first aid for the first responder

First Aid for the First Responder

As a firefighter, you are already a part of a proud tradition. Members of the fire service have always stood at the ready to save

lives and to protect property. You will receive training that will enable you to assess patients and provide first aid in the

challenging out-of-hospital environment. You will still be a firefighter, but you will also become a competent and valuable part

of the Emergency Medical Services ( EMS ) system.

Roles and Responsibilities

Your ultimate responsibility will be to provide excellent patient care. To fulfill this

responsibility, there are a number of different duties you must perform.

Roles and Responsibilities cont.• Assuring personal safety- remember that you

cannot carry out your responsibilities of caring for a patient if you yourself are injured. Keeping yourself safe is your first responsibility.

• Assuring the safety of the patient, or other firefighters and emergency care providers, and of bystanders at all times.

• Performing patient assessments in order to determine what care is necessary.

These are the top three responsibilities of the first responder

Roles and Responsibilities cont.• Lifting and moving the patients in a fashion that is safe for

the patient and minimizes the risk of related injuries to yourself and the crew.

• Providing for the safe transport of the patient or the smooth transition of patient care to those who will transport him.

• Providing complete, accurate, and appropriate documentation of your patient as required by your department.

• Respecting the patient as another human at all times.• Acting as a patient advocate – this means that you must at

all times speak up for the patients rights and needs and do what you can to assure his well being.

Infection control

Bloodborne pathogensThe federal government established standards ( title 29 Code of Federal

Regulation 1910-1030) in 1991 under the authority of the Occupational Safety and Health Administration ( OSHA ) regarding the exposure of emergency care workers to bloodborne pathogens.

Infectious diseases are those that spread from person to person. They are called pathogens. These microorganisms include bacteria and viruses. The Federal Government has developed guidelines aimed at preventing the spread of disease through contact with blood and body fluids. These safeguards involve a form of infection control known as body substance isolation( BSI ).

Handwashing is a simple measure that can be of great help in guarding against the spread of disease.BSI precautions involves the use of personal protective equipment( PPE ). This includes gloves, masks, goggles, and-when appropriate-gowns for protection against exposures.

PPEGloves- should be worn on every EMS call where there is a

possibility of the exposure to blood. Vinyl or latex specifically for patient care settings are the type most commonly used.

Eye protection- to be used in cases where there is a possibility that blood could come into contact with the eyes. In these cases, wear goggles or glasses with side protectors designed to prevent such contact.

Masks- are designed to prevent blood and body fluids from coming into contact with the mouth and nose.

Gowns- should be of the single-use, disposable to provide a barrier to blood and body fluids and should be worn whenever possible.

Cleaning and disinfection of equipmentAny equipment designed for single use should be disposed of properly

after each use. Materials contaminated with blood or body fluids, such as gloves, gauze, or bandages should be disposed in a red bag or container marked with a biohazard seal. Needles and other sharp objects should be disposed in a puncture proof container, sometimes called a “sharps” container. Once placed in the appropriate container, dispose of according to your departments guidelines for hazardous waste.

Non-disposable equipment used during a call, that may have come into contact with blood or body fluids must receive cleaning, disinfection, or sterilization.

Cleaning-refers to the washing of an object with soap and water.Disinfection-includes cleaning, but also involves use of disinfectant to kill

many of the microorganisms that may be on objects.Sterilization- is the use of chemical or physical methods to kill all

microorganisms on an object.

Legal aspects of the EMS system

Every time you respond to a call, you will be faced with some aspect of medical/legal

issues. The issue may be as simple as making sure that the patient will accept help or as

complex as a terminally ill patient who refuse care.

Legal aspects cont.

You are governed by many medical, legal, and ethical guidelines. This collective set of

regulations and considerations may be referred to as a scope of practice because it defines the

scope, or extent and limits that you may perform.

Legal aspects cont.

Before you treat any patient you must first obtain consent to treat that patient. Most of

the time the patient or their families will have called for your assistance and will

readily accept it.

Legal aspects cont.

Consent can be either expressed or implied.

• Expressed consent- the consent given by adults who are of legal age and mentally competent to make a rational decision in regard to their medical well-being.

• Implied consent- in the case of an unconscious patient, consent may be assumed. The law states that rational patients would consent to treatment if they were conscious. In this situation, the law allows EMS personnel to provide treatment, at least until the patient becomes conscious and able to make rational decisions.

Consent cont.

Children and mentally incompetent adults are not legally allowed to provide consent or to refuse medical care and transportation. For these patients, their parents and legal guardians have the legal authority to give consent. In life-threatening incidents, when a parent or guardian is not present, care may be given based on implied consent.

When a patient refuses care, several conditions must be fulfilled.

• The patient must be mentally competent and oriented.

• The patient must be fully informed.

• The patient must sign a “release” form, aka an AMA(against medical advice).

It will only be a matter of time before you come upon a patient who has a do not resuscitate(DNR)order. This is a legal

document, usually signed by the patient and his physician, which states that the patient has a terminal illness and does not wish to prolong life through resuscitation efforts.

More legal aspects.

There are more legal aspects that you should know before hand. If a legal situation arises that could possibly involve you or your department, certain things need to be found. These are; was there negligence, was there a duty to act, was the patients confidentiality violated, and was the patient abandoned.

negligence

Negligence is the finding of failure to act properly at a situation in which there was a duty to act, needed care as would reasonably be expected of the first responder was not provided, and harm

was caused to the patient as a result.

Duty to act

Duty to act is an obligation to provide care to a patient.

confidentiality

Confidentiality is the obligation not reveal information obtained about a patient except to other health care professionals involved in the patients care, or under subpoena, or in a court of law, or when the patient has signed a release of confidentiality.

abandonment

Abandonment is when the first responder leaves the patient after care has been initiated and before the patient has been transferred to someone with equal or greater medical training.

Good Samaritan Laws have been developed in all states to provide immunity to individuals trying to

help people in emergencies

Special Situations

A patient may wear a medical identification device. This device is worn to alert the first responder that the patient has a particular medical condition. Examples of these conditions are:

• Heart conditions

• Allergies

• Diabetes

• Epilepsy

Special Situations cont.

You may also respond to a call to find that a patient is an organ donor. An organ donor is a patient who has a completed legal document that allows for donation of organs and tissues in the event of their death.

Crime scenes

A crime scene is identified as the location where a crime has been committed or any place that evidence relating to a crime may be found. Once police have made the scene safe, the priority of the first responder is to provide patient care. While providing patient care you should take care to preserve evidence, but first you need to know what evidence is.

Examples of evidence at a crime scene

• The condition of the scene• The patient• Fingerprints and footprints• Microscopic evidence

Remember that your first priority is patient care. But you should also remember what you touch and minimize your impact on the scene. You should work with the police on any crime scene, you may be needed to provide a statement about your actions or observations at the scene

Vital Signs

Vital signs are outward signs of what is going on inside the human body. They include pulse;

respirations; skin color, temperature, and condition; pupils;and blood pressure.

Pulse

The pumping action of the heart is normally rhythmic, causing blood to move through the arteries in waves-not smoothly and continuously at the same pressure like water flowing through a pipe. A finger tip held over an artery where it lies close to the surface can be felt as a “beat.” this is what is called the pulse. The pulse rate is the number of beats per minute. Pulse rates vary among individuals depending on the their age, physical condition, degree of exercise just completed, medications and other substances being taken, blood loss, stress, and body temperature.

Pulse cont.

The normal rate for an adult at rest is between 60 and 100 beats per minute. Any pulse rate above 100 beats per minute is a rapid pulse. A rapid pulse is called tachycardia. Any pulse below 60 beats per minute is a slow pulse. A slow pulse is called bradycardia. Two factors determine pulse quality: rhythm and force. Pulse rhythm reflects regularity, while pulse force refers to the pressure of the pulse wave. Pulse rate and quality can be determined at a number of points throughout the body. You should initially find a radial pulse in patients 1 year of age and older. In an infant less than 1 year of age you should find the brachial pulse. If you are not able to measure the radial or brachial pulse, you should find the carotid pulse. Count the pulsations for 30 seconds and multiply by 2 to determine the beats per minute.

Pulse rates

Adults 60 to 100

Infants and childrenAdolescent 11 to 14 years 60 to 105

School age 6 to 10 years 70 to 110

Preschooler 3 to 5 years 80 to 120

Toddler 1 to 3 years 80 to 130

Infant 6 to 12 months 80 to 140


Newborn 120 to 160

Pulse quality Rapid, regular, and full Exertion, fright, fever,high

blood pressure, first stage of blood loss

Rapid, regular, and thready Shock, later stages of blood loss

Slow Head injury, drugs, some poisons,some heart problems, lack of oxygen in children

No pulse Cardiac arrest( clinical death )

Respiration The act of breathing is called respiration. A single breath is considered to be the

complete process of breathing in( inspiration or inhalation ) followed by breathing out( expiration or exhalation ). The respiratory rate is the number of breaths a patient takes in in one minute. The rate of respiration is classified as normal, rapid, or slow. A normal respiration rate for an adult at rest is between 12 and 20 breaths per minute. However, if you have an adult patient maintaining a rate above 24( rapid ) or below 8( slow ), you must administer high concentration oxygen and be prepared to assist with ventilations. Respiratory quality, the quality of a patients breathing, may fall into any of four categories: normal, shallow, labored, or noisy. Respiratory rhythm is not important in most of the conscious patients you will see. If you observe irregular respirations in an unconscious patient you should report and document. To record respiratory rate, start counting respirations as soon as you have determined the pulse rate. Count the number of breaths taken by the patient during 30 seconds and multiply by 2 to obtain the respiratory rate. Be sure to keep in mind that brain cells will start to die off after 4 to 6 minutes without oxygen, from the time of the accident or illness. So, the faster you can assess the patients respirations the better the chance for a full recovery of the patient.

Respiratory quality

Normal – means that the chest or abdomen moves an average depth with each breath and the patient is not using their accessory muscles.

Shallow – occurs when there is only slight movement of the chest or abdomen. This especially serious in the unconscious patient.

Labored – can be recognized by signs such as an increase in the work of breathing , the use of accessory muscles, nasal flaring, and retractions above the collarbones or between the ribs, especially in infants and children.

Noisy – is obstructed breathing. Sounds to be concerned with are snoring, wheezing, gurgling, and crowing. A patient with snoring respirations needs to have their airway opened. Wheezing may respond to prescribed inhalers or medications. Gurgling sounds usually mean that you need to suction the patients airway. Crowing(a noisy, harsh sound when breathing in ) may not respond to any treatment you give.

Respiration

Adults 12 to 20 above 24 : serious below 10 : serious

Infants and childrenAdolescent 11 to 14 years 12 to 20

School age 6 to 10 years 15 to 30

Preschooler 3 to 5 years 20 to 30

Toddler 1 to 3 years 20 to 30



Newborn 30 to 50

Skin

The color, temperature, and condition of the skin can provide valuable information about your patients circulation.the best places to assess skin color in adults are the nail beds, inside the cheek, and inside of the lower eyelids. In infants and children, the best places to look are the palms of the hands and the soles of the feet. In patients with dark skin you can check the lips and nail beds. The normal color in any of these places should be pink. Abnormal colors include pale, cyanotic( blue-gray ), flushed( red ), and jaundiced( yellow ).

Skin cont.

To determine skin temperature feel the patients skin with the back of your hand. A good place to do this is the patients forehead. Note if the skin feels normal( warm ), hot, cool, or cold. At the same time notice the skins condition, is it dry( normal ), moist, or clammy( both cool and moist ). Also look for goose pimples, which are often associated with chills.

Skin colorPink Normal in light skinned patients.

Normal at the eyelids, lips, and nail beds

Pale Constricted blood vessels possibly resulting from blood loss, shock, hypotension, emotional distress

Cyanotic ( blue-gray ) Lack of oxygen in blood cells and tissues resulting from inadequate breathing or heart function

Flushed ( red ) Exposure to heat, high blood pressure, emotional excitement

Jaundiced ( yellow ) Abnormalities of the liver

Mottling ( blotchiness ) Occasionally in patients with shock

Skin temperature

Cool, clammy Sign of shock, anxiety

Cold, moist Body is losing heat

Cold,dry Exposure to cold

Hot, dry High fever, heat exposure

Hot, moist High fever, heat exposure

“ goose pimples “ accompanied by shivering, chattering teeth, blue lips, and pale skin

Chills, communicable disease, exposure to cold, pain, or fear

Pupils

The pupil is the black center of the eye. One of the things that can cause it to change is the amount of light entering the eye. When the environment is dim the pupil will dilate( get larger ) to allow more light in. when there is a lot of light the pupil will constrict( get smaller ). To check the pupil for reactivity you would shine a light into the patients eyes. You will need to look for three things: size, equality, and reactivity. Both pupils are normally the same size, and when light is shined into them they react by constricting.

pupils

Dilated Fright, blood loss, drugs, treatment with eye drops

Constricted Drugs( narcotics ), treatment with eye drops

Unequal Stroke, head injury, eye injury, artificial eye

Lack of reactivity Drugs, lack of oxygen to brain

Blood pressure

Each time the ventricle ( lower chamber ) of the left side of the heart contracts, it forces blood out into the circulatory system. This force of blood against the walls of the blood vessels is called blood pressure. The pressure created during contraction is called the systolic blood pressure. When the heart relaxes, the pressure remaining in the blood vessels is called the diastolic blood pressure. These pressures vary, just like with the pulse, from person to person, depending on their lifestyle and medical history.

Blood pressure cont.

To measure blood pressure, you would use a sphygmomanometer cuff ( blood pressure cuff ) with gauge. Position yourself at the patients side and place the cuff around the patients upper arm, the cuff should cover two-thirds of the upper arm. Take care as to not put the cuff on the patients arm if you suspect an injury to that arm. The center of the bladder inside of the cuff needs to be centered over the brachial artery, the major artery in arm. There are two common ways to measure the

blood pressure with a blood pressure cuff; auscultation and palpation. Auscultation requires using a stethoscope to listen for characteristic sounds. Palpation of the blood pressure requires using you fingers to feel the pulse as it starts when pressure is released from the cuff. Palpation is not as accurate as auscultation.

Blood pressure ( auscultation )

To measure the blood pressure using the auscultation method, you would, after putting the cuff on the patients arm , put the stethoscope on the patients arm above the brachial artery. Begin inflating the cuff to a point 30mm above the point that you last heard pulse sounds. Begin to slowly deflate the cuff by releasing the air in the bladder, at a rate of 5 to 10 mm per second. Listen for the sounds of the pulse to obtain the systolic reading. Continue deflating the cuff until you no longer hear the pulse sounds, at the point that you last hear pulse sounds will be your diastolic reading. Record the measurement and the time at which it was taken.

Blood pressure ( palpation )

To measure the blood pressure using the palpation method , you would first out the blood pressure cuff on the patients arm just as you would for auscultation. Next, you will need to find the radial pulse. After finding the radial pulse, begin inflating the blood pressure cuff to a point 30 mm above where you last feel the pulse. Then slowly begin deflating the cuff, noting the point where the radial pulse returns.

Blood pressure

Blood pressure normal ranges

Systolic Diastolic

Adults 90 to 150 60 to 90

Infants and children

Approx. 80 + 2 x age ( years )

Approx. 2/3 systolic

Adolescent 11 to 14 years

Avg.114 ( 88 to 140 )

Average 59

School age 6 to 10 years

Avg. 105 ( 80 to 122 )

Average 57

Preschooler 3 to 5 years

Avg. 99 ( 78 to 116 )

Average 55

The SAMPLE History

SAMPLE history

When you obtain a patients medical history, you are gathering information that will help shape your subsequent assessment and treatment. The most effective way of taking a patients history is to use the SAMPLE format. The elements of the SAMPLE history are as follows:

•Signs/Symptoms

•Allergies

•Medications being taken

•Pertinent past history

•Last oral intake

•Events leading up to the illness or injury

Signs/Symptoms

Signs are objective findings that you can see, hear, feel, or smell without having to question the patient

Symptoms are subjective findings. You can’t observe them; you only know about them because the patient tells you

Allergies

Determine, if possible, if your patient is allergic to any medications, foods, or environmental agents, such as bee stings or molds. Also check to see if your patient is wearing a medical identification device that might list any allergies.

Medications

Determine if the patient is taking any medications. This information can give important clues about the patients past medical history and the reasons for the illness. To determine what medications the patient is taking, ask “do you take any medications on a regular basis?”. As a rule, avoid using the word “drugs” when questioning the patient. Some patients may have several medical conditions, and they may have many medications. Rather than sorting through these large collections, gather them in a bag and send with the patient to the hospital.

Pertinent past history

To obtain the patients past medical history, ask such as these:

• “Have you had any medical problems in the past?”

• “Have you had any recent injuries?”

• “Have you ever been hospitalized?”

• “Are you currently under the care of a doctor for any problems? Have you recently seen a doctor? What is your doctors name?”

• “Have you ever had_______( chest pain, shortness of breath, etc.) like this in the past?”

Last oral intake

To determine the patients last oral intake, ask: “ when was the last time you had anything to eat or drink today? What did you eat or drink then ?”. Of all the SAMPLE history you will gather, this is the least crucial to out-of-hospital care.

Events leading up to the illness or injury

Determining the events leading up to the onset of a medical emergency or injury is a crucial part of the patient history. Knowing what the patient was doing prior to an incident began can be very helpful in a patient assessment.

Cardiac emergenciesAny problem with the heart that causes symptoms such as chest pain or shortness

of breath is referred to as cardiac compromise. Some of the signs and symptoms can include the following:

• pain, pressure, or discomfort in the chest, upper abdomen, neck, or left shoulder.

• Difficulty breathing ( dyspnea )

• Palpitations.

• Sudden onset of heavy sweating ( diaphoresis )

• Nausea and/or vomiting.

• Anxiety or irritability.

• feelings of impending doom.

• Abnormal pulse.

• Abnormal blood pressure.

Use these questions when obtaining information from a cardiac compromise patient.

Onset When did the pain start and what were you doing when it started?

Provocation What makes the pain worse?

Quality What does the pain feel like?

Radiation Does the pain move anywhere?

Severity On a scale between 1 and 10, with 10 being the worst, how bad is your pain?

Time How long have you had this pain?

Cardiac Arrest

The most serious form of cardiac compromise is cardiac arrest. When a patient is in cardiac arrest, their normal heart beat stops or is replaced by a different kind of electrical activity. The American Heart Association has identified four key factors that affect the chances of successful resuscitation of cardiac arrest patients.

• Early access- having a means of early contact of EMS providers.

• Early CPR- can increase the patients chances of survival.

• Early defibrillation- since the likelihood of successful resuscitation decreases by approximately 10 percent with each minute following the onset of cardiac arrest, early defibrillation is critical.

• Early advanced cardiac life support(ACLS)- by having advanced EMS personnel responding with you, early ACLS( paramedics, doctors, and hospital staff) can further the chances of survival. Remember, you are the first responder and you are usually the first on scene.

How to know if CPR is effective• If possible have someone else feel for carotid pulse during

compressions and watch to see the patients chest rise during ventilations

• Listen for exhalation of air, either naturally or during compressions

• Pupils constrict

• Skin color improves

• Heartbeat returns spontaneously

• Spontaneous, gasping respirations are made

• Arms and legs move

• Swallowing is attempted

• Consciousness returns

Environmental emergencies

Exposure to the cold

Hypothermia- when cooling affects the entire body. Exposure to cold reduces body heat. With time, the body is unable to retain its core( internal) temperature. If not treated immediately, can lead to death.

Hypothermia

Signs and symptoms

• Shivering in the early stages

• Numbness

• Stiff or rigid posture

• Drowsiness

• Rapid breathing

• Loss of coordination

• Decreased level of consciousness

• Cool abdominal skin temperature

• Skin may appear red in early stages

Hypothermia- cont.

Treatment of a hypothermic patient, is the re-warming of the patient.

There are two ways to re-warm a hypothermic patient:

Passive re-warming- allows the body to re-warm itself by simply covering the patient with a blanket and removing the patients wet clothes.

Active re-warming- includes the application of an external heat source to the body plus steps in passive re-warming.

Exposure to heat The body generates heat as a result of its internal chemical process.

Hyperthermia is an abnormally high body temperature.

Heat cramps- are painful muscle cramps caused by continued sweating. As the body sweats salts are lost. Treatment would be to remove the patient to a cool area and replenish with fluids.

Heat exhaustion- develops when the body’s fluid volume is depleted, this can occur as a result of excessive sweating and the patients failure to drink enough fluids. Early signs may include fatigue, light-headedness, nausea, vomiting, and headache and will present with moist and pale skin.treatment would include to remove to a cool area and loosen clothing allowing to cool.

Heat stroke- usually develops over several days and most often affects the very young and the elderly. The patients skin will likely feel hot and dry or moist. Patient will have an altered mental status. Treatment would include rapid cooling.

Shock ( hypoperfusion )

Shock ( hypoperfusion )- inadequate perfusion of the cells and tissues of the body caused by insufficient flow of blood through the capillaries.

There are three major causes of hypoperfusion: failure of the heart to pump correctly; failure of the blood vessels to constrict normally; and loss of blood or other body fluids

Shock that results from blood loss is termed Hemorrhagic or Hypovolemic shock.

Signs and symptoms of shock

• Altered mental status, including anxiety, confusion, restlessness, or combativeness

• Weakness, faintness, or dizziness

• Marked thirst

• Nausea or vomiting

• Dilated pupils that are sluggish to respond to light

• Increased breathing rate

• Shallow, labored, or irregular breathing

• Rapid, weak pulse

• Pallor( pale or gray skin )

• Cyanosis( bluish discoloration ) of the lips or conjunctiva of eyes

• Capillary refill of greater than 2 seconds in infants and children

• A low or falling blood pressure

Emergency Care- Hypovolemic Shock1. Assure scene safety2. Take appropriate BSI precautions3. Maintain an open airway4. Administer high flow oxygen5. Control any external bleeding6. Use the PASG, if appropriate conditions apply7. Elevate the lower extremities approximately 8 to 12

inches8. Splint any suspected bone or joint injuries9. Prevent additional heat loss from the patient10. Provide immediate transportation to the emergency

department11. Continue to monitor the patient

Poisonings and Allergic reactions

Poisonings and allergic reactions

Poison- is any substance that can harm the body.

Allergens- substances known to set off an exaggerated response in the body’s immune system. This exaggerated response is called an allergic reaction and can potentially life-threatening.

Poisons

There are thousands of substances that are considered poisonous. There are four routes of poisons into the human body: ingestion, inhalation, injection, and absorption.

Ingestion ( swallowing a poison )- can be anything from pills, household cleaners, toiletries, and plants.

Inhalation ( breathing in a poison )- the most common cause of inhalation poisoning is carbon monoxide, but can also be cleaning fluids or sprays.

Injection ( inserting a poison through the skin through the use of a sharp object )-can be an insect, snake, or intravenous needles or “drugs”.

Absorption ( taking a poison in through the unbroken skin or mucous membranes including the eyes, nose, or mouth )- can be in the form of plants, insecticides, or industrial and agricultural chemicals.

Assessment and emergency care-poisoning by ingestion

Signs and symptoms:

• History of ingesting a poisonous substance

• Nausea

• Vomiting

• Abdominal pain

• Altered mental status

• Chemical burns around the inside of the mouth

• Unusual odors on the breath

Assessment and emergency care-poisoning by inhalation

Signs and symptoms:• History of inhalation of toxic substances.• Difficulty breathing• Chest pain.• Cough.• Hoarseness.• Dizziness.• Headache.• Altered mental status.• Seizures.

Assessment and emergency care-poisoning by injection

Signs and symptoms:• A history of injection of a harmful substance• Weakness• Dizziness• Chills• Fever• Nausea• Vomiting• Tiny, pinpoint pupil• Altered mental status• Chest pain• Inadequate breathing

Assessment and emergency care-poisoning by absorption

Signs and symptoms:• History of exposure• Liquid or powder on the patients skin• Excessive saliva production• Excessive tear production• Uncontrolled diarrhea• Burns• Itching• Skin irritation• Redness of the skin

Allergic reactions

A severe allergic reaction can be life-threatening. The major physiologic change that makes this so dangerous is that the body’s blood vessels lose their normal tone and ability to contain fluids. “Leaking “ from these vessels produces the swelling of the face, neck, and tongue, which are common characteristics of a severe allergic reaction. The leaking can also cause swelling in the linings of the bronchioles of the lungs and upper airway structures, which can lead to the narrowing of the airway passages, as well as fluid loss sufficient enough to cause hypoperfusion( shock ). Hypoperfusion that results from a severe allergic reaction is commonly referred to as anaphylactic shock.

Allergic reactionsAllergic reactions can range from watery eyes and runny nose

of hay fever to severe hypoperfusion and respiratory failure. A wide variety of different substances can cause an allergic reaction.

• Venom from insect bites and stings, especially those of bees, wasps, hornets, and yellow jackets.

• Foods, including nuts, shellfish/crustaceans, peanuts, milk, eggs, chocolate, etc.

• Plants, including contact with poison ivy, poison oak, and pollen from ragweed and grasses.

• Medications, including penicillin and other antibiotics, aspirin, seizure medications, muscle relaxants, etc.

• Other causes include dust, latex, glue, soaps, make-up, etc.

Assessment of the patient with an allergic reaction

Controlling the patients airway is the top priority during the initial assessment and subsequent care. Quickly obtain information about the allergic reaction, if the patient is unable to help you , try to obtain the information from family members.

• does the patient have a prior history of allergic reactions?

• What substance was the patient exposed to?

• How long ago did the exposure occur?

• What symptoms has the patient experienced?

• Have the symptoms progressed?

• Has the patient taken any medications, such as Benadryl or an epinephrine auto-injector?

• Has any other care been provided for them?

Indications of a patient with a severe allergic reaction

• Skin- swelling of the face, lips, tongue, neck, hands- hives-itching-red skin

• Respiratory system- cough- rapid breathing- labored/inadequate breathing- noisy breathing- hoarseness- stridor- wheezing

• Cardiovascular system- increased heart rate- decreased blood pressure- signs of hypoperfusion( cool, clammy skin )

• Decreased mental status

• Generalized symptoms- itchy, watery eyes- headache- sense of impending doom- runny nose

Musculoskeletal injuries

There are three main functions of the musculoskeletal system:

* To give the body its shape.* To protect vital internal organs.* To provide body movement.

One of the most serious types of trauma the musculoskeletal system can sustain is a break or a fracture to the bone.A break or fracture can also cause serious bleeding, some from the bone itself. This bleeding can lead to substantial swelling of the injured area. Breaks and fractures can also affect nearby nerves, which can be damaged or compressed due to the trauma.The combination of loss of structure, internal bleeding, and involvement of nerves leads to the classic finding associated with musculoskeletal injuries- a painful, swollen, and deformed area.All injuries that result in a painful, swollen, and deformed area are presumed to be serious and require appropriate immobilization with splinting.

Mechanisms of injury- direct force

Direct force injuries are forces that are applied directly to the bone or other structure. The injury occurs where the force is applied.

Example:the forearm being struck with a pipe during an assault, or an unrestrained driver in a head-on-collision where the driver strikes the steering wheel with their chest or head.

Mechanisms of injury- indirect force

Indirect force is when energy is applied to one area of the body and transmitted through the bone to another, causing injury to the other site.

Example: head-on-collision where the jams their knees against the dash and the force is transferred to the hips causing a dislocation to the pelvic area.

Mechanism of injury- twisting force

Twisting force is a variation of indirect force, the weight and motion of the body itself contributes to the application of abnormal strain on the bones and joints of the body.

Example: skier falls on a slope, twisting in the opposite direction of their lower extremities, causing an injury to the lower leg.

Types of injuries

There are four types of injuries associated with musculoskeletal injuries:

• Fracture- when a bone is broken or is simply cracked, can produce severe bleeding, great pain, and the potential for long-term disability. The risk of disability is greater when the fracture is at the end of the bone.

• Dislocation- is he disruption of the normal structure of a joint where it connects with another bone. The extreme flexion or extension of a joint is what usually renders a joint “dislocated.“

• Sprain- is the stretching or tearing of the ligaments that surround of support a joint.

• Strain- an injury that results from the abnormal stretching of tendons that connect muscles to bones.

Open and closed musculoskeletal injuries

Open musculoskeletal injury- when the skin overlying a painful, swollen, and deformed extremity is broken.

Closed musculoskeletal injury- when there is no break in the skin of a painful,swollen, deformed extremity.

Pre-hospital personnel assume that an injury is closed unless otherwise informed.

Open injuries are of particular concern because they may have resulted from a fractured bone puncturing the skin from within rather than from an external object breaking the skin. These injuries are a high risk for development of limb-threatening infections in the exposed bone.

Open and closed musculoskeletal injuries

Signs and symptoms of a musculoskeletal injury

• Deformity or abnormal angulation of an extremity

• Pain and tenderness at the site of the injury

• Swelling

• Bruising or discoloration at the site

• The sensation or sound of grating at the site if the limb is moved

• Open wounds or exposed bone at the site of the injury

• A joint that no longer moves normally or is locked into position

• Paleness, coolness, or lack of pulse in the limb distal to the injury

Spinal injuries

Spinal injuries are very serious, and failure to handle them properly can have long-term, even fatal consequences for patients. The most feared consequence of spinal injuries is damage to the spinal cord. This damage can result in the loss of voluntary muscle control. The vertebrae of the spinal column surround, and protect the spinal cord. Damage to the bones of the spinal column does not by itself cause paralysis or the other signs and symptoms of spinal cord injury.

Mechanism of injury• Flexion- the bending forward of the spine

• Extension- the bending backwards of the spine

• Lateral bending- is the bending of the spine to one side or the other

• Rotation- is the twisting of the spine

• Compression- is the application of force directly onto the spine from either a superior or inferior direction

• Distraction- is the application of force that results in the spinal cord and vertebrae being stretched or pulled apart

• Penetration- this occurs when some object enters the spinal cord or spinal column

Assessment for spinal injury patients

Emergency scenes that involve those mechanisms include the following:

• Motor vehicle crash

• Motorcycle crash

• Pedestrian vs. automobile collision

• Falls

• Blunt trauma

• Sporting injuries

• Hangings

• Diving accidents or near drownings

• Penetrating trauma


If the patient is responsive, perform a brief neurological exam to test for sensation and motor function in all four extremities:

• Ask patient if they can move their fingers or toes

• Ask patient to grip your fingers with both hands and squeeze

• Ask patient to push their feet against your hands

• Ask patient if they can feel you touching their fingers or toes


Keep the following in mind when conducting the rapid assessment:

• Assume that any unresponsive patient with a mechanism of injury that suggests the possibility of spinal injury has one

• Remember that patients who deny having tenderness in the area of the spine may still have a spinal injury

• Never ask the patient to move their spine in order to test for pain with motion


Signs and symptoms of spinal injury

• Tenderness of the spine in the area of injury

• Deformity of the spine

• Soft tissue injuries associated with spinal injuries:

- injury to the head and/or neck

- injury to the shoulders, back, or abdomen

- injury to the pelvis or lower extremities

• Loss of sensation or paralysis below the level of the injury

• Loss of sensation or weakness in the upper extremities

• Priapism, a persistent and emotionally unjustified erection of the penis

• Evidence of bowel or bladder incontinence

• Impaired breathing

• Pain, either with or without movement, along the spinal column

• Pain, either constant or intermittent, in the buttocks and legs

Immobilization and spinal injuries

Immobilization is the key element in emergency care of patients with suspected spinal injuries, and is performed in conjunction with other interventions that may be necessary such as maintaining an open airway. There are many different types of spinal immobilization devices.

• Manual in-line stabilization• Cervical collars• Short spinal immobilization devices( short, rigid spine

board and vest type extrication devices )• Full body spinal immobilization devices( spine boards or

back boards )

Injuries to the headInjuries to the head fall into two general categories: injuries to the brain and

injuries to the other soft tissue and the bony structures of the head.

Scalp and facial injuries are less serious than to the brain itself.although injuries to the facial structure can cause serious complications. Can produce partial or complete obstruction of the airway.

The skull, like all other bones, can be fractured if enough force is applied. Because the skull is in such close proximity to the brain, fracture are often associated to the brain itself. Signs of a skull injury include:

• Mechanism of injury that generates substantial force

• Severe contusions, deep lacerations, or hematomas( swelling ) of the scalp

• Deformities of the skull such as depressions or sudden “step offs “ on the surface of the skull

• Blood or clear fluid leaking from nose or ears

• Bruising around the eyes ( raccoon eyes )

• Bruising behind the ears over the mastoid process

Injuries to the head

Injuries to the brain can vary widely. Sometimes the brain tissue itself can be damaged or the brain tissues can be damaged at the level of the cells. An open soft tissue injury that reaches down through the skull to the level of the brain, is termed an open head injury. Signs and symptoms of traumatic brain injuries are :

• Decreasing mental status

• Deformity of the skull

• Drainage of spinal fluid or blood from nose or ears

• Discoloration around the eyes

• Disorientation or confusion

• Unconsciousness or coma

• Unequal pupils or pupils that do not respond to light

• Respiratory or circulatory changes

• Total or partial paralysis

Head injuries- special considerations

The assessment of a patient with a possible head injury can be complicated if the patient is wearing a helmet. Some instances where you would find a patient wearing a helmet are: motorcycle drivers and passengers, bicycle riders, football players, ice hockey players, skiers, construction workers, and firefighters.

Helmet removalIndications that the helmet can be left

in place:

• The helmet does not interfere with assessment and monitoring of the airway and breathing

• There are no current or impending airway or breathing problems

• Removal of the helmet would risk further injury to patient

• The patient can be adequately immobilized with helmet in place

• The patients head rests snugly within the helmet, assuring that there will be little to no movement of the patients head once secured to long board

Indications that the helmet should be removed:

• the helmet prevents assessment and monitoring of airway and breathing

• The helmet interferes with efforts to manage the airway or breathing

• The design of the helmet prevents adequate spinal immobilization

• The patients head moves too freely inside of the helmet

• The patient is in respiratory or cardiac arrest

first aid for the first responder

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