed and

dressing selection changed accordingly
147

Properties of an ideal
dressing

Bacteria proof

Allows gaseous exchange

Manages exudate

Non-adherent

toxin free

Hypoallergenic

Maintain haemostasis and optimum

temperature.

Acceptability to patient

Cost effective.

148

Types of Topical Wound

Dressings
1.transparent film.

feature of transparent dressing

Allow exchange of oxygen between wound and
environment
are self adhesive

Water proof

Prevent loss of wound fluid

facilitate autolytic debridement

149

Conn,,,

No absorption of drainage

Remain in place 24 to 72 hrs

Use /indication/

Stage I pressure sore

Minimal drainage and partial thickness wound

e.g

-bioclusive

-poly skin

-uniflex
150

2.Hydrocolloid dressing

One of the first modern dressings

Provides moist wound healing and promotes

debridement and formation of healthy granulation
tissue.

Occlusive and waterproof

Low to medium exudate wounds-limited

absorption capacity.

Caution if used on infected wounds.

May have slight odour on removal

Should not be used if you need to change more

than q 2-3 days

151

Con..
Which

is characterized by.

Limit exchange of oxygen between wound and

enviroment

Protect against contamination

May left in place 3 to 7 day

Facilitate autolytic debridement

are self adhesive

Occlusive should not be used on infected wounds

152

Con

Use /indication/

partial and fullthickness wound

Light to moderate drainage

Wound with necrosis or slough

Not used for infected wound

E.g;

duoderm

comfeel

exuderm

153

3.Hydrogles dressing

Contain high water content up to 96%

Excellent biocompatibility (also occur in contact

lenses and ECG gel)

Starch compounds (Carboxymethylcellulose) are

integrated to provide gel forming properties.

Promotes debridement of eschar and slough.

Hydrogel sheets may reduce pain.

Caution if used on infected wounds.

Requires secondary dressing

154

con,,,
Which

is characterized by.

Maintain moisten wound environment

Minimal absorption

Facilitate autolytic debridement

Do not adhere to wound

Required secondary dressing to secure.

Should be used in dry wounds

Should not be used with an absorbant dressing, e.g.

hydrocolloid, foam, etc
155

Con..

Used /indication/ for.

partial and fullthickness wound

Necrosis wound

Burn

Dry wound

Infected and minimal wound drainage

e.g
clearsite

hypergel

aquasorb

intrasite gel

156

4.Alginate dressing

their composition (calcium/sodium salts)

Which

is characterized by;

Absorb exudate

Required secondary dressing to secure

Left in place 1 to 3 day

Maintain moisten wound environment

Facilitate autolytic debridement

157

con

Some alginates have haemostatic

properties due to release of calcium ions.

Promotes debridement of slough

Highly absorbent and biodegradable can

absorb 20 times own weight. Made from
brown seaweed.

Suitable for wet or cavity wounds.

158

Con,,,,
Used

for.

Infected and non infected wound

Moist red and yellow wound

Moderate to heavy exudate

Not used for minimal drainage and dry eschar

partial and fullthickness wound

E.g

sorbsan

algicell

aquacel

159

5.Antimicrobial dressing

In wounds that are infected

Should be used for 2 weeks then review

treatment:

May be used in conjunction with antibiotics

If no improvement discontinue

If infection still present but improvement noted

continue for further 2 weeks then review

If your patient has been on antimicrobials for over

2 weeks ensure that they have been reviewed by
the qualified staff.
160

con,,,,

Which is characterized by;

Has antibacterial action

Reduced and prevent infection.

Use/indication/

Drainage,exudate and non healing wound

to protect from contamination.

For acute and chronic wound

E.g: -acticoat
- excilon
- Silver

161

6.Composite dressing
Which

is characterized by

allow

exchange of oxygen between

wound and environment

Combine

two or more physical

distinct product

Serve
Semi

physical bacterial barrier

and non adhesive

Facilitate

autolytic debridement

162

Con,,,,
Use

for

Mixed

/granulation and necrotic

wound.

Infected
e,g

wound

.-alldress
-covaderm
-stratasorb
163

Clean dressing procedure

Purpose

To keep wound clean

To prevent the wound from injury and contamination

To keep in position drugs applied locally

To keep edges of the wound together by immobilization

To apply pressure

Technique

Aseptic technique to prevent infection

Hand washing, boiling the dressing materials for 15 minutes, and dry it.

If available, ironed clothes or the inner surface of a folded cloth can be

used for immediate use.

Do not touch or breath or cough on the surface of a dressing that is to be

placed next to wound.
164

Equipmenet
Sterile dressing set
1. One kidney dish
2. Sterile gloves
3. Cotton balls in a galipot
4. Sterile gauze (44 inch) or squares
5. Sterile Dressing forceps (3)
6. Sterile Scissor
7. Sterile galipot
8. Sterile fenestrated towel (drape)
9. Spatula if ointment
165

clean tray
1. Clean glove
2. Cleaning solution (Normal Saline, Sterile 0.9% sodium chloride),
3. Adhesive tape (Plaster)
5. Rubber and draw sheet
6. Bandage scissors or surgical blade
7. Anti microbial Ointment: if prescribed
8. Bath Blanket: (if needed)
9. Screen
10. Adhesive remover
11. Protective apron: as the condition of the wound
12. Waste Receiver( disposable plastic container)
13. Chart
166

procedure
1. Check order for dressing change
2. Explain the procedure to the patient
3. Hand washing
4. Assemble the supplies at a convenient work area
5. Apply screen, close door and curtain.
6. Assist the patient to a comfortable position to expose the wound.
7. Place a rubber sheet under the patient to prevent soiling the
linen.
8. Place opened, cuffed plastic bag near working area.
9. Loosen tape on dressing. Use adhesive remover if necessarily.
If tape is soiled don gloves
167

Con,,,,
10. Wear a protective apron when caring for a patient with a
draining wound. Don non sterile gloves.
11. Gently remove and discard the old tape and soiled
dressing in a plastic trash bag.

Roll or lift an edge of the dressing, then gently remove it

while supporting the surrounding skin. When possible,
remove the dressing in the direction of hair growth.

If the dressing sticks to the wound, moisten with sterile

normal saline and then remove.

Sterile saline provides for easier removal of dressing.

Assess amount, type and odor of draining if present

168

Con..
12. Remove and discard non sterile gloves.
13. Using aseptic technique open the packed sterile
instruments, sterile dressings, the irrigation and cleaning
solution, and the instrument set to provide a sterile field,
14. Pour cleaning solution to galipot, gauze and cotton from
a drum.

169

Con.
17. Don sterile gloves.
18. Apply fenestrated towel to the wound to increase the sterile
field
19. If sample is needed, take the sample first then clean.
20. Take the second sterile forceps, and clean wound with
cotton balls soaked in antiseptic solution starting from inside
to the outside.
21. Use one gauze square for each wipe, discard each square
by dropping in to plastic bag, do not touch bag with forceps.
22. Again use the third forceps to dry wound using gauze,
sponge and same motion by another new forceps then
discard.
170

Con,,,,
23. Apply medication if any and dress the wound with sterile gauze with
sterile another dressing forceps

Ointment and paste must be smeared with spatula on gauze and then applied
on the wound.

Solutions or powder can be applied direct on the wound.

24. Make sure that the wound is properly covered

25. Fix dressing in place using adhesive tape or bandage.
26. Remove fenestrated towel, rubber and draw sheet.
27. Remove gloves from inside out, and discard them in plastic waste bag.
28. Provide patient comfort measures.
29. Clean and return equipment to proper place.
30. Wash your hands
31. Document the procedure
171

BANDAGES

A bandage is a strip of woven material used to hold a wound dressing or

splint in place

It helps to immobilize, support and protect an injured part of the body

Bandages and dressings are both used

in wound management.
A bandage is a piece of cloth or other

material used to bind or wrap a diseased

or injured part of the body.
172

PURPOSE OF BANDAGES

Hold a dressing in place

Apply direct pressure over a dressing

Prevent or reduce swelling

Provide stability for an extremity

Creates pressure that controls bleeding

Helps keep the edges of the wound closed

Secures a splint to an injured part of the body

Provides support for an injured part of the body

173

Kinds of Bandages

1. Gauze bandages

2. Elastic bandage

3. Triangular bandages (94 X 94 X 133 Cm)

4. A binder of muslin (many tailed

bandage)

5. Formed from handkerchiefs, household

linen, belts, ties, socks or stockings

6. Combinations of dressing and bandages

7. Special pads

174

Parts of a Bandage
Bandages

have 3 parts

Absorbent

Pad

Gauze
Tape
All

three are needed for an

effective bandage
175

type of bandage

A .Triangular Bandages

Support fractures and dislocations

Apply splints

Form slings

Make improvised tourniquets

Can be used as a cold compress or for padding

when they are made into a pad.

When folded up they can be used to provide

support or pressure.

When unfolded they can be used as a support sling

or cover bandage.

176

con..
Cravat- A folded triangular

bandage
B.Roller gauze bandage- A
form-fitting bandage designed to
be wrapped around a wound site
C .Elastic bandage,can be
hazards if applied too
tightly,which stimulate circulation
177

Bandages promote healing by

Controlling bleeding and aiding hemostasis

Absorbing seepage; protects the wound from

infection and drying

Decreasing the possibility of self trauma & selfinflicted injury

Decreasing swelling and edema (pooling of fluid

under the wound)

Decreasing seroma or hematoma formation

Seroma: An accumulation of lymphatic fluid under

178
an incision

Hematoma: a localized swelling filled with blood

Signs of improper bandage

Bandages must be applied carefully and

must be fit to the wound.

Signs of improper bandage fit and/or

problems include:
1) swelling above or below bandage
2) redness or discoloration of skin near
bandage
3) odor
4) moisture
5) excessive chewing or licking
6) cool skin around the bandage

179

SIGNS THAT THE BANDAGE IS TOO TIGHT

Blue tinge to the fingernail/toenail

Blue or pale skin colour

Tingling or loss of sensation

Coldness of the extremity

Inability to move the fingers/toes

The victim complains of pain, usually only a few

minutes after you apply the bandage.

Capillary refill is absent or diminished in the

fingernails or toenails beyond the bandage

You cannot feel the pulse beyond the bandage

(distal), or it is very weak

180

Rules of Bandaging

Bandages must be changed every day or two

The wound must be kept clean and dry between

changes

Swelling above or below the bandage means it is on too

tight.

If your pet suddenly starts licking or chewing the

bandage, or if theres a bad smell, remove the bandage
immediately to be sure there is not an infection or
other problem.

-Yes, smell the bandage daily

Bandages are a short term solution until treatment from
a vet is available.
- If a bandage is needed, most likely a specialist
will need to be seen

181

methods of wrapping bandages

1 . Spiral Bandage

Used to apply an elastic bandage to an arm or leg

2 .Spiral Reverse Bandage

Used to wrap an extremity that has vary

thickness.

Provides a means to secure, smooth, even-fitting

bandage on extremity.
3 .Recurrent Bandage

Applied to hold pressure dressings in place over

the tip end of a finger, toe, fist or on the head.

182

con
4. Figure-8 Bandage

Used whenever a joint is included in wrapping.

It protects dressings and keeps them in place,

supports and limits the movement of the joint and
promotes the venous blood return, which reduces
swelling or edema.

5. Arm Sling

Patients who have an injury to the arm or shoulder

often need to support the arm in an elevated
position to avoid edema of the hand, pain,
183
discomfort, and fatigue.

How to do an arm sling

Put one end of the triangle over the shoulder on the

uninjured side.

Place the point(apex) of the triangle toward the elbow.

Bring the other end over the injures arm and shoulder.

Tie the two ends with a square knot.

Fold the apex of the triangle neatly over the elbow

toward the front.

Check the circulation in the fingers frequently.

184

Principles of Dressing and

Bandaging

The dressing is opened carefully and handled so it

does not get contaminated.

The dressing adequately covers the entire wound.

Bandages are not placed directly against the

wound.

Wounds are bandaged snugly, but not too tightly.

Bandages are not too loose; neither the dressing

nor the bandage should shift or slip.

There are no loose ends of cloth, gauze, or tape

that could get caught.

Loosen bandages immediately if the victim

complains of numbness or tingling sensation

185

CON

Tips of the fingers and toes are left exposed when

arms and legs are bandaged.

A small bandage on an arm or leg is covered with a

larger bandage to more evenly distribute the
pressure and to avoid causing a pressure point.

Start a bandage on an arm or leg at the end

nearest the hand or foot,
then work upward to
prevent applying the bandage too tightly.

The body part is bandaged in the position in which

it is to remain.

Ask the victim how the bandage feels.

Never use a circular bandage around the neck.

186

Methods of applying bandages

A.

Arm slings

187

Triangular Bandage Folded as a Cravat ( If it is

folded into a strip)

188

Triangular Bandage for the

Scalp and Fore Head

189

Cravat Bandage for

Forehead, Ears or Eyes

190

Cravat Bandage for Cheek

or Ear

191

Anchoring a bandage

192

Tying of a Bandage

Circular Turn

193

Figure of Eight Bandage for

Hand and Wrist

194

Finger Tip Bandage

195

Figure of Eight for the Ankle Joint

196

First Aid Kits and Supplies

There are two general types of first aid kits
1. The unit type
2. The two cabin type
Unit - Type Kit
It has a complete assortment of first aid materials, put up in standard packages of
unit size or multiples of the unit size and arranged in case, containing 16,24 or
32 units with the 16 and 24 unit kits being the most popular.

197

First Aid Kits and Supplies ---2. Cabinet -Type Kits

They are made for a wide variety of uses and range in size from pocket
versions to large industrial kits.

They are made to accept packages in different shapes and sizes.

198

possible contents for first aid kit

Bandage any type

Alcohol

Activated charcoal or syrup ipecac

Painkiller

Emergency drug
like,,adrenaline,hydralazine,hydrocortisone,ASA

Scissors

sugar or Glucose solution

Decongestant tablate or spray

Cotton ball or swab

Face shiled
199

quiz 1
1.Bandage enhance wound healing by Decreasing the
possibility of self trauma & self-inflicted injury on wound.
2.Among the following type of dressing one is best
recommended for burn due to its non adherent quality on
wound?
A.hydrocolloid dressing

B.alginate dressing

C.hydrogel dressing

D.composite dressing

3.One is odd regarding with the ideal property of dressing.

A.bacteria proof

B.toxin free

C.non adherent

D.induce allergic formation

4.Write down at least 3 purpose of dressing?

5.Mention at least 4 contents of first aid kit?

200

Unit V. Specific injuries

Learning Objectives
1.

Describe eye injuries, its sign and symptoms and first aid measures.

2. Give first aid for scalp and brain injuries.

3. Provide first aid measures for face and jaw injuries.
4. Apply first aid management of ear and nose injuries.
5. Explain precautionary measures for neck injuries and open wounds of the
abdomen.

201

Eye Signs
Injuries
and Symptoms

Redness of the eye

Burning sensation

Pain

Headache

Over production of tears

Swelling

Wound

Presence of foreign body

202

Lacerated/torn eyelids

Cover the injured eye with dressing

DO NOT put pressure on the wound because you may

injure the eyeball.

Handle torn eyelids very carefully to prevent further

injury.

203

Lacerated eyeball (injury to

Cover the
injury with a loose sterile dressing.
the
globe)

DO NOT put pressure on the eyeball because additional damage may occur. The
eyeball contains fluid. Pressure applied over the eye will force the fluid out,
resulting in permanent injury.

An important point to remember is that when one eyeball is injured, you should
immobilize both eyes with bandages.

204

Penetrating Injuries of the

DoEye
not try to remove the object or to wash the eye.

Cover both eyes loosely with a sterile or clean dressing to limit eye movement

Keep and transport the victim by stretcher.

Take the victim to emergency room of hospital to get quick medical attention.

205

Extruded eyeballs

Gently cover the extruded eye with a loose moistened dressing and also
cover the unaffected eye.

Do not bind or exert pressure on the injured eye while applying the
dressing.

Keep the casualty quiet, place him on his back, treat for shock, and
evacuate him immediately.

206

Burns of the eyes

A. Chemical burns
Mainly acids or alkalies cause chemical burns

If the burn is an acid burn, you should flush the eye for at least 5 to 10
minutes.

If the burn is an alkali burn, you should flush the eye for at least 20
minutes.

After the eye has been flushed apply bandage & evacuate the casualty
immediately.

207

B. Thermal burns
DO NOT apply a dressing.
DO NOT touch.
SEEK medical assistance immediately.

208

C. Light burns

Exposure to intense light can burn an individual. Infrared rays, eclipse

light (if the casualty has looked directly at the sun), or laser burns cause
injuries of the exposed eyeball.

Ultraviolet rays from arc welding can cause a superficial burn to the
surface of the eye.

These injuries are generally not painful but may cause permanent damage
to the eyes.

Immediate first aid is usually not required.

209

Scalp Injuries
First Aid measures

Do not try to clean scalp wounds.

Control bleeding by raising the victims head and shoulder; do not bend the
neck (fracture may be present)

Place a sterile dressing on the wound.

Apply a bandage to hold the dressing in place and to provide pressure.

210

Brain Injury
Signs and Symptoms

Clear or blood tinged

cerebrospinal fluid

draining from the nose or ears following skull fracture.

Temporary loss of consciousness.

Partial or complete paralysis of muscle of extremities of the opposite side

and facial paralysis on the same side of brain injury.

Disturbance of speech.

Local or generalized convulsions.

211

Brain Injury: Signs and

Symptoms --Bleeding from the nose, ear canal or mouth which is
indicative of skull fracture

Pale or flushed face

Fast and weak pulse

Head ache and dizziness

Vomiting

Unequal size of pupils

Loss of bowel and bladder control

212

First
Aid
for
Suspected
Brain
Injury
C

all for ambulance, and obtain medical assistance as quickly as possible--ABC

Keep the victim lying down and treat for shock

Give particular attention to insure an open air way

Control hemorrhage

Do not give fluid by mouth to the victim (keep NPO)

Apply dressing and bandage over the skull if wound is present

Record the level of consciousness

213

Face and Jaw Injury

First Aid Measures

Call for ambulance and seek immediate medical assistance. ABC

Maintain open air way.

Provide continues support to the head to prevent air way obstruction.

If the victim is conscious help to lean foreword to drain secretion from

mouth and cough up.

Give artificial respiration if necessary.

Treat for shock.

Apply protective dressing as necessary

214

Ear Injuries
Perforation of the Eardrum
First Aid Measures

Put a small gauze or cotton loosely in the outer ear canal for protection.

Obtain medical care.

Do not insert instrument or any kind of liquid in to the ear canal.

N.B. Perforation of ear drum associated with skull fracture requires special
attention

Don't clean the ear

Don't stop the flow of cerebrospinal fluid from the ear

Turn the victim on to his injured side (unless there is some reason not to
do so) to allow fluid to drain away

215

Nose Injuries and Nose Bleeds

First Aid Measures

Keep the victim quiet.

Keep the victim in sitting position.

Apply direct pressure to the bleeding nostril by pinching.

Apply cold compress to nose and face of the victim.

If bleeding does not stop, insert a small clean pad of gauze into one or
both nostrils and apply pressure externally with thumb and index finger.

If it does not stop, obtain medical assistance.

Make sure that nasal bone fractures, like all other fractures, have medical
attention.

216

Neck Injuries

Apply mouth to mouth or mouth to nose artificial respiration.

Obtain immediate medical assistance in case emergency tracheostomy is

needed.

Place the victim at rest on his back (supine position) to relax the
abdominal muscles.

Control bleeding.

Give first aid for shock.

217

Open Wounds of the Abdomen

First Aid Measures

Don't try to replace protruding intestines or abdominal organs but cover with
sterile dressings

Hold the dressing in place with a firm bandage, but don't tighten the bandage

Don't give food or fluid because surgery may be necessary

Keep the victims head and shoulders elevated to avoid breathing difficulty

Seek medical attention as rapidly as possible and take extreme care to gently
transport the victim

218

DEBRE BIRHAN
UNIVERSITY

institute of medicine and

health science
First aid and Accident prevention for
nursing Students
Compiled by wondimeneh219.s/BSC N/

Unit VI. Shock

Learning objectives
1. Define shock.
2. List different causes of shock.
3.Describe different types of shock
4. Mention the main signs and symptoms of shock
5. Describe the first aid measures for shock

220

Brain storming

1.what does mean shock and hypotension?

2.mention sub type of shock?

3.list some complication of shock?

4 .Describe clinical feature of hypovolemic shock?

221

Definition
Shock:

is a life threatening condition

resulting from an imbalance
between the oxygen supply and
demand ,and is characterized by
hypoxia and inadequate cellular
function that leads to organ failure
and
potentially
death(kleinpell,2007)

Cont

Shock can best be defined as a physiologic state in which systemic

blood pressure is inadequate to deliver oxygen and nutrients to
support vital organs and cellular function (Mikhail, 1999)

the state of profound depression of the vital processes associated

with reduced blood volume and pressure and caused usually by
severe esp. crushing injuries, hemorrhage, or burns.

Oxygen delivery <oxygen consumption.

Failure to remove metabolic end product

Cont
Inadequate tissue perfusion can result in:

generalized

cellular hypoxia

(starvation)
widespread

impairment of cellular

metabolism
tissue
death

damage leads to organ failure

Cont

High mortality - 20-90% (Epidemiologically)

Early on the effects of O2 deprivation on the cell are REVERSIBLE

Early intervention reduces mortality

Inadequte systemic o2 delivey activate autonomic response and Renin

angiotensin axis.

Con

Cellular response to decrease systemic o2

delivery

ATP depletion

hydrolysis of cell membrane

cellular edema

cellular death.

226

Circulatory Control
Mechanisms

Closest, fastest

Carotid Bodies (Baroreceptors)

Mid-level

Kidneys- Juxtaglomerular Apparatus

Stimulate Sympathetic Nervous System

Sense low flow and stimulate Renin resulting in

vasoconstriction (splancnic)

Down-line

Adrenal Cortex

227
Senses need for more Sodium and Fluid Reabsorbtion to deal with upright posture volume
needs

Approach to a patient in
shock

ABC

Cardio respiratory monitor

Pulse oximetery

Supplemental o2

Iv access

ABG ,lab

Vital signs

Foley catheter

History $ p.examination
228

Diagnosis of Shock

MAP
Clinical

< 60

s/s of
hypoperfusion of
vital organs

Cont

.m,../.

Cont

All Types of shock eventually result in

impaired tissue perfusion & the

development of acute circulatory failure
or shock syndrome.
DDX: Hypotension
:Hyperglycemic coma

Failure of Compensatory Response

Decreased blood flow to the tissues causes cellular hypoxia
Anaerobic metabolism begins
Cell swelling, mitochondrial disruption, and eventual cell death
If Low Perfusion States persists:
IRREVERSIBLE

DEATH IMMINENT!!

Developmental cascades
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death

Net results of cellular shock:

systemic lactic acidosis

decreased myocardial contractility
decreased vascular tone
decrease blood pressure, preload, and
cardiac output

Stages of Shock
Initial

stage (Insult)- tissues are under perfused, decreased CO,

increased anaerobic metabolism, lactic acid is building ---> Abdominal
tenderness & girth.
Compensatory stage (preshock) - Reversible.
SNS activated by low CO, attempting to compensate for the decrease tissue perfusion.
MAP is maintained, HR increased, extremities cool due to vasoconistriction.

Cont

Progressive stage (shock) - Failing compensatory mechanisms: profound

vasoconstriction from the SNS
ISCHEMIA Lactic acid production is high
metabolic acidosis. MAP is reduced, tachycardia, Dyspnea & restless.

Irreversible or refractory stage - Cellular necrosis and Multiple Organ Dysfunction

Syndrome may occur(Liver f., DIC, the patient does not respond to treatment
and cannot survive.
DEATH IS IMMINENT!!!!

Sign and symptoms of generalized Shock

Altered

Level of consciousness

b restless,
b

irritable, apprehensive

unresponsive, painful stimuli only

Initially

may show few symptoms

Continuum

starts with

Anxiety
Agitation
Confusion

and Delirium
Obtundation and Coma

Changes with V/s- objective findings

Pulse

Tachycardia

HR > 100 - What are a few

exceptions?
Rapid,

weak, thready distal pulses

Respirations

Tachypnea

: blow off CO2 --->Respiratory

alkalosis
Shallow, irregular, labored

Cont

Blood Pressure

May

be normal!
Definition of hypotension
Systolic < 90 mmHg
MAP < 65 mmHg
40 mmHg drop systolic BP from
from baseline

Cont

Skin

Cold,

clammy (Cardiogenic,
Obstructive, Hemorrhagic)
Warm (Distributive shock)
Look for petechia

Dry Mucous membranes

Low urine output <0.5 ml/kg/hr

Sign of shock

241

Cont
Hemodynamic Changes Correlate with volume loss

Low CO

Decreased preload

Increased SVR (Afterload)

Empiric Criteria for Shock

4 out of 6 criteria have to be met

Ill appearance or altered mental status

Heart rate >100

Respiratory rate > 22 (or PaCO2 < 32 mmHg)

Urine output < 0.5 ml/kg/hr

Arterial hypotension > 20 minutes duration

Lactate > 4

244

Types of Shock
Hypovolemic
blood

VOLUME problem

Cardiogenic
blood

Shock

Shock

PUMP problem

Distributive

Shock

[septic;anaphylactic;neurogenic]

blood

VESSEL problem

1. Hypovolemic shock
Decreased intra vascular volume
Can be hemorrhagic $ non-hemorrhagic
ETIOLOGY/Risk factors:

Fluid loss: Dehydration

Nausea

& vomiting, diarrhea,

massive diuresis, extensive burns

Blood loss:

trauma: blunt and penetrating

BLOOD YOU SEE-internal hemorrhage

BLOOD YOU DONT SEE-External hmg.

Risk Factors for Hypovolemic Shock

External: Fluid Losses

Trauma

Surgery

Vomiting

Diarrhea

Diuresis

Diabetes insipidus

Internal: Fluid Shifts

Hemorrhage

Burns

Ascites

Peritonitis

247

Con,,,

Hypovolemic shock, the most common type of shock, is

characterized by a decreased intravascular volume.
Body fluid is contained in the intracellular and
extracellular compartments.

Intracellular fluid accounts for about two thirds of the

total body water.

The extracellular body fluid is found in one of two

compartments:intravascular (inside blood vessels) or
interstitial (surrounding tissues).

248

Acute Volume Loss

Shock

- Classes:

0-15%

blood loss

II

15-30% blood loss

III 30-40% blood loss

IV

>40%

blood loss

249

Con,,,

Major goals in treating hypovolemic

shock are to ;

(1) restore intravascular volume to reverse the sequence of

events leading to inadequate tissue perfusion,
(2) redistribute fluid volume, and
(3) correct the underlying cause of the fluid loss as quickly
as possible.

250

treatment of hypovolemic shock

Large bore access

1l NS iv bolus run for 15 minute

2 upper extremity IVs

16 gauge or larger

Bolus therapy

20 cc/kg

Adults- 2 liters

Monitor Effect

Repeat if necessary

After 2nd bolus: need blood txn

10cc/kg
251

Trendelenburg position

252

End Points of Resuscitation:

Restoration

of normal vital signs

Adequate Urine output
0.5

- 1.0 cc/kg/hr

Tissue

Oxygenation measurement
Adequate Cardiac Index
Normalization of Oxygen delivery DO 2I
Normal Serum Lactate levels
none proven helpful, some deleterious
253

2.Cardiogenic Shock
The

impaired ability of the

heart to pump blood

Pump

failure of the right

or left ventricle

Most

common cause is LV
MI (Anterior)

Occurs

when > 40% of

ventricular mass damage

Mortality

rate of 80 % or >

Con,,,,

Etiologies/risk factors/

AMI

Sepsis

Myocarditis

Myocardial contusion

Aortic or mitral stenosis

Acute aortic insufficiency

255

pathopysiology
Decreased cardiac contractility

.
Decreasedstroke
stroke
Decreased
volumeand
and
volume
cardiacoutput
output
cardiac

Pulmonary
congestion

Decreased
systemic
tissue perfusion

Decreased
coronary artery
perfusion

256

Con

The causes of cardiogenic shock are known as either

coronary or noncoronary.

Coronary cardiogenic shock is more common than

noncoronary cardiogenic shock and is seen most often in
patients with myocardial infarction.

Coronary cardiogenic shock occurs when a significant

amount of the left ventricular myocardium has been
destroyed

257

Con,,,

SIGNS

Cool,mottled skin.

Tachypnea

Hypotention

Altered mental status

Narowed pulse pressure

rale and murmur

258

Con,,,

First-line treatment of cardiogenic shock involves the

following actions:

Supplying supplemental oxygen

Controlling chest pain

Providing selected fluid support

Administering vasoactive medications

Controlling heart rate with medication or by

implementation of a transthoracic or intravenous pacemaker

Implementing mechanical cardiac support (intra-aortic

balloon counterpulsation therapy, ventricular assist systems,
or extracorporeal cardiopulmonary bypass)
259

con,,

Oxygen by nasal cannula

IV access

Pain medication

Nitrates prn

may need unloading only after volume status

addressed

Treat arrythmias

CPR as needed

260

con,,,
AMI
Aspirin, beta blocker, morphine, heparin
If no pulmonary edema, IV fluid challenge
If pulmonary edema
Dopamine will HR and thus cardiac work
Dobutamine May drop blood pressure
Combination therapy may be more effective

thrombolytics

RV infarct
Fluids and Dobutamine (no NTG)

Acute mitral regurgitation or VSD

Pressors (Dobutamine and Nitroprusside)
261

Con..

The goals of intra-aortic balloon counter pulsation

include the following:

Increased stroke volume

Improved coronary artery perfusion

Decreased preload

Decreased cardiac workload

Decreased myocardial oxygen demand

262

3. Distributive Shock
Circulatory

or distributive shock occurs when blood

volume is abnormally displaced in the vasculature
for example, when blood volume pools in peripheral
blood vessels.

The

displacement of blood volume causes a relative

hypovolemia because not enough blood returns to the
heart, which leads to subsequent inadequate tissue
perfusion.

Cont
Intravascular

volume is maldistributed
because of alterations in blood vessels
Cardiac pump & blood volume are
normal but blood is not reaching the
tissues.

MAP =

CO (HR x SV) x SVR

Etiologies/Risk factors
Loss

of Vessel tone could be

Inflammatory
Sepsis

cascade

and Toxic Shock Syndrome

Anaphylaxis

Post

resuscitation syndrome
following cardiac arrest

Decreased

sympathetic nervous system function

Neurogenic

- (spine or upper thoracic cord injuries)

Toxins
Due

to cellular poisons -Carbon monoxide, methemo -globinemia, cyanide

Drug

overdose (a1 antagonists)

Types of Vasogenic
/Distributive Shock

Etiologies

Anaphylactic
Neurogenic
Septic

Shock

Shock

Shock (Most Common)

3.1 Anaphylactic Shock

Anaphylaxis:-asevere systemic hypresensitive rxn

charactezied by multisystem involevement.
IgE MEDIATED

A type of distributive shock that results from widespread

systemic allergic reaction to an antigen

This

hypersensitive reaction is LIFE THREATENING

Cont
Antigen
body

exposure

stimulated to produce IgE antibodies specific

to antigen

drugs, bites, blood, foods, vaccines,,etc

Re

exposure to antigen

IgE binds to mast cells and basophils

Anaphylactic

response

con..

Anaphylaxis occurs in an individual after

reexposure to an antigen to which that person has
produced a specific IgE antibody. The antigen to
which one produces an IgE antibody response that
leads to an allergic reaction is called an allergen.

The IgE antibodies produced may recognize

various epitopes of the allergen.These IgE
antibodies then bind to the high-affinity IgE
receptor (FceRI) on the surface of mast cells and
basophils.

269

Con

Anaphylactic shock is caused by a severe

allergic reaction when apatient who has
already produced antibodies to a foreign
substance (antigen) develops a systemic
antigenantibody reaction.This process
requires that the patient has previously
been exposed to the substance

An antigenantibody reaction provokes

mast cells to release potent vasoactive
substances, such as histamine or
bradykinin, that cause widespread
vasodilation and capillary permeability.

270

Anaphylactic Response
Vasodilatation
Increased

vascular permeability

Bronchoconstriction
Increased

mucus production

Increased

inflammatory mediators recruitment to sites of

antigen interaction

symptom:-first
Next;throt
Finaly;

:prurit,flushing,urticaria appear

fullness,anxitey chest tight ness,dyspnea.

altred mental status , respiatory distress and

circulatory collapse

Clinical Presentation Anaphylactic Shock

Almost

immediate response to inciting

antigen
Cutaneous
urticaria,

manifestations

erythema, pruritis, angioedema

Respiratory

compromise

stridor, wheezing,

Circulatory

resp. distress

collapse

tachycardia,

vasodilation, hypotension

mild to moderate allergic

reaction:

Swelling of face, lips and eyes

Hives or welts on the skin

Tingling mouth

Stomach pain, vomiting (these are signs of

a mild to moderate allergic reaction to
most allergens,however, in insect allergy
these are signs of anaphylaxis).

273

severe allergic reaction

Difficult/noisy breathing

Swelling of tongue

Swelling/tightness in throat

Difficulty talking and/or hoarse voice

Wheeze or persistent cough

Loss of consciousness and/or collapse

Pale and floppy (in young children)

274

Treatment protocol.

Abc,of life

normal saline IV; volume expanders (colloid solution) for

severe hypotension

oxygen 6-8l/m

Pulse oximetry

Epinephrine

Corticosteroid

H1andH2 bloker

Bronchodilator

For insect allergy, flick out the sting if it can be seen (but do
not remove ticks)
275

con,,,

Epinephrine* (adrenaline) 1:1000 aqueous solution

lifesaving: first and most important drug to give!

Administer 0.01 mL/kg (maximum 0.5 mL per injection)

intramuscularly (IM) if there is no response add after 5
minutes.

Diphenhydramine (benadryl) (50 mg/mL) Secondary

drug to administer in addition to epinephrine to treat
symptoms such as pruritus,erythema, urticaria.
Remember: never give diphenhydramine alone or before
epinephrine.
276

con,,

ranitidine, 50 mg in adults and 12.5 - 50 mg (1 mg/kg) in children,

D/W, total 20 ml, inject slowly IV, over 5 minutes
(cimetidine 4 mg/kg OK for adults, )

for bronchospasm
- nebulized albuterol (salbutamol) 2.5 - 5 mg in 3 ml normal saline

for refractory hypotension

- dopamine, 400 mg in 500 ml normal saline IV 2 - 20 g/kg/min

- glucagon, 1- 5 mg (20 - 30 g/kg, max 1 mg in children), IV over 5
minutes followed with continuous IV infusion 5-15 g/min
-methylprednisolone, 1- 2 mg/kg per 24 hr
277

dilute in 5%

con,,
Corticosteroids

Methylprednisolone 125 mg IV

Prednisone 60 mg PO

Antihistamines

H1 blocker- Diphenhydramine 25-50 mg IV

H2 blocker- Ranitidine 50 mg IV

Bronchodilators

Albuterol nebulizer

Atrovent nebulizer

Magnesium sulfate 2 g IV over 20 minutes

Glucagon

For patients taking beta blockers and with refractory hypotension

1 mg IV q5 minutes until hypotension resolves

278

management for radio contrast media

prednisone 20-50 mg orally 12,7, and 1 hours before

administration of RCM

diphenhydramine 50 mg orally/intramuscularly 1 hour

prior to RCM

ephedrine 25 mg orally 1 hour before RCM administered

279

Factors affecting prognosis

Factor

Poor
Prognosis

Onset of symptoms

Good
Prognosis

Early

Late

Initiation of treatment

Late

Route of exposure

Injection

-adrenergic blocker use

Presence of underlying disease

Early

Yes

Oral*
No

Yes

No

* true for drugs, not foods

280

3.2 Neurogenic shock

Cervical

spinal cord injury can interrupt the normal

control of the Autonomic Nervous System (blocks
sympathetic nerves).

Blood

vessels dilate, the size of the vascular system

increases, and blood can not fill the enlarged system

Classic

Picture:

Warm, flushed, dry skin, Low blood pressure,

Normal or slow (bradycardia) heart rate

Con
In

neurogenic shock, vasodilation

occurs as a result of a loss of
sympathetic tone. This can be
caused by spinal cord injury, spinal
anesthesia, or nervous system
damage. It can also result from the
depressant action of medications or
lack of glucose (eg, insulin reaction
or shock).
282

Spinal Shock vs Neurogenic Shock

Spinal Shock
*Due to acute spinal cord
injury
*Absence all voluntary
and reflex neurologic
activity below level of
injury

Decreased reflexes
Loss of sensation
Flaccid paralysis below
injury

Lasts days to months

(Transient)
*Spinal shock &
neurogenic shock can in
same patient-BUT not
same disorder (some sources

Neurogenic Shock*

*Hemodynamic phenomenon

*Critical features

Hypotension (due to massive vasodilation

Bradycardia- due to unopposed paraynmpathetic

stimulation

Poikilothermia; *Unable to regulate temperature-

Occurs

* Loss of vasomotor tone & Loss of sympathetic

nervous system tone > inpaired cellular
metabolism

Within 30 min cord injury level T 5 or above; last up to 6

weeks; also due to effect some drugs that effect
vasomotor center of medulla as opioids, benzodiazedines

Management (*Determine underlying cause)

Airway support

Fluids as needed- Typically 0.9 NS , rate depends upon

need

Atropine for bradycardia

Vasopressors as phenylelphrine (Neo-synephrine) for

BP support

may group both together)

283

Clinical finding of Neurogenic

shock

Hypotension
Bradycardia
Hyprethermia
Warm, dry skin
dry, warm skin rather than the cool, moist
skin seen in hypovolemic shock

first aid management

A,B,Cs
Remember c-spine precautions

Fluid resuscitation
Keep MAP at 85-90 mm Hg for first 7 days
Thought to minimize secondary cord injury
If crystalloid is insufficient use vasopressors

Search for other causes of hypotension

For bradycardia
Atropine
Pacemaker
285

Initial Management

Immobilization

Rigid collar

Sandbags and straps

Spine board

Log-roll to turn

Prevent hypotension

Pressors: Dopamine, not Neosynephrine

Fluids to replace losses; do not overhydrate

Maintain oxygenation

O2 per nasal canula

If intubation is needed, do NOT move the neck

286

Management in the hospital

NGT to suction

Foley

Prevents aspiration
Decompresses the abdomen (paralytic ileus is common in
the first days)
Urinary retention is common

Methylprednisolone (Solu-Medrol)

Only if started within 8 hours of injury

Exclusion criteria

Cauda equina syndrome

Pregnancy

Age <13 years

Patient on maintenance steroids

287

Soft and hard collars

288

3.3 SEPTIC SHOCK

Sepsis:

systemic response to infection manifested by 2

of:
Temp

> 38oC or < 36oC

HR > 90 bpm
RR > 20 bpm or PaCO2 < 32 mmHg
WBC > 12 x 109/L, < 4 x 109/L or >10% band form

Septic

shock: sepsis with hypotension (SBP < 90 or >

40 reduction from baseline) despite adequate fluid
resuscitation, with perfusion abnormalities that
could include, but are not limited to, lactic
acidosis, oliguria, and/or acute mental status.
289

Con,,
After

bolus of 20-40ml/kg patient

still has one of the following

SBP<90mmhg
MAP<65mmhg
Decrease

of 40 mmhg from baseline

290

Diagnostic feature

291

292

293

294

295

296

risk factor of Septic Shock

Immunosuppression

Extremes of age (<1 yr and >65 yr)

Malnourishment

Chronic illness

Invasive procedures

Traumatic
Drug

wounds

Therapy
297

298

Organ dysfunction at time of

severe sepsis recognition

299

Con,,

Nosocomial infections (infections occurring in the

hospital) in critically ill patients most frequently
originate in the bloodstream,lungs, and urinary tract (in
decreasing order of frequency)

The source of infection is an important determinant of

the clinical outcome. The greatest risk of sepsis occurs
in patients with bacteremia (bloodstream) and
pneumonia

The most common causative microorganisms of septic

shock are the gram-negative bacteria;

300

Con,,,,

Septic shock typically occurs in two phases. The first phase,

referred to as the hyperdynamic, progressive phase, is

characterized by a high cardiac output with systemic
vasodilation. The blood pressure may remain within normal
limits. The heart rate increases, progressing to tachycardia.
The patient becomes hyperthermic and febrile, with warm,
flushed skin and bounding pulses.

The respiratory rate is elevated. Urinary output may remain

at normal levels or decrease. Gastrointestinal status may be
compromised as evidenced by nausea, vomiting, diarrhea, or
decreased bowel sounds. The patient may exhibit subtle
changes in mental status, such as confusion or agitation.

301

Con,,,

The later phase, referred to as the hypodynamic,

irreversible phase, is characterized by

low cardiac output with vasoconstriction,

reflecting the bodys effort to compensate for the

hypovolemia caused by the loss of intravascular volume
through the capillaries.

In this phase, the blood pressure drops and the skin is

cool and pale.

Temperature may be normal or below normal. Heart and

respiratory rates remain rapid.

302

Molecular architecture of the IR to sepsis

Bacterial factors
Cell wall components
Extracellular products
Effector mechanisms
Lymphokine storm
Chemokine activation
Neutrophil migration
Vascular inflammation

Host factors
Acquired immunity
Innate immunity
Genetic susceptibility

303

Con,,,

Clinical signs

hyperthermia o hypothermia

tachycardia

wide pulse pressure

low bp (SBP<90)
mental status change

Be aware of compensated shock

blood pressure may be normal

304

Some Characteristics of
Septic Shock
Systemic vasodilation and hypotension
Tachycardia; depressed contractility
Vascular leakage and edema; hypovolemia
Compromised nutrient blood flow to organs
Disseminated intravascular coagulation
Abnormal blood gases and acidosis
Respiratory distress and multiple organ failure
305

Treatment of Sepsis
Antibiotics- Survival correlates with how
quickly the correct drug was given
Cover gram positive and gram negative
bacteria
ceftriaxone 1 gram IV or
Imipenem 1 gram IV

Add additional coverage as indicated

Pseudomonas- Gentamicin or Cefepime
MRSA- Vancomycin
Intra-abdominal or head/neck anaerobic infectionsClindamycin or Metronidazole
Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae
Neutropenic Cefepime or Imipenem
306

con,,,

2 large bore IVs

NS IVF bolus- 1-2 L wide open (if no contraindications)

Supplemental oxygen

Empiric antibiotics, based on suspected source, as soon

as possible

307

308

309

non antibiotic therapy for

sepsis/Current controversies/
Low

dose steroids ? / Not

confirmed

Intensive

insulin therapy ? / Not

confirmed safety concerns

Activated

protein C Licensed but

? requires confirmation

Goal

directed therapy ?/ Requires

confirmation
310

Overall Management
Strategies in Shock

Fluid replacement to restore

intravascular volume

Vasoactive medications to restore

vasomotor tone and improve cardiac
function

Nutritional support to address the

metabolic requirements that are often
dramatically increased in shock

311

Multiple Organ Dysfunction

Syndrome

Multiple organ dysfunction syndrome

(MODS) is altered organ function in an
acutely ill patient that requires medical
intervention to support continued organ
function.

Primary MODS is the result of direct tissue

insult, which then leads to impaired
perfusion or ischemia.

Secondary MODS is most often a

complication of septic shock or SIRS.
312

Clinical feature

an initial event that results in low blood pressure.

respiratory compromise

Hyperglycemia

Hyperlacticacidemia

The metabolic rate is 1.5 to 2 times basal metabolic

rate.

irreversible organ failure

death occur.

313

Complications of shock
1. Shock lung (ARDS)
2. Acute renal failure
3. Gastrointestinal ulceration
4. Disseminated intravascular clotting (DIC)
5. Multi-organ failure
6. Death
Shock-Treatment
1.Positioning
2. Maintain body temperature
3. Administer fluid if the pt is conscious
314

first aid measure

Maintain verbal contact- calm the affected person,

ensure quiet

Prevent loss of blood

Reduce pain by treatment, but dont give the affected

person pain pills

Keep the affected person warm- danger of growing cold

Dont give drinks to the affected person- only moisten

lips and wipe the face

Lay the affected person in anti-shock or autotransfusion position (in case of massive bleeding)

Call for medical aid as quickly as possible

315

Shock- First Aid Measures--Regulating Body Temperature

Keep the victim warm enough to avoid or over come
chilling.
Administering Fluids
Give fluids by mouth if there is no medical help near by.
NB. tsp salt + 2-3 tsp sugar or honey + some orange or
lemon juice in a litter of water.

316

Shock- First Aid Measures--Don't give fluid by mouth if:

Victim is unconscious

Victim is vomiting or about to vomit and having a convulsion

When a victim likely to have surgery or anesthetic or have

brain or abdominal injury

Discontinue fluids if the victim becomes nauseated or

vomits

WARNING

If you must leave the casualty, turn his/her

head to the side to prevent choking, if
vomiting occurs.
317

318

UNIT FIVE

FRACTURES
SPRAINS &
DISLOCATIONS
319

Learning objectives
1.

Define fracture , dislocation, sprain, & strain

2.

Demonstrate first aid management for dislocation

3.

Apply first aid management for sprain & strain

4.

Apply first aid management for fracture

320

fracture.

Trauma or injury has been defined as

damage to the body caused by an
exchange with environmental energy that
is beyond the body's resilience.* Trauma
remains the most common cause of death
for all individuals between the ages of 1
and 44 years and is the third most
common cause of death regardless of age.

In general, more energy is transferred

over a wider area during blunt trauma
than from a gunshot wound (GSW) or stab
wound (SW).

321

fracture

A fracture is a break in the continuity of

bone and is defined according to its type
and extent. Fractures occur when the
bone is subjected to stress greater than it
can absorb.
Fractures are caused
by direct blows, crushing forces, sudden
twisting motions, and even extreme
muscle contractions.
322

Con,,

When the bone is broken, adjacent

structures are also affected, resulting in
soft tissue edema,hemorrhage into the
muscles and joints, joint dislocations,
ruptured tendons, severed nerves, and
damaged blood vessels.

Body organs may be injured by the force

that caused the fracture or by the
fracture fragments.
323

Con

A contusion ;is a soft tissue injury

produced by blunt force, such as a blow,
kick, or fall. Many small blood vessels
rupture and

Bleed into soft tissues (ecchymosis, or

bruising). A hematoma develops when the
bleeding is sufficient to cause an
appreciable collection of blood.

Local symptoms (pain, swelling, and

discoloration) are controlled with
intermittent application of cold. Most
contusions resolve in 1 to 2 weeks.

324

Joints
Dislocation
What is Dislocation?

Is the total displacement of the articular end of a bone from the

joint cavity.
Subluxation : Is an incomplete displacement.
Reduction : Is the restoration of the normal alignment of the
bones.
Classification:
Dislocations are classified
as follows:
A. Congenital
B. Traumatic
C. Pathological
D. Paralytic
325

What is sprain?

The bones at a joint are held together by tough bands

called ligaments.
A sprain is an injury to a ligament
1st degree stretched
2nd degree partially torn
3rd degree completely torn
Most common are the fingers, wrist, ankle, and knee

326

Con,

A dislocation of a joint; is a condition in

which the articular surfaces of the bones
forming the joint are no longer in
anatomic contact.

Bursitis and tendinitis are inflammatory

conditions that commonly occur in the
shoulder. Bursae are fluid-filled sacs that
prevent friction between joint structures
during joint activity. When inflamed, they
are painful.
327

Fracture---A strain
Is

a "muscle pull" due to overuse, overstretching or

excessive stress.

Strains

are microscopic, incomplete muscle tears with

some bleeding in to the tissue

The

patient experience sudden pain with local

tenderness during muscles use.

Strains

are injuries to muscle resulting from over

stretching.

328

Con..

A sprain is an injury to the ligaments

surrounding a joint that is caused by a
wrenching or twisting motion. The
function of aligament is to maintain
stability while permitting mobility.

Atorn ligament loses its stabilizing ability.

Blood vessels rupture and edema occurs;
the joint is tender, and movement of the
joint becomes painful.
329

Causes of fracture

Direct injury--- accident

Indirect injury--- Osteoporosis

Muscular contraction

330

CAUSES OF FRACTURES

Automobile accidents major cause

Motor

adults

cycle injury common in young

Fall from height

Sports injury
Trivial injury fall at home
Machine injuries
Repetitive stress (stress fracture)
Gun shot injuries
Pathological problems of bone
Metabolic bone diseases

331

Fracture Types
1/ Traumatic
Closed fracture: A closed fracture is one where the fracture hematoma
does not communicate with the outside

Open fracture: This is one where the fracture hematoma communicates

with the outside through an open wound.

Stress fracture :
It is a fracture occurring at a site in the bone subject to
repeated minor stresses over a period of time.
Birth fracture:
It is a fracture in the new born children
due to injury during delivery.
332

cal
i
g
o
l
o
2/Path
It is a fracture occurring after a trivial violence in a bone
weakened by some pathological lesion. This lesion may
be :

- Localized disorder
(e.g. secondary malignant deposit)
- Generalized disorder
(e.g. osteoporosis).

333

Fracture Types
According to the Path of the # Line
Transverse Fracture
A fracture in which the # line
is perpendicular to the long
axis of the bone .

Oblique Fracture
A fracture in which the # line is at
oblique angle to the long axis of
the bone.

334

Fracture Types
According to the Path of the # Line
Spiral Fracture
A severe form of oblique fracture
in which the # plane rotates
along the long axis of the bone.
These #s occur secondary to
rotational force.

Longitudinal Fracture
A fracture in which the # line runs
nearly parallel to the long axis of
the bone. A longitudinal fracture
can be considered a long oblique
fracture.

335

Fractures

Anatomical classification of
fractures
Stellate fracture:
Comminuted # :
The bone is broken into than
two fragments.

This # occurs in the flat bones of

the skull and in the patella, where
the fracture lines run in various
directions from one point.

336

Fracture Types
Anatomical classification of fractures
Impacted fracture:
This # where a vertical force
drives the distal fragment of
the fracture into the proximal
fragment.

Depressed fracture:
This # occurs in the skull
where a segment of bone gets
depressed into the cranium.

337

Fracture Types
Anatomical classification of
Avulsion fracture:
fractures
This is one, where a chip of bone is avulsed by the sudden and
unexpected contraction of a powerful muscle from its point of
insertion,
Examples
1. The supra spinatus muscle avulsing the
greater tuberosity of the humerus.
2. Avulsion fracture of the tibial tuberosity

338

TYPES OF FRACTURES ACCORDING TO REGION

INVOLVED

Metaphyseal

fractures

Diaphyseal

fractures

Epiphyseal

or intra-articular

fractures
339

Specific classification of
fracture

A complete fracture involves a break

across the entire cross-section of the
bone and is frequently displaced
(removed from normalposition).

incomplete fracture (eg, greenstick

fracture), the break occurs through only
part of the cross-section of the bone.

340

Compression: a fracture in which bone has been

compressed (seen in vertebral fractures)

Depressed: a fracture in which fragments are driven

inward (seen frequently in fractures of skull and facial
bones)

Epiphyseal: a fracture through the epiphysis

Greenstick: a fracture in which one side of a bone is

broken and the other side is bent

341

Impacted: a fracture in which a bone fragment is

driven into another bone fragment

Oblique: a fracture occurring at an angle across the

bone (less stable than a transverse fracture)

Pathologic: a fracture that occurs through an area of

diseased bone (eg, osteoporosis, bone cyst, Pagets
disease, bony metastasis, tumor); can occur without
trauma or a fall

342

Open fractures

Open fractures are graded according to

the following criteria:

Grade I is a clean wound less than 1 cm

long.

Grade II is a larger wound without

extensive soft tissue damage.

Grade III is highly contaminated, has

extensive soft tissue damage, and is the
most severe.
343

FRACTURE HEALING
Fracture healing is considered as a series of phases which
occur in sequence as follows:
(I) Inflammatory Phase.
(A) Stage or hematoma formation.
(B) Stage of granulation tissue.(more fibrin
to the hematoma and increase blood flow

(II) Reparative Phase.

(A) Stage of fibro cartilaginous callus.

(B) Stage of bony callus (woven bone
become calcified)).

(III) Remodeling Phase.

Excess material inside bone shaft is
replaced by more compact bone

344

Sign & symptoms of fracture

Deformity, swelling, pain, Loss of power

Unnatural movement,
Protruding bone (do not attempt to put
back)
Bleeding, or discoloration

Crepitus - A grinding or cracking sound as

you move the affected area (usually
accompanied by extreme pain)

Irregularity

Shortening of bone

345

Factors That Inhibit Fracture Healing

Extensive local trauma

Bone loss
Inadequate immobilization
Space or tissue between bone fragments

Infection

Local malignancy

Metabolic bone disease (eg, Pagets disease)

Irradiated bone (radiation necrosis)

vascular necrosis

Intra-articular fracture (synovial fluid contains fibrolysins,which lyse the

initial clot and retard clot formation)

Age (elderly persons heal more slowly)

Corticosteroids (inhibit the repair rate)

346

Factors That Enhance Fracture Healing

Immobilization of fracture fragments

Maximum bone fragment contact

Sufficient blood supply

Proper nutrition

Exercise: weight bearing for long bones

Hormones: growth hormone, thyroid, calcitonin,

vitamin D,

anabolic steroids

Electric potential across fracture

347

Fracture-Treatment

DR-ABC , make the victim comfortable

Stop bleeding

Treat for shock

Treat for fracture

- Reassure the casualty
- Prevent any movement
- Immobilize the part (Splinting)
- Assess paleness, cold skin, numbness, tightness and
tingling sensation
- Give support( cold compress, elevate the part)
-Transportation
348

Con,,

Initial fluid resuscitation is a 1-L

intravenous (IV) bolus of normal saline,
Ringer's lactate, or other isotonic
crystalloid in an adult, or 20 mL/kg
Ringer's lactate in a child.

This is repeated one time in an adult and

twice in a child prior to administering red
blood cells (RBC). The goal of fluid
resuscitation is to re-establish tissue
perfusion.

349

Con,,,
PRICE
p= Protect the injured limb from further injury
R=Rest the injured limb/immobilize/
I=Ice the area(Applying a cold pack to decrease swelling)
C= Compress the area with bandage
E= Elevate the part above the heart
RICE ( Fracture)
R= Rest
I =Immobilize
C= Cold
E= Elevate

350

Con,,,,,

The principles of fracture treatment

include reduction, immobilization,and
regaining of normal function and strength
through rehabilitation.

Reduction of a fracture (setting the

bone) refers to restoration ofthe fracture
fragments to anatomic alignment and
rotation. Either closed reduction or open
reduction may be used to reduce a
fracture.
351

Con,,,

IMMOBILIZATION After the fracture has been reduced,

the bone fragments must be immobilized, or held in
correct position and alignment,

Traction (skin or skeletal) may be used to effect

fracture reduction and immobilization.

Fixation.

Swelling is controlled by elevating the injured

extremity and applying ice as prescribed.

Open fractures internal fixation is not indicated

Open fractures are mostly treated by the external

fixation
352

First aid measures at district level

hospital

Support to the injured extremity by backslab or

traction/ collar and cuff sling for upper limb or back
slab for the tibia or knee fractures

Analgesics and i.v fluids

Open fractures with bleeding require blood transfusions

Anti-tatanus toxoid treatment

Prophylactic i/v antibiotics

Careful and gentle shifting of pateint is required

353

Four ways of open fracture treatment

OPEN

FRACTURE IS THE ORTHOPAEDIC

EMERGENY

Life

preservation
Limb preservation
Infection avoidance
Functional preservation

354

Principles of Management:
Aims :

(A)- safe life

(B)-save the limb

(C)-save the

function
1. Efficient First Aid: This relieves the pain and prevents
complications.
2. Safe transport: This help to minimize complications in injures to the spine,
fracture of the lower limbs, ribs etc (all fractures should be immobilized
immediately ) .
3. Assessment of condition of the patients for shock & other injuries.
4. Assessment of local condition of the injured limb regarding
complications like vascular injury, nerve involvement and injury to
neighboring joints .

5. Resuscitation. If needed
Radiography
X-ray before plaster
AP & LAT( to determine site and degree of
6.
of the part

7.

displacement)
Post Reduction films ( wet plaster) for insurance of good alignment
Follow up films to assess healing
Films Before removal of plaster to confirm complete healing

Reduction of the fracture(correction

displacement of fragments and done by :

closed Manipulation
open reduction

of

355

Principles of Management:
8.

Immobilization of the fragments.

External fixation
Cast (plaster)
Internal fixation
Screws
Plates
intramedullary nails and rod
wires & pins

356

9. Early physiotherapy : for the preservation of function of the limb (local

complication such as ischemia ,nerve damage ,joint stiffness ,infection ..etc may
endanger the function of the limb.
10. Rehabilitation : After union of the fracture to restore full muscle power and
joint movements and to make the patient fit for his original job.
NOTE:

Fractures are treated by reduction (realignment) &immediate

immobilization
In most cases, simple fractures heal completely in approximately 6 - 8
weeks
Compound # better to deal with it within6hrs of injury to avoid
infection
The accurate diagnosis of the fracture (site ,lines and displacement )
is made from X- ray examination.
Tow projections is required AP or PA +lateral or oblique
Tow joints above and below the site of the # should be included in
the radiographs
Tow limbs radiographs for comparison of value in children.
357

Fractures treated by plaster cast

or traction followed by plaster
cast

Femoral fractures in children

Undisplaced or minimally displaced fractures

Undisplaced intra-articular fractures

Patients who are not medically fit

Fracture of tarsal or metatarsal bone with less

displacement

Fractures of the metacarpal bones less displaced

358

Open fractures external fixation

359

Complication of fracture

Complications of fractures fall into two categoriesearly and

delayed.

Early complications

include

Shock,

Fat Embolism,

Compartment Syndrome,

Deep Vein Thrombosis,

Thromboembolism (Pulmonary Embolism)

Disseminated Intravascular Coagulopathy (DIC),

Infection (Osteomyelitis)

360

Delayed complications

include

Delayed Union

Nonunion,

Avascular Necrosis of Bone,

Reaction to Internal Fixation Devices,

Complex Regional Pain Syndrome (formerly called

Reflex Sympathetic Dystrophy) characterized by include
severe burning pain, local edema, hyperesthesia,
stiffness, discoloration,

vasomotor skin changes,

Heterotrophic Ossification.
361

the end

THANK
YOU

362

DEBRE BIRHAN
UNIVERSITY

institute of medicine and

health science
First aid and Accident prevention for
nursing Students
compiled by;wondimeneh .s(BSC N)
363

UNIT VIII. Poisoning

Learning Objectives
1. Describe poisoning
2. Identify different causes of poisoning
3. State different poisonous substances around home environment
4. Explain signs and symptoms of poisoning
5. Mention first aid measures for different types of poisoning

364

BRAIN STORMING QUESTION

1. Define poisoning
2. What do you think the different causes of
poisoning?
3. List different types of poisoning.
4. What are the most common poisoning
substances around your area?
5. Explain signs and symptoms of poisoning.
6. Describe first aid measures for different
types of poisoning.
365

Poisoning

A poison is any substance solid, liquid or gas that tends to impair health or
cause death when introduced in to the body or on to the skin surface.

Is any such thing which after coming in to contact or entering the body is
capable of causing harm leads to death

It can be accidental or intentional

The poisoning could occur due to diverse

causes and could be classified as

accidental,
homicidal or
suicidal.

366

Erroneous administration of over dosage of

drugs by the parents or by the medical staff is
also frequent considered as poisoning.

Organophosphates are highly poisonous agricultural insecticides that are

harmful when absorbed through the skin, by inhalation, or by swallowing.

Acute exposure is a single contact that lasts for

seconds, minutes or hours, or several exposures over
about a day or less.

Chronic exposure is contact that lasts for many days,

months or years

367

poisoning could be
result of ,,

Chemical products, most often swallowed by

children include household cleaners (bleach,
detergents) fuel (kerosene, paraffin),
cosmetics, medicines, paints and products for
household repairs and household pesticides.

Bites and stings of animals and insects, and

ingestion of poisonous plants and seeds also
considerably account for outdoor poisoning in
children.

Carbon monoxide poisoning can happen when fires, stoves,

heaters or ovens are used in rooms, huts which do not have
proper ventilation to let the gas out.
368

Risk Factors for Poisoning

Unsupervised home setting

Childs less than 5 years old
Lower level of education
Substance abuse
Depressed adolescents
Adolescent females
369

BASED OF ITS NATURE

1 man-made; such as chemicals and drugsand are found in the home as well as in
industry.
may be dangerous if taken in excessive
amounts.
2. natural ; example, plants produce
poisons that may irritate the skin or cause
more serious symptoms if ingested, and
various insects and creatures produce
venom in their bites and stings.
370

Causes of Poisoning

Aspirin overdose especially in children.

Poisons transferred from original containers to other containers or soft

drink bottles.

Carelessness of the parents in leaving dangerous substance and medicines

within reach of children.

Lack of supervision of children.

Improper storage and disposal of poisonous substances.

371

Causes of Poisoning--

Improper handling of spray equipment including the mixing of pesticides,

insecticides and weed killers.

Inhalation or swallowing of poisonous substance.

Carelessness in taking a poison from the medicine cabinet.

Over doses of drugs taken either accidentally or with suicidal intent

Combining some drugs and alcohol

372

con..

Chemical agents that cause toxicity

include:

Drugs

Insecticides/herbicides

Plant toxins, Animal toxins

Chemical weapons,

Radioactive elements
373

Important causes of child

poisoning

Kerosene and other hydro carbons(8-55%)

Household products-insecticides,
rodenticides, phenol, alkalis, turpentine,
naphthalene, neem oil, alcohol(14-30%).
Drugs- iron salts, barbiturates,
anticonvulsants, antihypertensives, aspirin,
antiseptics(16-30%).
Plant and plant products- Dhatura, castor
seeds(6-32%).
Food poisoning(7-15%).
Venomous bites & stings(7-11%).
374

Classification of poisons
Based on the chief symptoms they produce
1.

Corrosives- strong acids, strong alkalis,

metallic salts.

2.

Irritants- organic, inorganic.

Systemic- cerebral, spinal, peripheral,
CVS, asphyxiants.
Miscellaneous- food poisoning &
botulism.

3.
4.

375

Household poisons are listed below

Cosmetics and hair preparations

Gasoline, kerosene and other petroleum products.

Paint and turpentine , Strong detergents

Bleaches , Cleaning solutions

Acids , Ammonia , Glue ,Poisonous plants

Non edible mushrooms , DDT ,Dry cell

Malathin, etc.

376

Severity and reversebility:

Depend on

Concentration (dose)

Contact time

The potency of the chemical

Type and condition of the exposed surface

Functional reserve of the individual/affected tissue

Presence of secondary complications

Coexisting illness

377

Types and ways in which

poisoning may occur

Through the mouth (by ingestion-solid & fluids)

Through the skin (by absorption-sting,contact)

Through the lung (by inhalation-gases,toxic fumes)

By injection

378

Signs and Symptoms of

Poisoning
Symptoms of poisoning vary greatly
Nausea, vomiting, lose motions,
stomach ache
Burns around the lips , mouth & throat.
Deep sleep, fits, unconsciousness, &
giddiness
Stains mouth, Breath odor
379

Cont
Presence

of poison container
Pinpoint pupil
Information from the victim or from an observer.
Conditions of the victim (sudden onset of pain or
illness).

Signals of food poisoning include:

Nausea.

Vomiting.

Abdominal pain.

Diarrhea.

Fever.

Dehydration .
380

Diagnosis of Poisoning

To evaluate the diagnosis:

-history

-physical examination

-routine/toxicology lab evaluaton

Cardiac arrythmias. Tricyclic antidepressants,
amphetamine, aluminium phosphide, digitalis,
theophylline, arsenic, cyanide, chloroquin.
Metabolic acidosis. Isoniazid, methanol,
salicylates, phenformin, iron, cyanide.
GIT disturbances. Organophosphorus, arsenic,
iron, lithium, mercury.
Cyanosis. Nitrobenzene compounds, aniline 381
dyes, and dapsone.

Con,,,,

Often, the scene itself is the best clue that a

poisoning may have occurred. Factors to notice
include

Unusual odors.

Flames or smoke.

An open medicine cabinet.

Open or spilled containers.

Overturned or damaged plants.

Drug paraphernalia or empty containers

382

con

History:

-Time, route and duration of exposure

Name/amount of each drug/chemical

Time of onset of the symptoms

Nature /severity of symptoms

Post medical and psychiatric history

383

Poisoning severity
Grades
The

severity of a poisoning depends on

The type and amount of poison.

How and where the poison entered the body.

The time elapsed since the poisoning.

The victims size, weight, medical condition and age

None(0)-

no symptoms or signs/vague symptoms judged

not to be related to poisoning.
Minor(1)- Mild, transient & spontaneously resolving
symptoms.

Moderate(2)- pronounced or prolonged symptoms.

Severe(3)- severe or life threatening symptoms.

384

KEROSENE POISONING

Reasons for high incidence

1.

Extensive use for cooking & lighting in low socioeconomic status

2.

Stored in soft drink bottles, beer bottles within reach of children

SYMPTOMS
RS breathlessness, cough
CNS convulsions, coma
, restlessness
GI

vomiting, diarrhea
385

Management

Avoid emetics

Avoid gastric lavage In case of massive amount use a cuffed

endotracheal tube

Oxygen may be useful

Assisted Ventilation

Antibiotics - Penicillin G 50000/Kg/24 hrs IV qid

Complications

Pneumothorax

Pleural effusion

Bronchopneumonia $ Coma
386

Organophosphorus (insecticides
and pesticides) Poisoning

Organic phosphate insecticides cause irreversible

inhibition of the enzyme cholinesterase. As result
acetylcholine accumulates in various tissues.
Excessive parasympathetic activity occurs. These
agents are absorbed by all routes including skin and
mucosa.

Symptoms manifest quickly usually

within a few hours and include
weakness, blurred vision, headache,
giddiness, nausea, and pain in chest.
387

Con,,,
These

patients have excessive

secretion in the lungs and they
sweat profusely.

Salivation is marked. Pupils are

constricted and papilledema may
occur. Muscle twitching, convulsions
and coma occur in severe cases.
Reflexes are absent and sphincter
control is lost.
388

Treatment

If the insecticide was in contact with skin or

eyes, these are thoroughly washed. Stomach
wash is done.

Atropine sulphate: 0.03 to 0.04 mg/kg IV

(atropine sulphate is usually available in
ampules 1 in 1,000 or 1 mg/mL). Other
strengths may also be available. Repeat half the
dose in 15 minutes and if necessary every hour
(until signs of toxicity disappear), subject to a
maximum of 1 mg/kg in 24 hours.

Pralidoxime (PAM) is given in dose of 25-50

mg/kg IM or IV over 30 min infusion. The dose
may be repeated in 1-2 hours, then at 6-12 hour
389
intervals as needed

Salicylate Poisoning

Ingestion of 150 mg/kg of salicylates

causes intoxication. Salicylate level of
50-80 mg/dL causes moderate
symptoms. Severe symptoms are
associated with blood levels above 80
mg/dL.
Initially, there is a respiratory alkalosis,
because of hyperventilation induced by
sensitization of the respiratory center
by salicylates. Kidneys compensate for
this alkalsis by increasing the excretion
of sodium and potassium bicarbonate
390

managment

Urine is alkalinized by administering 1-2 mEq/kg of

sodium bicarbonate at half hourly intervals for 4 hours
to promote excretion of urine, because in alkaline
urine, salicylates do not diffuse back into the tubular
cells from the lumen. Potassium salts should be given
(3-5 mEq/kg/day) to replace the potassium losses.

IV fluids +/- vasopressors

Avoid intubation if at all possible ( acidosis)

Supplemental glucose (100 mL of 50 percent dextrose in

adults) to patients with altered mental status regardless
of serum glucose concentration to overcome
neuroglycopaenia

Hemodialysis
391

Acetaminophen
(paracetamol)

Toxicity is likely with single ingestions greater than 250 mg/kg

or those greater than 12 g over a 24-hour period

The risk of toxicity is best predicted by relating the time of

ingestion to the serum paracetamol concentration

Massive hepatic necrosis due to poisoning by acetaminophen

result in hepatic encephalopaty and death 48-72 hours or
longer ingestion.

It is safe in pharmacological doses. Overdosage may cause

hepatic damage. Acetaminophen overdosage is treated with
acetylcysteine to be used orally/iv 150mg/Kg over 15 min;
50mg/Kg over next 4 hrs; 100mg/kg over next 16 hrs up to
36hrs

Beyond 8 hours, NAC efficacy progressively decreases

392

Hydrocarbon Poisoning

These may be divided into aliphatic or aromatic

compounds. Aliphatic hydrocarbons include kerosene,
turpentine, lubricating oils, tar and have greatest risk
of aspiration and pulmonary symptoms.

Aromatic compounds have mainly neurological and

hepatic toxicity and include benzene compounds.

Halogenated hydrocarbons are

used as solvents and spot
removers.
Freon

is used as a refrigerant.
393

Con,,,

Benzene derivates, toluene and xylene are

components of various solvents and degreasers.
These are highly volatile but have low viscosity.
Inhalation is the primary route of toxicity which
manifests with CNS symptoms. Gasoline and
naphtha are constituents of lighter fuel and
lacquer diluent and primarily cause depression of
the central nervous system (CNS).

Toxic exposure to hydrocarbons may result in

cardia, gastrointestinal, neurological, pulmonary,
renal, hepatic, metabolic and hematological
manifestations.
394

Carbon Monoxide
Poisoning

Carbon monoxide poisoning results from inhalation

of fire smoke, automobile exhaust, fumes from
faulty gas stoves and ingestion of paint and varnish
removers. Clinical manifestations include
headache, cyanosis, convulsions, and coma.

CO gas is colorless, odorless, tasteless, and

nonirritating, which makes it especially
dangerous.

Patients are administered 100 percent oxygen and

if carboxyhemoglobin levels are above 40 percent,
hyperbaric oxygen therapy is considered.

Pale or bluish skin color indicates lack of oxygen,

which may indicate exposure.
395

Lead Poisoning

Exposure to lead occurs from old lead based

deteriorated house paint (in old houses) and dust and
soil contaminated with lead such as from leaded
gasoline, lead electrode plates from old automobile
batteries, adultered food, folk remedies, broken lead
typesets scattered around old printing
establishments. Food may be adulterated with
colored metallic salts or the black collyrium used as
surma may contain a proportion of black oxide of
lead.

396

Con,,,

Chronic lead intoxication occurs usually

in children who eat non-edible
substances (pica) and manifests as pain
in abdomena and resistant anemia. Lead
is deposited in the bones. Acute
infections may mobilize lead from
storage areas in bones and cause acute
lead poisoning leading to acute lead
encephalopathy.
397

Treatment

In symptomatic children, therapy is

usually started with dimercapol (BAL)
(75 mg/m2 every 4 hourly IM). calcium
disodium edetate is used for another 3
days but at a lower dosage of 50 mg/kg
or 1000 mg/M2 per 24 hours by
continuous IV infusion. Stop BAL when
blood lead level falls below 60
microgram/dL
398

Barbiturate Poisoning

Clinical features include hypoxia,

depression of respiration, pulmonary
complications and kidney failure.
Peripheral vascular bed is dilated; shock
which may sometimes be delayed may
occur

399

Treatment

Hypoxia is managed by oxygen inhalation

and maintenance of open air way.
Circulatory collapse is treated with fluids
and plasma. Patients do not respond to
epinephrine.

Urine is alkalinized to facilitate excretion

of barbiturates. Mannitol is given. This
causes osmotic diuresis. In severe cases
peritoneal dialysis may be
necessary to remove barbiturates.
400

Alcohol Poisoning

Clinical features of acute alcohol poisoning include:

Ataxia and anaesthesia leading to accidental injury

Dysarthria and nystagmus

Drowsiness which may progress to coma

Inhalation of vomit which can be fatal & should be

prevented

Hypoglycaemia in children and some adults

401

management

Ethyl alcohol 0.75-1 mL/kg is given IV followed by

0.5 mL/kg every 4 hours. 3 mL of 7.5% sodium
bicarbonate solution diluted 1 in 4 is given IV.
Dialysis should be done

The airway and circulation must be maintained

But glucose- containing fluids may precipitate

Wernicke's encephalopathy

Thiamine should given to all

Intravenous naloxone has reversed coma in a

proportion of cases

402

CYANIDE POISONING

Common chemical

Rapidly acting

No direct effect in blood

WHERE IS CYANIDE FOUND

Occurs naturally in foods (some fruits, lima beans)

and in cassava plant
Cyanide salts used in industry
(eg. NaCn,KCn)

Produced in smoke of burning plastics/synthetics

Metal polishing
Smells like bitter almonds
403

WHAT IS THE CELLULAR

MECHANISM OF CYANIDE
POISONING

Inhibits cellular respiration

Cytochrome

a-a3

Tissues cannot utilize oxygen

Arterialization of venous blood

Dont have direct effect on o2 binding

enzyme like hemoglobin

404

TREATMENT

Amyl nitrite perle until IV established

Sodium Nitrite (300mg IV)
Sodium Thiosulfate (12.5gm IV)

Remove from source

Oxygen

Cyanide antidote kit

405

con,,,,,

Sodium nitrite 2.5 to 5 mL of 3.5 percent solution is

given IV every minute followed by sodium thiosulfate
2.5 mL of 25 percent solution every minute subject to
a maximum of 50 mL. Amylnitrite capsules (10mg/kg)
may be inhaled.

Opium (Morphine) Poisoning

Respiratory depression occurs and pupils
are constricted; patients are excessively
drowsy. Treatment:-Stomach wash is
done. Specific antidote for opium
poisoning is naloxone given IV in a dose
of 0.03 mg/kg/dose.
406

Injected Poisons

Injected poisons enter the body through the bites or

stings of certain insects, spiders and scorpions, ticks,
marine life, animals and snakes or as drugs or
misused medications injected with a hypodermic
needle.

Insect and animal bites and stings are the most

common sources of injected poisons.

407

Care for Poisoning

General guidelines of care for any poisoning

emergency:

Check the scene.

Check for life-threatening conditions. Call 9-1-1 or the

local emergency number if the victim is unconscious or
is having trouble breathing.

If the victim is conscious, ask questions.

What type of poison did the victim ingest, inhale, inject or

come into contact with?

How much poison did the victim ingest, inhale, inject or

come into contact with?

When did the poisoning take place (approximate time)?

408

Initial resuscitation
stabilization
ABC

Symptomatic & supportive

Management

-Hemodynamic support- Cardiac dysrrhythmias

ConvulsionsManagement of hypothermiaManagement of pulmonary edema- administer 100%

oxygen, intermittent positive pressure ventilation,
IV aminophylline(5-8mg/kg), IV frusemide(1-2
mg/kg).
409

Principles of Management

Keep

the phone numbers emergency medical

system .
Removal of the patient from the site of
poisoning.
Initial resuscitation and stabilization.
Symptomatic and supportive measures.
Removal of unabsorbed poisons- from GI tract
or from skin, eye.
Hastening the elimination of absorbed poisons.
Use of specific antidote if available
Disposition of the patient with advice for
prevention.
410

con

I)Supportive care:

-Airway protection

-Oxygenation/ventilation

-Hemodynamic support

-Treatment of seizures

-Correction of temperature abnormalities

-Prevention of secondary complications

411

con

All symptomatic patients should have:

-IV line

O2 supplemetation

Cardiac monitoring

Baseline laboratory

Continous observation

412

II) Prevention of further

poison absorbtion

Vomitting:

-Spontaneously

-Sirop d ipeca

-Apomorphine (!!! CNS depression)

-Salt

Vomitting is contraindicated:

Caustic, corosive toxins

Petrollium distillation products

Coma, seizures (Aspiration)

413

con
Gastric lavage:
In trandelenburg and left lateral decubitis position to prevent
aspiration
It should be performed in first 4 hour (can be delayed to 6 hour
in salicylates)

It can be performed later if the poison taken after meals

Gastric lavage is contraindicated:

-corosive poisons (acid, alkaline)

-striknine

-petrol distillation products

414
*It is too late for gastric lavage in a comatose patient; if wanted
should be entubated

gastric lavage

415

con..
Activated charcoal:
-by mouth or by a stomach tube before and after gastric lavage
-as an adsorban for:
alcohol-atropin-morphin-opium
arsenic-barbiturate-nicotin-penicilin
salicylates

Whole bowel irrigation:

Bowel cleansing solution (electrolytes and

polyethyleneglicol).

It may be of particularly benefit in patients with foreign

body, drug packed and slow release medication injections
416

con
Dilution:

Ingestion of corrosive (acid-alkaline)

Water or other clean liquid

Endoscopic or surgical removal:

Ingestion of a potentially toxic foreign body that

fails to transit the GI tractus (potentially lethal
amount of a heavy metal-arsenic,iron, Hg,
thallium)

Ingestion of packets of drugs (cocaine)

417

III.Enhancement of poison
elimination
A) Multiple dose activated charcoal
A dose of 1 g/kg for every 2 to 4 hour (with sorbitol as needed to enhance
GI motility

B) Force diuresis and alteration of urinary pH

-For the poisons that are excreted by the kidney
(excreted by glomerular filtration and active tubular secretion)
-Renal reabsorbtion of poison is prevented
-Mannitol (20%-250 ml-IV)
*Contraindications:Congestive heart failure, renal failure
418

con..

-Alkaline

diuresis (pH>7.5):

Na HCO3 / Na lactate added in fluid.

salicylates, phenobarbital, chlorpropamide

-Acide diuresis

**(not used because of significant risks)

(amphetamines, cocain, quinidine)

*Acid-base balance, Fluid and electrolyte parameters
should be carefully monitored
419

con
C) Extracorporal removel

-Dialysis
-Peritoneal dialysis
-Haemodialysis
-Haemoperfusion
-Exchange transfusion

420

con

Dialisable molecule:

-Low molecular weight

-High water solubility

-Low protein binding

-small volume of distribution

-prolonged elimination (long half life)

-high dialysis clearence

421

con

Dialysis is preferred:

-in anuric cases

The metabolites of the poison is more toxic

(Methanol - Formic acid)

-ethanol, methanol, salicylate, lithium, heavy metals,bromide, etc.

Exchange transfusion:

- Less effective, but it may be used when other

procedures are not effective or are contraindicated
-removes poison affecting red blood cells
(methemoglobinemia)
422

Neutralisation
-Adsorbsion
Active carbon
-Neutralisation of the acids
Milk of magnesia
Na HCO3
CaCO3
Ca(OH)2

-Neutralisation of alkaline
Asetic acid
Lemon juice
Orange juice
*Milk, olive oil,white of the egg and starch protect the mucosa and delay the
absorbtion of the poison

423

Specific Antidotal Therapy

The antidotes may be physiological, chemical or

physical.

Chemical antidotes combine with the poison and

render it innocuous.

Physiological antidotes counteract the effects of

the poison on the metabolism and physiological
functions of the body and thus prevent its harmful
effects.

Physical antidotes prevent the contact of the

poisonous substance with the target organ or adsorb
the toxic components, thus preventing their toxicity.
424

Treatment of Poisoning by
Mouth
For Conscious victims

Give enough water to drink.

Keep pt warm

Induce vomiting(by Luke warm salty water)

Do not induce vomiting if the poison is unconscious, or takes petrol/

kerosene ,strong acid & alkali Instead, give milk with egg whites or a
mixture of flour and water.

Water or milk--- universal antidotes

Activated Charcoal 1gm/kg (if available)

425

Con,,,
Gut

decontamination. This includes (i) gastric

evacuation; (ii) adsorbent administration; and
(iii) catharsis. Emesis is the preferred method
of emptying the stomach in conscious
children. Vomiting can be induced by (a)
tickling the fauces with a finger, feather or a
leafy twig of a tree; (b) administration of
copious draughts of warm water; (c) gurgling
with non-detergent soap; or (d) saline emetics
in warm water. To prevent aspiration in small
children, the head should be kept low.
426

Con,,

Syrup of ipecac

Induction of vomiting is contraindicatied in

corrosive or kerosene poisoning and in comatose
patients or those with absent gag reflex .

Activated charcoal is the most widely used adsorbent

Dose of activated charcoal administered should

be at least 10 times the dose of ingested toxic
material

administration of activated charcoal should be

within 1-2 hours of ingestion

427

Catharsis

Laxative and purgatives may be given in

poisoning with substances which do not
cause corrosive action on gastrointestinal
mucosa. Increased motility of the gut may
reduce absorption. Commonly used
cathartics include sorbitol and mannitol
(1-2 g/kg), and magnesium or sodium
sulfate (200-300 mg/kg). Do not give
magnesium salt cathartics in cases with
renal failure
428

Treatment of Poisoning by
Mouth---

For Unconscious Victim

Call/shout for help

Maintain ABC

Keep samples (bottles , box, cup , etc)

Dont give fluids and dont induce vomiting

If the victim is vomiting, position him and turn the head so that the vomits
drains out of the mouth Recovery position

429

RX-Contact with Poisonous

Maintain ABC
-Remove contaminated clothing.

Wash all exposed areas thoroughly with soap and water for at least 5 minutes
followed by running alcohol.

Apply calamine or other soothing skin lotion if the rash is mild.

If poisoning is from a pesticide, a corrosive substance (strong acid or alkali),

send for ambulance immediately.

Keep the victims air way open, give artificial respiration if indicated

Do not leave the victim alone.

430

RX-Poisoning Through
Inhalation
Move the patient in to fresh air to help get rid of the gas in his lungs.

Give mouth-to-mouth respiration and cardiac massage if necessary.

Take care that his breath does not contaminate your breathing, by turning
your mouth away from the victims mouth between breathes.

431

RX- Poisoning Through

Injection (Snake Bites)

Calm the victim

Apply a firm but not tight cord just above the bite . This must be removed
within 15 minutes or when you have the medical assistance.

Wipe the wound of venom which may have spilled from the fang at the time
of biting.

432

Prevention

Parental education

Keep away from reach of children

Properly capped containers

Avoid storage in beverage bottles or colorful containers

which attract children

Immediately seek medical care

Use poison symbols to identify dangerous substances.

Use chemicals only in well-ventilated areas.

Wear proper clothing.

Dispose of outdated medications and household

products
433

Preventing childhood
poisoning

Education is the major component of any poison

prevention programme.

Keep medicines, insecticides, etc out of the reach

and sight of your children.

Never store food & cleaning products together. Store

medicine and chemicals in original containers.

Use childproof safety caps on containers of medications

and other potentially dangerous substances.

Use special latches and clamps to keep children from

opening cabinets.

434

435

436

Sudden illness &

Unconsciousness
Learning objectives
1. Define heart attack , stroke , convulsion & epilepsy
1. Identify clinical pictures of stroke
2. Describe first aid measures for stroke
3. Describe first aid measures for convulsion

437

438

Sudden illness

439

Types of Sudden Illnesses

1. Fainting
2. Diabetic emergency
3. Seizures
4. Stroke
5. Poisoning
6. Heart attack
7. Shock
440

Fainting
One of the most common sudden
illnesses
Definition-partial or complete loss of
consciousness.
Cause-temporary reduction of blood flow
to the brain due to
1. stressful event
2.disturbing site
3. getting up too quickly
441

Sign and symptoms

Loss of consciousness
Light headed/dizzy
Pale/cool skin
Sweating
Vomiting
Distortion of vision
442

Care for fainting

1. Try to catch the person
2. Position person on their back
3. Elevate the leg 12 inches- to keep blood
to vital organs.
4. Loosen restrictive clothing
5. Check for life-threatening conditions
6. Do not give food or drink
7. Do not slap person or pour water on them
443

Diabetic Emergencies
Diabetes mellitus-a condition where
the body does not produce enough
insulin or use insulin effectively.
Insulin is a hormone that allows sugars
to be passed into our cells for energy.
A diabetic emergency-is an imbalance
of insulin and sugar in the
bloodstream.
444

2 types of diabetes
1. Type I (juvenile diabetes)-the body
produces little or no insulin.

2. Type II (adult onset diabetes)-body

produces insulin but the cells do
not use the insulin correctly or not
enough insulin is produced.
445

Hypoglycemia
Low levels of blood sugar
Some may experience hypoglycemia but are not
diabetic
protein is often recommended, sometimes along with
sugar

Sudden onset
Occurs when eating has been delayed or when
too much insulin was administered (blood sugar
level drops)
May be fatal if left unattended
446

Hypoglycemia: Signs and

Symptoms
Sudden onset
Sudden hunger
Trembling / Shaking
Anger, bad temper (mood change)
poor coordination
Pale
Confusion, disorientation, altered
mental status
Sweating
Eventual stupor or unconsciousness or
seizure
447

Hypoglycemia: What To Do
If victim is known diabetic, has altered
mental status, and is awake enough to
swallow:
GIVE 10-15 grams of sugar
can regular soda
6 jelly beans

If no improvement after 15 minutes, give 15

more sugar
If no improvement, take to the hospital
(trim gym, student at ballgame)

Glucagon: injectable medication

448

Hyperglycemia
The body has too much sugar in the blood
Pancreas fails to produce insulin to lower
sugar levels
When sugar levels remain high, over time, it
damages the walls of the vessels, leading to
impairment of the circulatory system
Affects functioning of most organs
Problems healing (small cuts, amputations)
Blindness
449

Hyperglycemia
Diabetic coma (ketoacidosis)
Levels may rise to 600 mg/dl
Body begins to burn fat as primary
fuel
Fat as fuel results in production of
acids and ketones = fruity breath

450

Hyperglycemia: Signs and

Symptoms
Gradual onset
Drowsiness
Extreme thirst / dry mouth
Frequent urination
Flushed skin
Vomiting / nausea
Fruity breath
Heavy breathing
Eventual stupor or unconsciousness
451

Hyperglycemia: What To Do
Have conscious victim follow
physicians recommendations
If you are uncertain if sugar level is
high or low, GIVE SUGAR
If no response in 15 minutes, get to
the hospital
452

Treatment
Check for life threatening conditions
Give person sugar fluids or food ie.
Candy, fruit juice or non diet soda.
If victim doesnt feel better within 5
minutes call 911
Insulin shock (hypoglycemia)-too much
insulin, low sugar level
Diabetic coma (hyperglycemia)High blood sugar level, low insulin.
453

Asthma
Chronic,
inflammatory
lung disease
Air passages narrow
Difficulty exhaling
Tends to resolve with age
454

455

456

Signs of Asthma Attack

Coughing
Wheezing or whistling sound
Flared nostrils
Cyanosis (blue)
Difficulty speaking
Blue lips / fingertips
These symptoms may also indicate other
health problems such as pneumonia, cystic
fibrosis
457

Asthma: What To Do
Sit in upright position, leaning slightly
forward
Oxygen administration
Adrenaline but consider other
condition like HTN

Deep breathing and coughing

Inhaler or other medications
Monitor ABCs if necessary
458

Con,,,,
Determine cause of attack remove victim from causative
environment
Abrupt change in outdoor
temperature, dust, feathers,
animals, tobacco smoke, paint, etc.
Figure show salbutamol puff

Keep conversations brief

Seek medical attention if
necessary
459

460

461

Heart Attack
Blood supply to
a portion of heart
muscle is severely
reduced or stopped

462

463

464

465

Heart attack

Due to clot in one of the blood vessels that supply the heart

Sign & symptoms

Chest pain,

Gasping

or dyspnea

Paleness ,

extreme prostration

Shock , Ankle swelling

466

Signs and Symptoms #2

May occur during rest or activity
Pain not relieved by nitroglycerin
Not all signs are always present
Victim will be in denial
Get help immediately
RX

Sitting position , ABC

- Warm pt
- Call for ambulance
467

Other Causes of Chest Pain

Rib injury
Pneumonia, bronchitis, pleurisy
Lung injury
Indigestion
Nerve impingement

468

Chest Pain: Heart Attack /

What To Do
Call EMS or transport
Monitor ABCs / give CPR if necessary
Place victim in least painful position
(Usually in half sitting position, knees bent)
Loosen tight clothing around neck and mid-section

Maintain composure / reassure

Determine if there is a history of heart disease
Check for medications
Nitroglycerine / give one aspirin if not allergic

469

470

Stroke;Cerebrovascular Accident
(CVA) Brain Attack;

CVA
Blood vessels that deliver
O2 to the brain rupture or
become obstructed
Nerve (brain) cells die
Effects often are permanent
471

con,,,
2 Kinds

1.Ischemic stroke: is Disruption of

the blood flow in the brain caused
by a clot (thrombus or embolus)
TIA-temporary
disruption of blood flow
2. Hemmroagic stroke: Bleeding from a
ruptured artery
(aneurysm) to the part of brain.
472

Con,,,
Occurs as a result of:
Clot (80%)
Ruptured vessel (20%)

Lack of oxygen to brain: cells die

Third largest cause of death in
U.S.
Major cause of disability
473

Transient Ischemic Attacks

(TIAs)
Mini-strokes
Precursor to major stroke
May last a few minutes to
several hours
Function normally returns
474

475

476

Stroke Risk Factors

>50 years of age
Birth control pills and > 30 years old
Overweight
Hypertension
High cholesterol
Diabetes
Heart disease
Sickle cell disease
Substance abuse
Family history
477

478

479

480

481

482

483

Stroke: What To Do
Check ABCs
Call EMS

Victim conscious?
Have victim lay down with upper body
and head slightly elevated

Unresponsive but breathing?

Recovery position
Chin extended to keep airway open

Do not give liquids or food (throat

may be paralyzed)
484

First Aid Measures---Stroke

Provide moderate covering

Maintain an open air way---ABC

Give artificial respiration if indicated

Position the victim on his side to drain secretion

Do not give fluids unless the victim is fully conscious

Transport the patient to hospital immediately

485

486

487

Convulsion & epilepsy

- A convulsion is an attack of unconsciousness usually of violent onset
- Epilepsy is a chronic disease usually of unknown cause characterized by
repeated convulsions

488

Common Causes of Convulsion

Severe dehydration

Febrile illnesses such as

Meningitis , Malaria

Tetanus and other illnesses

Epilepsy

Toxemia of pregnancy

Tumor, an abscess or hemorrhage

489

Signs and Symptoms --Convulsion

Rigidity of body muscles from a few seconds to perhaps half a minute

followed by jerking movement

Bluish discoloration of the face and lips

Foaming at the mouth or drooling

Gradual subsidence (improvement )

490

First aid Measures

Prevent victim from hurting himself

Give artificial respiration ,if indicated

Do not place a blunt object between the victims teeth

Do not restrain him

Do not pour any liquid in to his mouth

Do not place a child in a tub of water

Avoid overcrowding

Reassure and advise to seek medical attention

491

Epilepsy

The epilepsies are a symptom complex of several

disorders of brain function characterized by
recurring seizures.

The basic problem is an electrical disturbance

(dysrhythmia) in the nerve cells in one section of
the brain, causing them to emit abnormal,
recurring, uncontrolled electrical discharges.

Sign & symptoms,& Rx---Similar to convulsion

492

Con.
Irregular loss of body control due to
abnormal electrical activity in the brain.
Signs and Symptoms
1. Aura-unusual sensation or feeling
2. Uncontrollable tremors-grand mal
seizure
3. Blank stare-petit seizure
4. Irregular breathing
5. Eyes roll back
493

Conditions That May Lead

To Seizures
Epilepsy
Heatstroke
Poisoning
Electric shock
Hypoglycemia
High fever in children (fever convulsions)
Brain injury, tumor, stroke
Alcohol withdrawal, drug abuse / overdose
494

Major Classifications of
Seizures
Generalized Tonic Clonic Seizures
Grand mal

Absence Seizures
Blank stare

Complex partial Seizures

Part of brain involved
Dazed, may mumble or wobble

Febrile Seizures
High fever (cool body / wet cloth)
495

DO NOTS For Seizure

Victims
Do not give food or drink
Do not restrain victim
Do not put anything between
victims teeth except spatula,
Do not move to another place
(unless to protect from injury)
496

Treatment

Protect the head/prevent further injury

Do not restrain
Move objects away from them
Call if first time or longer than 5 min.
Do not try to put anything in the mouth
Position person on their side
Speak calmly and reassure them
497

Febrile Seizure
Happens to infants who are
running a high fever quickly.
Additional Treatment: Cool
the body slowly
Call 911 for first time.
498

THANK YOU

49
9

UNIT X. Burn
Learning Objectives
1.

Define burn injury

2. Identify causes of burn in different areas

3. Describe common classifications of burn
4. Apply first aid measures for different types of burn

500

501

502

503

504

con,,,,

Contact with flame, flash, steam or scalding inhaling smoke, dry heat
(fire)sun,explosion .

explosive

2. Chemical Burn
Acids cause coagulative
necrosis
Alkalis cause
liquefactive necrosis with
deeper wounds
chemical burns should
always be considered
deep partial-thickness or
full-thickness burns.

3. Electrical burn

Outer skin might

not appear too bad.
But heat was conducted
along the bone.
Causes the most damage.
Burns from inside out.
Usually requires fasciotomy

508

509

4. Lightning

5. Radiation Burn/Exposure
The typical exposure to
radiation occurs in an
industrial or occupational
setting
Detonation of a nuclear
weapon would injure/kill by
three mechanisms
Thermal burns from initial
firestorm
Supersonic destructive blast
Radiation

Radioactive
materials

laser

3 types of smoke and inhalation

injuries

1. Carbon monoxide poisoning (CO)

poisoning and asphyxiation count for
majority of deaths)
2. Inhalation injury above the glottis
(caused by inhaling hot air, steam, or
smoke.). Mechanical obstruction can occur
quickly-True ER! Watch for facial burns,
signed nasal hair, hoarseness, painful
swallowing, and darkened oral or nasal
membranes

3. Inhalation injury below glottis

above glottis-injury is thermally

produced)
below glottis-it is usually
chemically produced.
Amount of damage related to
length of exposure to smoke or
toxic fumes
Can appear 12-24 hours after burn

514

Zones of Burn Injury

Zone of coagulation -This occurs

at the point of maximum damage.
In this zone there is irreversible
tissue loss due to coagulation of
the constituent proteins.

Zone of stasis
The surrounding zone is characterized by
decreased tissue perfusion. The tissue in this
zone is potentially salvageable. The main
aim of burns resuscitation is to increase
tissue perfusion here and prevent any
damage becoming irreversible. Additional
insultssuch as prolonged hypotension,
infection, or edemacan convert this zone
into an area of complete tissue loss.

Zone of hyperemia

In this outermost zone tissue

perfusion is increased. The
tissue here will invariably
recover unless there is severe
sepsis or prolonged
hypoperfusion.

Clinical image of burn zones. There is central necrosis,

surrounded by the zones of stasis and of hyperemia

Classification of burn
Superficial - First degree
burns
Partial-thickness (seconddegree)
Partial thickness Deep Second
degree burns
Full-thickness Third degree burns
Fourth-degree burns

Superficial - First degree burns

Epidermis only
damaged
Painful to touch
Area initially
erythematous due to
vasodilatation
Epidermis sloughed
off in 7 days with
complete scarless
healing

Partial thickness
Superficial Second degree burns
Epidermis & various degrees of
dermis destroyed
Are pink to cherry red and wet
May or may not have intact
blisters and are very painful
when touched or exposed to air
Heal in 7-14 days with topical
antimicrobials or wound dressings

Deep partial-thickness
(Deep 2nd degree)
Epidermis & deeper degrees
of dermis destroyed
Are pink to cherry red, wet,
shiny with serous exudates
Very painful when touched or
exposed to air
Heal in 14- 28 days with
scarring
May need early excision and
grafting

Full-thickness Third degree burns

Will appear as thick, dry,
leathery, waxy white to dark
brown regardless of race or
skin color
May have a charred
appearance with visible
thrombosis of blood vessels
Will have little to no sensation
because nerve endings have
been destroyed except in
surrounding tissues with partial
thickness burns

Fourth-degree burns
Extend
through all
layers of skin as
well as
extending to
underlying fat,
muscle, bone or
internal organs

Superficial
Very painful, dry, red burns which blanch with pressure. They usually take 3 to 7 days to heal without scarring. Also known as firstdegree burns. The most common type of first-degree burn is sunburn. First-degree burns are limited to the epidermis, or upper
layers of skin.

Burn Size Estimation( TBSA)

Critical to providing adequate

resuscitation
3 common guidelines used
Rule of Nines
Lund-Browder Chart
Palmer Method

Rule of Nines

Palmer Method

The palmer surface

of the patients hand
from crease at wrist
to tip of extended
fingers- equals ~ 1% of
the patients total
body surface area

LUND AND BROWDER METHOD

A more precise method of estimating
the extent of a burn
recognizes that the percentage of TBSA
of various anatomic parts, especially the
head and legs, and changes with growth.
By dividing the body into very
small areas, one can obtain a reliable
estimate of the TBSA burned.

531

Severity of Burn Injury

Minor Burns
Full-thickness burns involving
less than 2% of the total body
surface area
Partial-thickness burns covering
less than 15% of the total body
surface area
Superficial burns covering less
than 50% of the total body
surface area

Moderate Burns
Full-thickness burns involving 2%
to 10% of total body surface area
excluding hands, feet, face, upper
airway, or genitalia
Partial-thickness burns covering
15% to 30% of total body surface
area
Superficial burns covering more
than 50% of total body surface
area

Critical Burns
Full-thickness burns involving hands,
feet, face, upper airway, genitalia, or
circumferential burns of other areas
Full-thickness burns covering more than
10% of total body surface area
Partial-thickness burns covering more
than 30% of total body surface area
Burns associated with respiratory injury.
Burns complicated by fractures

535

CURLINGS ULCER

Acute ulcerative gastro duodenal disease

Occur within 24 hours after burn
Due to reduced GI blood flow and
mucosal damage
Treat clients with H2 blockers,
mucoprotectants, and early enteral
nutrition
Watch for sudden drop in hemoglobin

536

537

FLUID IMBALANCES

Occur

as a result of fluid shift and cell

damage

Hypovolemia
Metabolic

acidosis

Hyperkalemia
Hyponatremia
Hemoconcentration

(elevated blood
osmolarity, hematocrit/hemoglobin) due to
dehydration
538

FLUID REMOBILIZATION

Occurs

after 24 hours

Capillary

leak stops

See

diuretic stage where edema fluid

shifts from the interstitial spaces into the
vascular space

Blood

volume increases leading to

increased renal blood flow and diuresis

Body
See

weight returns to normal

Hypokalemia
539

Phases of Burn injury/mgt

Emergent/Resuscitative
First 48 hours
Acute
Approximately 48 hours after
injury to complete wound closure
Rehabilitative
Begins with wound closure and
ends when client returns to
highest possible level of

1.Emergent/Resuscitative
Phase
Goals:
Maintain open airway-intubate if
needed
Ensure adequate
breathing/circulation early
intubation or early escharotomy if
ventilation is impaired
Limit extent of injury
Maintain function of vital organs
Prevent potential complications

CLINICAL MANIFESTATIONS
IN THE EMERGENT PHASE
Clients with major burn injuries and
with inhalation injury are at risk for
respiratory problems
Inhalation injuries are present in 20% to
50% of the clients admitted to burn
centers
Assess the respiratory system by
inspecting the mouth, nose, and
pharynxa
Burns of the lips, face, ears, neck, eyelids,
eyebrows, and eyelashes are strong
indicators that an inhalation injury may
be present

542

Con.
Cardiovascular

will begin
immediately which can include shock
(Shock is a common cause of death in
the emergent phase in clients with
serious injuries)

Monitor

for edema, measure central

and peripheral pulses, blood
pressure, capillary refill and pulse
oximetry
543

Con
Changes

in renal function are related to

decreased renal blood flow
Urine is usually highly concentrated and
has a high specific gravity
Urine output is decreased during the first
24 hours of the emergent phase
Fluid resuscitation is provided at the rate
needed to maintain adult urine output at
30 to 50- mL/hr.
Measure BUN, creat and NA levels
544

Con
Sympathetic

stimulation during the

emergent phase causes reduced GI
motility and paralytic ileus
Auscultate the abdomen to assess bowel
sounds which may be reduced
Monitor for n/v and abdominal
distention
Clients with burns of 25% TBSA or who
are intubated generally require a NG
tube inserted to prevent aspiration and
removal of gastric secretions
545

SKIN
Assess

the skin to determine the size

and depth of burn injury

The

size of the injury is first estimated

in comparison to the total body surface
area (TBSA). For example, a burn that
involves 40% of the TBSA is a 40% burn

Use

the rule of nines for clients whose

weights are in normal proportion to
their heights
546

Pre-hospital/ first aid Burn

Care
I. Stop, drop and roll. Smother with blanket or do
use with water. DO NOT RUN!
II. Disconnect the person from the source of
electricity
III. Remove clothing and jewelry. Take off blanket
used to smother fire
IV. Cool burns or scalds by immediate immersion of
water for at least 20 min.
V. Irrigation of chemical burns should be for 1 hour.
VI. Do NOT use ice for cooling
VII.Cover with dry sheet

First aid management of burn

Remove the source and maintain ABC

Expose the burn & flush with water ???????

Remove ring, watch ,belt ,boots ,bangles ,etc

Apply dressing & elevate the part

Treat for shock give salty water

Do not break blisters

Do not apply grease or ointments to the burns

Electricity- Wrap with nonconductive materials & drag the victim (Turnoff the
power source if possible)

Do not remove adhered/charred/clothing

548

Fluid Resuscitation- estimate TBSA burn

percentage and weight then calculate fluids for
first 24 hour period using Parkland formula
Foley catheter- to monitor urine output
Secondary survey starting with a good scene
and patient history then head to toe exam
Pain Management- early and often based on
patients hemodynamic status and pain scale
Psychosocial issues- consider need for religious
intervention, legal consult for family affairs,
etc for patients with life-threatening burns

Fluid Therapy
1 or 2 large bore IV replacement lines (may
need jugular or subclavian)
Vein Cut downs are rare due to increased risk
of infection & sepsis
Fluid replacement based on: size/depth of
burn, age of pt., & individualized
considerations--ex. Dehydration in pre burn
state, chronic illness
Options- RL, D5NS, dextam, albumin, etc.
Parkland formula to determine adequate
amount to give

Parkland Formula
Lactated Ringers solution is
recommended 4ml/xkg/x%TBSA burn =
mls in first 24 hours
of this total given in the first 8 hours
post injury remaining given in the
next 16 hours.
Example given TBSA 60%, wt 50kg

COMMON FLUIDS

Protenate or 5% albumin in isotonic

saline (1/2 given in first 8 hr; given in
next 16 hr)
LR (Lactate Ringer) without dextrose (1/2
given in first 8 hr; given in next 16 hr)
Crystalloid (hypertonic saline) adjust to
maintain urine output at 30 mL/hr
Crystalloid only (lactated ringers)

552

Assessment of adequacy
of
fluid
replacement
Urinary output is most commonly used
parameter
Adequate urine output is 30 ml/hr in
adults
Cardiopulmonary factors- BP (systolic
90-100 mmHg), pulse less than 100, resp
16-20 breaths per min. (BP more
accurate with arterial line)
Sensoruim-alert, oriented to time, place,
& person

2.Acute phase
Begins with mobilization of extracellular
fluid and subsequent diuresis Lasts until
wound closure is complete

Is concluded when the burned area is

completely covered or when wounds are
healed. May take weeks or months
Patient is no longer grossly edematous due
to fluid mobilization, full & partial thickness
burns more evident,
bowel sounds return, pt more aware of

Con

Care is directed toward continued assessment and

maintenance of the cardiovascular and respiratory
system
Pneumonia is a concern which can result in
respiratory failure requiring mechanical ventilation
Infection (Topical antibiotics Silvadene)
Tetanus toxoid
Weight daily without dressings or splints and
compare to pre-burn weight
A 2% loss of body weight indicates a mild deficit
A 10% or greater weight loss requires modification
of calorie intake
Monitor for signs of infection
555

Acute phase
measures/actions
Fluid replacement
Physical therapy
Pain management
Nutritional therapy
Wound care
Excision and grafting

DIET

Initially NPO
Begin oral fluids after bowel sounds
return
Do not give ice chips or free water lead to
electrolyte imbalance
High protein, high calorie

557

DEBRIDEMENT

Done with forceps and curved scissor or through

hydrotherapy (application of water for
treatment)
Only loose eschar removed
Blisters are left alone to serve as a protector
controversial

SKIN

GRAFTS

Done during the acute phase

Used for full-thickness and deep partialthickness wounds
558

POST CARE OF SKIN GRAFTS

Maintain dressing
Use aseptic technique
Graft should look pink if it has taken
after 5 days
Skeletal traction may be used to prevent
contractures
Elastic bandages may be applied for 6 mo
to 1 year to prevent hypertrophic scarring

559

560

Rehabilitation Phase
beginning when the patients burn healed

and patient is capable of assuming some

self-care activity.
Can occur as early as 2 weeks to as long as
2-3 months after the burn injury throughout
the patients lifespan
Goals for this time is to assist patient in
resuming functional role in society &
accomplish functional and cosmetic
reconstruction

Con.
Technically

begins with wound closure

and ends when the client returns to the
highest possible level of functioning
Provide psychosocial support
Assess home environment, financial
resources, medical equipment, prosthetic
rehab
Health teaching should include
symptoms of infection, drugs regimens,
f/u appointments, comfort measures to
reduce pruritus
562

563