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»Chapter One-Basic life Support »Chapter Two-Bleeding »Chapter Three-Shock »Chapter Four-Soft Tissue Injuries »Chapter Five-Bones, Joints and Muscles »Chapter Six-Environmental Injuries »Chapter Seven-Chemical, Biological Radiological Casualities »Chapter Eight-Poisoning »Chapter nine-Rescue and Transportation »Near Drowning »Internal Bleeding »Carbon Monoxide |
Chapter One-Basic life Support Atmospheric air that is essential for life contains approximately 21% oxygen. When you breathe in (inhale) only a quarter of the air is taken by the blood in the lungs. The air you breath out (exhale) contains approximately 16% oxygen. Enough to support life! Seconds after being deprived of oxygen, the heart is at risk of developing irregular beats or stopping. Within four to six minutes, the brain is subject to irreversible damage. Basic life support is maintenance of the ABCs (airway, breathing, and circulation) without auxiliary equipment. The primary importance is placed on establishing and maintaining an adequate open airway. Airway obstruction alone may be the emergency: a shipmate begins choking on a piece of food. Restore breathing to reverse respiratory arrest (stopped breathing) commonly caused by electric shock, drowning, head injuries, and allergic reactions. Restore circulation to keep blood circulating and carrying oxygen to the heart, lungs, brain, and body. This course is not a substitute for formal training in basic life support. Airway Obstruction Airway obstruction, also known as choking, occurs when the airway (route for passage of air into and out of the lungs) becomes blocked. The restoration of breathing takes precedence over all other measures.. The reason for this is simple: If a casualty cannot breathe, he or she cannot live. Individuals who are choking may stop breathing and become unconscious. The universally recognized distress signal (Fig. 2-1) for choking is the casualty clutching at his or her throat with one or both hands. The most common causes of airway obstruction are swallowing large pieces of improperly chewed food, drinking alcohol before or during meals, and laughing while eating. The tongue is the most common cause of obstruction in the casualty who is unconscious. A foreign body can cause a partial or complete airway obstruction. Partial Airway Obstruction If the casualty can cough forcefully, and is able to speak, there is good air exchange. Encourage him or her to continue coughing in an attempt to dislodge the object. Do not interfere with the casualty's efforts to remove the obstruction. First aid for a partial airway obstruction is limited to encouragement and observation. When good air exchange progresses to poor air exchange, demonstrated by a weak or ineffective cough, a high-pitched noise when inhaling, and a bluish discoloration (cyanosis) of the skin (around the finger nails and lips), treat as a complete airway obstruction. Complete Airway Obstruction A complete airway obstruction presents with a completely blocked airway, and an inability to speak, cough, or breathe. If the casualty is conscious, he or she may display the universal distress signal. Ask "Are YOU choking?" If the casualty is choking, do the following: 1. Shout "Help"-Ask the casualty if you can help. 2. Request medical assistance - Say "Airway is obstructed" (blocked), call (Local emergency number or medical personnel).
Figure 2-1 Universal Distress Signal
Figure 2-2 Abdominal Thrust 3. Abdominal thrusts (Heimlich Maneuver)
If the casualty becomes unconscious, do the following:
Figure 2-3 Abdominal Thrust
Figure 2-4 Head Tilt-Chin Lift 4. Finger sweep - Place the casualty on his or her back, open casualty's mouth and grasp the tongue and lower jaw between your thumb and fingers, lift jaw with your index finger into the mouth along inside of cheek to base of tongue. Use "hooking" motion to dislodge object for removal. 5. Open airway (Head-tilt/Chin-lift) -Place your hand on the casualty's forehead. Place the fingers of your other hand under the (Fig. 2-4) bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not Breathing." (jaw-thrust maneuver) - If you suspect the casualty may have an injury to the head, neck, or back, you must minimize movement of the casualty when opening the airway. Kneeling at the top of the casualty's head, place your elbows on the surface. Place your fingers behind the angle of the jaw or hook your fingers under the jaw, bring (Fig. 2-5) jaw forward. Separate the lips with your thumbs to allow breathing through the mouth. Note that the head is not tilted and the neck is not extended.
Figure 2-5 Jaw Thrust 6. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. If unsuccessful, perform abdominal thrusts. 7. Perform abdominal thrusts
8. Continue steps 4 to 7 -Until successful, you are exhausted, you are relieved by another trained individual, or by medical personnel. If the casualty is found unconscious, do the following: 1. Check unresponsiveness - Tap or gently shake the casualty, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from casualty. 3. Position casualty - Kneel midway between his or her hips and shoulders facing casualty. Straighten legs, and move arm closest to you above casualty's head. Place your hand on the casualty's shoulder and one on the hip. Roll casualty toward you as a unit, move your hand from the shoulder to support the back of the head and neck. Place the casualty's arm nearest you alongside his or her body.
Figure 2-6 Abdominal Thrust Reclining 4. Open airway (Head-tilt/Chin-lift or Jaw-thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not Breathing." 5. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. If unsuccessful, reposition head, and give 2 full breaths. 6. Request medical assistance - Say "Airway is obstructed" (blocked), call local emergency number or medical personnel. 7. Perform abdominal thrusts
8. Finger sweep - Place the casualty on his or her back, open the casualty's mouth and grasp the tongue and lower jaw between your thumb and fingers, lift jaw, insert your index finger into the mouth along the inside of cheek to base of tongue. Use "hooking" motion to dislodge object for removal. 9. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. 10. Continue steps 7 to 9 - Until successful, you are exhausted, you are relieved by another trained individual, or by medical personnel. Chest Thrusts The chest thrust is the preferred method, in place of the abdominal thrust, for individuals who are overweight or pregnant. Manual pressure to the abdominal area in these individuals can be ineffective or cause serious damage. If the casualty is overweight or pregnant, do the following: 1. Conscious - Standing or Sitting.
2. Unconscious - Lying.
Repeat the last three steps until the obstruction is clear, you are exhausted, you are relieved by another trained individual, or by medical personnel. Self Abdominal Thrusts If you are alone and choking, try not to panic, you can perform an abdominal thrust (Fig. 2-7) on yourself by doing the following: 1. With the fist of your hand, place the thumb side against the middle of your abdomen, above the navel and below the tip of the breastbone. Grasp your fist with your other hand and give a quick upward thrust. 2. You also can lean forward and press your abdomen over the back of a chair (with rounded edge), a railing, or a sink.
Figure 2-7 Self-Help for Airway Obstruction If the casualty is not breathing, do the following: Rescue Breathing Rescue breathing is the process of breathing air into the lungs of a casualty who has stopped breathing (respiratory arrest), also known as artificial respiration. The common causes are air-way obstruction, drowning, electric shock, drug overdose, and chest or lung (trauma) injury. Never give rescue breathing to a person who is breathing normally. 1. Check unresponsiveness - Tap or gently shake the casualty, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from casualty. 3. Position casualty - Kneel midway between his or her hips and shoulders facing the casualty. Straighten legs and move arm closest to you above casualty's head. Place your hand on the casualty's shoulder and one on the hip. Roll casualty toward you as a unit, move your hand from the shoulder to support the back of the head and neck. Place the casualty's arm nearest you alongside his/her body. 4. Open airway (Head-tilt/Chin lift or Jaw thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not breathing." 5. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth (Fig. 2-8). Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. Look for the chest to rise, listen, and feel for breathing. 6. Check pulse - While maintaining an open airway, locate the Adam's apple with your middle and index fingers. Slide your fingers down into the groove (Fig. 2-9), on the side closest to you. Feel for a carotid pulse for 5 to 10 seconds. If you feel a pulse, say, "No breathing, but there is a pulse." Quickly examine the casualty for signs of bleeding.
Figure 2-8 Mouth-to-Mouth Ventilation
Figure 2-9 Check Carotid Pulse 7. Request medical assistance - Say "No breathing, has a pulse," call (Local emergency number or medical personnel). 8. Rescue breathing (mouth-to-mouth) Maintain an open airway with head-tilt/chin-lift or jaw-thrust maneuver, pinch nose. Open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 1 breath every 5 seconds, each lasting 1 to 1 1/2 seconds. Count aloud "one one-thousand, two one-thousand, three one-thousand, four one-thousand," take a breath, and then give a breath. Look at the chest, listen, and feel for breathing. Continue for 1 minute/12 breaths. 9. Recheck pulse - While maintaining an open airway, locate and feel the carotid pulse for 5 seconds. If you feel a pulse, say, "Has pulse." Look at the chest, listen, and feel for breathing 3 to 5 seconds. If the casualty is not breathing, say, "No breathing." 10. Continue sequence - Maintain an open airway, give 1 breath every 5 seconds, recheck pulse every minute. If pulse is absent, begin CPR. If pulse is present but breathing is absent, continue rescue breathing. If the casualty begins to breathe, maintain an open airway, until medical assistance arrives. Special Situations 1. Air in the stomach (Gastric Distention) - During rescue breathing and CPR, air may enter the stomach in addition to the lungs. To avoid this, keep the casualty's head tilted back, breathe only enough to make the chest rise, and do not give breaths too fast. Do not attempt to expel stomach contents by pressing on the abdomen. 2. Mouth-to-nose breathing - Used when the casualty has mouth or jaw injuries, is bleeding from the mouth, or your mouth is too small to make an air-tight seal. Maintain head tilt with your hand on the forehead, use your other hand to seal the casualty's mouth and lift the chin. Take a deep breath and seal your mouth around the casualty's nose and slowly breathe into the casualty's nose using the procedures for mouth-to-mouth breathing. 3. Mouth-to-stoma breathing - Used when the casualty has had surgery to remove part of the windpipe. They breathe through an opening in the front of the neck, called a stoma. Cover the casualty's mouth with your hand, take a deep breath, and seal your mouth over the stoma and slowly breathe using the procedures for mouth-to-mouth breathing. Do not tilt the head back. (In some situations a person may breathe through the stoma as well as his or her nose and mouth. If the casualty's chest does not rise, you should cover his or her mouth and nose and continue breathing through the stoma). 4. Mouth-to-mask breathing - Used when rescue breathing is required in a contaminated environment, such as after a chemical or biological attack. A resuscitation tube is used to deliver uncontaminated air to the casualty. This resuscitation tube has an adapter at one end that attaches to your mask and a molded rubber mouthpiece at the other end for the mouth of the casualty. 5. Dentures - Leave dentures in place, they provide support to the mouth and cheeks during rescue breathing. If they become loose and block the airway or make it difficult to give breaths, remove them. Circulation Circulation is the movement of blood through the heart and blood vessels. The circulatory system consists of the heart, which pumps the blood, and the blood vessels, which carry the blood throughout the body. Cardiac arrest is the failure of the heart to produce a useful blood flow or the heart has completely stopped beating. The signs of cardiac arrest include unconsciousness, the absence of a pulse, and the absence of breathing. If the casualty is to survive, immediate action must be taken to restore breathing and circulation. Cardiopulmonary Resuscitation (CPR) is an emergency procedure for the casualty who is not breathing and whose heart has stopped beating (cardiac arrest). The procedure involves a combination of chest compressions and rescue breathing. The casualty must be lying face up on a firm surface. Do not assume that a cardiac arrest has occurred simply because the casualty appears to be unconscious. This course is not a substitute for formal training in cardiopulmonary resuscitation (CPR).
Figure 2-11 Xiphoid Process Chest Compressions
Continue CPR - If the casualty has no pulse, give 2 full breaths and continue CPR. Check for a pulse every few minutes. If the pulse is present but breathing is absent, continue rescue breathing. If the casualty begins to breathe, maintain an open airway until medical assistance arrives. Continue CPR until successful, you are exhausted, you are relieved by another trained in CPR, by medical personnel, or the casualty is pronounced dead. Do not interrupt CPR for more than 7 seconds except for special circumstances. CPR with Entry of Second Person When a second person who is trained in administering CPR arrives at the scene, do the following: 1. The second person shall identify himself or herself as being trained in CPR and that they are willing to help. ("I know CPR. Can I help?") 2. The second person should call the local emergency number or medical personnel for assistance if it has not already been done. 3. The person doing CPR will indicate when he or she is tired; and should stop CPR after the next 2 full breaths. 4. The second person should kneel next to the casualty opposite the first person, tilt the casualty's head back, and check for a carotid pulse for 5 seconds. 5. If there is no pulse, the second rescuer should give 2 full breaths and continue CPR. 6. The first person will monitor the effectiveness of CPR by looking for the chest to rise during rescue breathing and feeling for a carotid pulse (artificial pulse) during chest compressions. CPR for Children and Infants If the casualty is an infant (0-1 year old) or child (1-8 years old), do the following: 1. Check unresponsiveness - Infant: Tap or shake shoulder only. Child: Tap or gently shake the shoulder, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from infant or child. 3. Position casualty - Turn casualty on back as a unit, supporting, the head and neck. Place casualty on a firm surface. 4. Open airway (Head-tilt/Chin-lift or jaw thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Infant: Do not overextend the head and neck. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. 5. Give breaths - Open your mouth, take a breath, and make an air-tight seal around the casualty's mouth and nose. Give 2 breaths (puffs for infants), each lasting 1 to 1 1/2 seconds. Pause between each breath. Look for the chest to rise, listen, and feel for breathing. 6. Check pulse - While maintaining an open airway, locate the carotid pulse (Infants: Locate the brachial pulse (Fig. 2-13) on the inside of the upper arm, between the elbow and shoulder). Feel for a pulse for 5 to 10 seconds. Quickly examine the casualty for signs of bleeding. 7. Request medical assistance - If someone responded to your call for help, send them to call the local emergency number or medical personnel. 8. Chest compressions (infant) -
9. Chest compressions (children) -
10. Continue CPR - If the infant or child has no pulse, give 1 breath and continue CPR. Check for a pulse every few minutes. If the pulse is present but breathing is absent, continue rescue breathing (Infant: 20 breaths/min; Child: 15 breaths/min.) If the infant or child begins to breathe, maintain an open airway, until medical assistance arrives. Continue CPR until successful, you are exhausted, you are relieved by another trained in CPR or medical personnel, or the infant or child is pronounced dead. This course is not a substitute for formal training in cardiopulmonary resuscitation (CPR). Top Chapter Two-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. Blood is a fluid that consists of a pale yellow liquid (plasma), red blood cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes). Plasma is the fluid portion of the blood that carries nutrients. Red blood cells give color to the blood and carry oxygen. White blood cells defend the body against infection and attack foreign particles. Platelets are disk shaped and assist in clotting the blood, the mechanism that stops bleeding. 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. In small wounds, only the capillaries are damaged. Deeper wounds result in damage to the veins and arteries. Damage to the capillaries is usually not serious and can easily be controlled with a Band-Aid. Damage to the veins and arteries are more serious and can be life threatening. The adult body contains approximately 5 to 6 quarts of blood (10 to 12 pints). The body can normally lose 1 pint of blood (usual amount given by donors) without harmful effects. A loss of 2 pints may cause shock, a loss of 5 to 6 pints usually results in death. During certain situations it will be difficult to decide whether the bleeding is arterial or venous. The distinction is not important. The most important thing to remember is that all bleeding must be controlled as soon as possible. External Bleeding While administering first aid to a casualty who is bleeding, you must remain calm. The sight of blood is an emotional event for many, and it often appears severe. However, most bleeding is less severe than it appears. Most of the major arteries are deep and well protected by tissue and bone. Although bleeding can be fatal, you will usually have enough time to think and act calmly. There are four methods to control bleeding: direct pressure, elevation, indirect pressure, and the use of a tourniquet. Direct Pressure Direct pressure is the first and most effective method to control bleeding. In many cases, bleeding can be controlled by applying pressure directly (Fig. 3-1) to the wound. Place a sterile dressing or clean cloth on the wound, tie a knot or adhere tape directly over the wound, only tight enough to control bleeding. If bleeding is not controlled, apply another dressing over the first or apply direct pressure with your hand or fingers over the wound. Direct pressure can be applied by the casualty or a bystander. Under no circumstances is a dressing removed once it has been applied. Elevation Raising (elevation) of an injured arm or leg (extremity) above the level of the heart will help control bleeding.
Figure 3-1 Direct Pressure
Figure 3-2 Pressure Points for Control of Bleeding Elevation should be used together with direct pressure. Do not elevate an extremity if you suspect a broken bone (fracture) until it has been properly splinted and you are certain that elevation will not cause further injury. Use a stable object to maintain elevation. Placing an extremity on an unstable object may cause further injury. 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 (Fig. 3-2) 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. Pressure points should be used with caution. Indirect pressure can cause damage to the extremity due to inadequate blood flow. Do not apply pressure to the neck (carotid) pressure points, it can cause cardiac arrest. Indirect pressure is used in addition to direct pressure and elevation. Pressure points in the arm (brachial) and in the groin (femoral) are most often used, and should be thoroughly understood. The brachial artery is used to control severe bleeding of the lower part of the upper arm and elbow. It is located above the elbow on the inside of the arm in the groove between the muscles. Using your fingers or thumb, apply pressure (Fig. 3-2E) to the inside of the arm over the bone. The femoral artery is used to control severe bleeding of the thigh and lower leg. It is located on the front, center part of the crease in the groin. Position the casualty on his or her back, kneel on the opposite side (Fig. 3-2H ) from the wounded leg, place the heel of your hand directly on the pressure point, and lean forward to apply pressure. If the bleeding is not controlled, it may be necessary to press directly over the artery with the flat surface of the fingertips and to apply additional pressure on the fingertips with the heel of your other hand. Tourniquet A tourniquet should be used only as a last resort to control severe bleeding after all other methods have failed and is used only on the extremities. Before use, you must thoroughly understand its dangers and limitations. Tourniquets cause tissue damage and loss of extremities when used by untrained individuals. Tourniquets are rarely required and should only be used when an arm or leg has been partially or completely severed and when bleeding is uncontrollable. The standard tourniquet is normally a piece of cloth folded until it is 3 or more inches wide and 6 or 7 layers thick. A tourniquet can be a strap, belt, neckerchief, towel, or other similar item. A folded triangular bandage makes a great tourniquet. Never use wire, cord, or any material that will cut the skin. To apply a tourniquet (Fig. 3-3), do the following: 1. While maintaining the proper pressure point, place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and wound. 2. Place a pad (roll) over the artery. 3. Wrap the tourniquet around the extremity twice, and tie a half-knot on the upper surface. 4. Place a short stick or similar object on the half-knot, and tie a square knot. 5. Twist the stick to tighten, until bleeding is controlled. 6. Secure the stick in place. 7. Never cover a tourniquet.
Figure 3-3 Applying a Tourniquet 8. Using lipstick or marker, make a 'T" on the casualty's forehead and the time tourniquet was applied. 9. Never loosen or remove a tourniquet once it has been applied. The loosening of a tourniquet may dislodge clots and result in enough blood loss to cause shock and death. Do not touch open wounds with your fingers unless absolutely necessary. Place a barrier between you and the casualty's blood or body fluids, using plastic wrap, gloves, or a clean, folded cloth. Wash your hands with soap and warm water immediately after providing care, even if you wore gloves or used another barrier. Internal Bleeding Internal bleeding, although not usually visible, can result in serious blood loss. A casualty with internal bleeding can develop shock before you realize the extent of their injuries. Bleeding from the mouth, ears, nose, rectum, or other body opening (orifice) is considered serious and normally indicates internal bleeding. The most common sign of internal bleeding is a simple bruise (contusion), it indicates bleeding into the skin (soft tissues). Severe internal bleeding occurs in injuries caused by a violent force (automobile accident), puncture wounds (knife), and broken bones. Signs of internal bleeding include: 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). If you suspect internal bleeding, do the following: 1. Bruise (contusion) - Apply ice or cold pack, with cloth to prevent damage to the skin, to reduce pain and (edema) swelling. 2. Severe internal bleeding:
Nosebleed Nosebleeds (epistaxis) can be caused by an injury, disease, the environment, high blood pressure, and changes in altitude. They frighten the casualty and may bleed enough to cause shock. If a fractured skull is suspected as the cause, do not stop the bleeding. Cover the nose with a loose, dry, sterile dressing and call the local emergency number or medical personnel. If the casualty has a nosebleed due to other causes, do the following: 1. Keep the casualty quiet, sitting with head tilted forward. 2. Pinch the nose shut (if there is no fracture), place ice or cold packs to the bridge of the nose, or put pressure on the upper lip just below the nose. Inform the casualty not to rub, blow, or pick his or her nose. Seek medical assistance if the nosebleed continues, bleeding starts again, or bleeding is because of high blood pressure. If the casualty loses consciousness, place them on their side to allow blood to drain from the nose and call the local emergency number or medical personnel. Foreign bodies in the nose usually occur among children. First aid consists of seeking professional medical attention. Nasal damage and the possibility of pushing the object farther up the nose can result from searching and attempts at removal by unqualified personnel. Casualties with severe external bleeding and suspected internal bleeding must be seen by medical personnel as soon as possible. All casualties with external and internal bleeding should be treated for shock. Top Chapter Three-Shock Shock, is the failure of the heart and blood vessels (circulatory system) to maintain enough oxygen-rich blood flowing (perfusion) to the vital organs of the body. There is shock to some degree with every illness or injury; shock can be life threatening. The principles of prevention and control are to recognize the signs and symptoms and to begin treating the casualty before shock completely develops. It is unlikely that you will see all the signs and symptoms of shock in a single casualty. Sometimes the signs and symptoms may be disguised by the illness or injury or they may not appear immediately. In fact many times, they appear hours later. The usual signs and symptoms (Fig. 4-1) of the development of shock are: 1. Anxiety, restlessness and fainting. 2. Nausea and vomiting. 3. Excessive thirst (polydipsia). 4. Eyes are vacant, dull (lackluster), large (dilated) pupils. 5. Shallow, rapid (tachypnea), and irregular breathing. 6. Pale, cold, moist (clammy) skin. 7. Weak, rapid (tachycardia), or absent pulse.
Figure 4-1 Symptoms of Shock Hypovolemic Shock Hypovolemic shock is caused by a decreased amount of blood or fluids in the body. This decrease results from injuries that produce internal and external bleeding, fluid loss due to burns, and dehydration due to severe vomiting and diarrhea. Neurogenic Shock Neurogenic shock is caused by an abnormal enlargement of the (vasodilation) blood vessels and pooling of the blood to a degree that adequate blood flow cannot be maintained. Simple fainting (syncope) is a variation, it is the result of a temporary pooling of the blood as a person stands. As the person falls, blood rushes back to the head and the problem is solved. Psychogenic Shock Psychogenic shock is a "shock like condition" produced by excessive fear, joy, anger, or grief. Shell shock is a psychological adjustment reaction to stressful wartime experiences. Care for shell shock is limited to emotional support and transportation of the casualty to a medical facility. Anaphylactic Shock Anaphylactic (allergic) shock occurs when an individual is exposed to a substance to which his or her body is sensitive. The individual may experience a burning sensation, loss of voice, itching (pruritus), hives, severe swelling, and difficulty breathing. The causative agents are injection of medicines, venoms by stinging insects and animals, inhalation of dust and pollens, and ingestion of certain foods and medications. Individuals with known sensitivities carry medication in commercially prepared kits. Prevention and Treatment of Shock While administering first aid to prevent or treat shock, you must remain calm. If shock has not completely developed, the first aid you provide may actually prevent its occurrence. If it has developed, you may be able to keep it from becoming fatal. It is extremely important that you render first aid immediately. To provide first aid for shock, do the following: 1. Maintain open airway - Head-tilt/chin-lift or jaw-thrust. 2. Control bleeding - Direct pressure, elevation, indirect pressure, or tourniquet if indicated. 3. Position casualty - Place the casualty on his or her back, with legs elevated 6 to 12 inches (Fig. 4-2). If it is possible, take advantage of a natural slope of ground and place the casualty so that the head is lower than the feet. If they are vomiting or bleeding around the mouth, place them on their side, or back with head turned to the side. If you suspect head or neck injuries, or are unsure of the casualty's condition, keep them lying flat. 4. Splint - Suspected broken and dislocated bones in the position in which they are found. Do not attempt to straighten broken or dislocated bones, because of the high risk of causing further injury. Splinting not only relieves the pain without the use of drugs but prevents further tissue damage and shock. Pain and discomfort are often eliminated by unlacing or cutting a shoe or loosening tight clothing at the site of the injury. A simple adjustment of a bandage or splint will be of benefit, especially when accompanied by encouraging words.
Figure 4-2 Position for Treatment of Shock 5. Keep the casualty comfortable, and warm enough to maintain normal body temperature. If possible, remove wet clothing and place blankets underneath the casualty. Never use an artificial means of warming. 6. Keep the casualty as calm as possible. Excitement and excessive handling will aggravate their condition. Prevent the casualty from seeing his or her injuries, reassure them that their injuries are understood and that professional medical assistance will arrive as soon as possible. 7. Give nothing by mouth - Do not give the casualty anything to eat or drink because it may cause vomiting. If the casualty complains of thirst, wet his or her lips with a wet towel. 8. Request medical assistance - Ask bystanders to call the local emergency number or medical personnel. Top Chapter Four-Soft Tissue injuries The most common injuries (trauma) seen in a first aid setting are soft tissue injuries with bleeding and shock. Injuries that cause a break in the skin, underlying soft tissue, or other body membrane are known as a wound. Injuries to the soft tissues vary from bruises (contusion) to serious cuts (lacerations) and puncture wounds in which the object may remain in the wound (impaled objects). The two main threats with these injuries are bleeding and infection. Classification of Wounds Wounds are classified according to their general condition, size, location, the manner in which the skin or tissue is broken, and the agent that caused the wound. It is usually necessary for you to consider some or all of these factors in order to determine what first aid treatment is appropriate. General Condition If the wound is new, first aid consists mainly of controlling the bleeding, treating for shock, and reducing the risk of infection. If the wound is old and infected, first aid consists of keeping the casualty quiet, elevating the injured part, and applying a warm wet dressing. If the wound contains foreign objects, first aid may consist of removing the objects if they are not deep. Do not remove impaled objects or objects embedded in the eyes or skull. Size Generally, large wounds are more serious than small ones and they usually involve severe bleeding, more damage to the underlying tissues and organs, and a greater degree of shock. However, small wounds are sometimes more dangerous than large ones: they may become infected more readily due to neglect. The depth of a wound also is important because it may lead to a complete (through & through) perforation of an organ or the body, with the additional complication of an entrance and exit wound. Location Since a wound can cause serious damage to deep structures, as well as to the skin and tissues below it, the location is an important consideration. A knife wound to the chest is likely to puncture a lung and cause difficulty breathing. The same type of wound in the abdomen can cause a life-threatening infection, internal bleeding, or puncture the intestines, liver, or other vital organs. A bullet wound to the head may cause brain damage, but a bullet wound to the arm or leg, may cause no serious damage. Types of Wounds As the first line of defense against most injuries, soft tissues are most often damaged. There are two types of soft tissue injuries: open and closed. An open wound is one in which the skin surface has been broken, a closed wound is where the skin surface is unbroken but underlying tissues have been damaged. Closed Wounds A blunt object that strikes the body will damage tissues beneath the skin. When the damage is minor, the wound is called a bruise (contusion). When the tissue has extensive damage, blood and fluid collect under the skin causing discoloration (ecchymosis), swelling (edema), and pain. First aid consists of applying ice or cold packs to reduce swelling and relieve discomfort. To guard against frostbite, never apply ice or cold packs directly to the skin. Hematomas are the result of a severe blunt injury with extensive soft tissue damage, tearing of large blood vessels, and pooling of large amounts of blood below the skin. With large hematomas, look for broken bones, especially if deformity is present. First aid consists of applying ice or cold packs to reduce swelling and relieve pain, direct pressure (manual compression) to help control internal bleeding, splinting, and elevation. When large areas of bruising are present, shock may develop. Open Wounds In open soft tissue injuries, the protective layer of the skin has been damaged. This damage can cause serious internal and external bleeding. Once the protective layer of skin has been broken, the wound becomes contaminated and may become infected. When you consider the way in which the skin or tissue has been broken, there are six basic types of open wounds: abrasions, amputations, avulsions, incisions, lacerations, and punctures. Many wounds are a combination of two or more of these types. Abrasions Abrasions are caused when the skin is rubbed or scraped off. Rope burns, floor burns, and skinned knees or elbows are common examples of abrasions. Abrasions easily can become infected, because dirt and germs are usually ground into the tissues. There is normally minimal bleeding or oozing of clear fluid. Amputations Amputations (traumatic) are the non-surgical removal of the fingers, toes, hands, feet, arms, legs, and ears from the body. Bleeding is heavy and normally requires a tourniquet, to control the blood flow. There are three types of amputation: 1. Complete - Body part is completely torn off (severed). If the casualty has an amputation, do the following: 1. Establish and maintain the airway, breathing, and circulation (ABCs). 2. Control bleeding with direct pressure, elevation, indirect pressure, or tourniquet only as a last resort, never remove or loosen a tourniquet once it has been applied. 3. Apply dressing to the stump with an ace wrap to replace direct pressure. 4. Treat for shock. 5. Request medical assistance immediately. Avulsions An avulsion is an injury in which the skin is torn completely away from a body part or is left hanging as a flap. Usually, there is severe bleeding. If possible, obtain the part that has been torn away, rinse it in water, wrap it in a dry sterile gauze, seal it in a plastic bag, and send it on ice with the casualty. Do not allow part to freeze and do not submerge in water. If the skin is still attached, fold the flap back into its normal position. Incisions Incisions, commonly called cuts, are wounds made by sharp cutting instruments such as knives, razors, or broken glass. Incisions tend to bleed freely because the blood vessels are cut cleanly, without ragged edges. The wound edges are smooth and there is little damage to the surrounding tissues. Of all the classes of open wounds, incisions are the least likely to become infected. Lacerations Lacerations are wounds that are torn, rather than cut. They have ragged, irregular edges and torn tissue underneath. These wounds are usually made by a blunt, rather than a sharp, object. A wound made by a dull knife is more likely to be a laceration than an incision. Many of the wounds caused by machinery accidents are lacerations, often complicated by crushed tissues. Lacerations are frequently contaminated with dirt, grease, or other materials that are ground into the wound; they are very likely to become infected. Punctures Punctures are caused by objects that enter the skin while leaving a surface opening. Wounds made by nails, needles, wire, knives, and bullets are normally punctures. Small puncture wounds usually do not bleed freely; however, large puncture wounds may cause severe internal bleeding. The possibility of infection is great in all puncture wounds, especially if the penetrating object is contaminated. Perforation (through & through) is a variation, it is the result of a penetrating object entering, passing through, and exiting the body. Causes Although it is not necessary to know what object or method has caused a wound, it is helpful. Knowing what caused the wound and how it occurred can help you determine its general condition, possible size, type, and seriousness of the wound. This information will help you provide the appropriate first aid to the casualty. Treatment of Wounds First aid treatment for all wounds consists of controlling the flow of blood, treating for shock, and preventing infection. When providing first aid to casualty with multiple injuries, treat the wounds that appear to be life-threatening first. Since most of the body is covered by clothing, carefully examine the entire body for bleeding. When necessary, tear or cut clothing away from the wound because excessive movement of the injured part will cause pain and additional damage. Bleeding After establishing an adequate open airway, the main concern will be to control bleeding, by direct pressure and elevation. Indirect pressure and the use of a tourniquet should be used only if direct pressure and elevation do not control the bleeding. Bleeding control is discussed further in Chapter 3 . A protective covering (dressing) that is properly applied should adequately control the bleeding. In cases of severe bleeding, you may need to double the dressing. Never remove a dressing that is soaked with blood to replace it with another; just place the new dressing over the old one. Shock Shock may be severe in a casualty who has lost a large amount of blood or suffered a serious injury. The causes and treatment of shock are discussed further in Chapter 4. Infection Infections can occur in any wound. Infection is a hazard in wounds that do not bleed freely; in wounds where tissue is torn or the skin falls back into place and prevents the entrance of air; and in wounds that involve the crushing of tissue. Incisions, in which there is a free flow of blood and relatively little crushing of tissues, are the least likely to become infected. The signs of infection are tenderness, redness, heat, swelling, and a discharge. Serious infections develop red streaks that lead from the wound to the heart. Infections are dangerous, especially in the area of the nose and mouth. From this area, (Fig. 5-1) infections spread easily into the bloodstream, causing blood poisoning (septicemia), and into the brain, causing a collection of pus (abscess) and infection. Small wounds should be washed immediately with soap and water, dried, and treated with an application of a mild, non-irritating antiseptic. Apply a dressing if necessary. Make no attempt to wash a large wound and do not apply an antiseptic. Cover the wound with a dry, sterile dressing. Further treatment of large wounds should be conducted by medical personnel. All puncture wounds must be evaluated by medical personnel.
Figure 5-1 Danger Zone for Infection Foreign Bodies Many wounds contain foreign bodies. Wood or glass splinters, bullets, metal fragments, wire, fishhooks, nails, and small particles from grinding wheels are examples of materials that are found in wounds. In most cases, first aid will include the removal of this material if the wound is minor and the object is near the surface and exposed. However, first aid does not include the removal of deeply embedded objects, powdered glass, or any scattered material. Never attempt to remove bullets, examine the casualty to find out whether the bullet remains in the body by looking for both an entrance and exit wound. The general rule is: Remove foreign objects from a wound ONLY when you can do so easily and without causing further damage. Do not attempt to remove an object that is embedded in the eye or that has penetrated the eye. Treatment of Specific Conditions It is impossible to list all wounds in simple categories. Some require special treatment and precautions. You may see wounds that are not described in this course, but most wounds can be treated by calmly remembering the general treatment of wounds. Eye Wounds Foreign bodies such as particles of dirt, sand, paint chips, or fine pieces of metal frequently find their way into the eyes. They not only cause discomfort, but if not removed, they can cause inflammation and infection. Fortunately, through an increased flow of tears, nature dislodges many of these particles before any damage is done. Never let the casualty rub the eye, since rubbing, can cause scratches (abrasions) to the eye and can push a foreign body deeper into the eye, causing further damage. Gently flush the casualty's eye with water at least 15 to 20 minutes. If flushing the eye is not successful in removing the foreign body, patch both eyes and get the casualty to medical personnel. It is always safer to send the casualty to medical personnel than for you to attempt to remove foreign bodies. If the casualty has an object embedded in, or penetrating from, the eye, or the eyeball is protruding from the socket, do the following: 1 .Take a thick dressing or several dressings and cut a hole in the middle, large enough to go over the eye without touching the object. If you cannot cut a hole in the dressing, you can build several dressings around the object. 2. Take a paper cup or other object that is wide enough and strong enough to adequately protect the object without putting pressure on the eye. Place this over the top of the object. Close and cover the unaffected eye to minimize movement of the injured eye. 3. Take a roller bandage and wrap it over the cup and around the head several times ensuring that the cup and dressing are snug enough not to come off, but not tight enough to cause discomfort. When finished, this type of dressing will adequately protect the eye. Laceration of the Eyelids Soft tissues around the eye bleed extensively. This bleeding may make the wound look more serious than it is. However, the bleeding can be controlled easily with a pressure dressing. Before any pressure is applied to the eye, make sure that the eyeball is not cut. If the eye is cut, do not apply pressure to the eye, even to stop bleeding from the eyelid. Pressing on the eye will cause the fluid to leak out, and will result in irreparable damage. If the eyelid is cut and you find fragments of skin, rinse them in water, wrap in a dry sterile gauze, seal in a plastic bag, and send it on ice with the casualty. Do not allow part to freeze and do not submerge in water. If the skin is still attached, fold the flap back into its normal position. When you cover the injured eye you must also cover the good eye. The eyes move together, and even when the injured eye is patched it will move when the good eye moves. Tell the casualty what you are doing, this will reduce their fears of not being able to see. Foreign Objects in the Ear Foreign bodies such as particles of dirt, paint chips, or small insects find their way into the ears. They not only cause discomfort but, if not removed, they can cause inflammation and infection. Never insert anything into the ear to dislodge foreign bodies because you can damage the lining of the ear or cut (perforate) the ear drum. Do not attempt to flush objects out with water; many absorb water and can cause damage from swelling. In the case of insects, if it is alive, shining a light into the ear may attract the insect and cause it to come out. It is always safer to send the casualty to medical personnel than for you to attempt to remove foreign bodies. Head Wounds Injuries to the head (scalp) can occur as a result of diving, automobile accidents, falls, blunt trauma, knives, bullets, and many other causes. Head wounds can be open or closed. In open head wounds there is an obvious injury in which there is normally a lot of bleeding. Closed head wounds may not be obvious, many times you will have to treat the casualty based on how the accident happened. You may see only the delayed symptoms, such as a seizure, confusion, or personality changes. Head wounds must be treated with particular care, since there is always the possibility of brain damage. If you suspect the casualty has suffered a head injury, look for the following: 1. Depressions, lacerations, deformities, bruising around the eyes (Raccoon's Sign) or behind the ears (Battle's Sign). 2. Never touch a wound, examine a wound to determine depth, separate the edges of a wound, or remove impaled objects. 3. Check the eyes: Are the pupils (constricted) small, (dilated) large, equal, or unequal? 4. Blood or clear (cerebrospinal) fluid dripping from the nose or ears. (Cover loosely with a sterile dressing to absorb but not stop the flow). If you suspect a head injury, do the following: 1. Position the casualty flat, stabilize the head and neck as you found them by placing your hands on both sides of the head. 2. Establish and maintain open airway using the jaw-thrust maneuver. Note that the head is not tilted and the neck is not extended. Check the airway, breathing, and circulation (ABC's). 3. Finger sweep to remove any foreign bodies from the mouth. 4. Maintain a neutral position of the head and neck and, if possible, apply a cervical collar or improvised (towel) collar. 5. Control bleeding using gentle, continuous pressure. Never apply direct pressure if the skull is depressed or bone fragments are seen. 6. Apply dressing - Do not use direct pressure or tie knots over the wound. Apply ice or cold packs with cloth to prevent damage to the skin. 7. Treat for shock - Casualtyies with suspected head and neck injuries are to remain flat. Do not raise the casualty's feet. If casualty is vomiting or bleeding around the mouth, place them on their side keeping the neck straight. Do not give anything to eat or drink. 8. Request medical assistance immediately - Time is critical. Facial Wounds Facial wounds are treated, generally, like other flesh wounds. However, ensure that the tongue or soft tissue does not cause an airway obstruction. Keep the nose and throat clear of all foreign material and position the casualty so that blood will drain out of the mouth and nose. Facial wounds and scalp wounds bleed freely. Any casualty that has suffered a facial wound that involves the eye, eyelids, or the tissues around the eye must receive professional medical attention as soon as possible. First aid for other facial wounds is the same as head wounds. Standard First Aid Boxes Non-medical personnel are an important element in providing first aid to casualties prior to the arrival of professional medical personnel. Many lives have been saved by the first aid rendered by a shipmate. Standard first aid boxes are distributed throughout a ship to provide easy access to first aid supplies. The number of first aid boxes and their location depends on the ship's mission and the size of her crew. Various dressings, wire splints, tape, Band-Aids, tourniquets, skin pencils, and other first aid supplies are included in these boxes. Each box is secured with a wire or plastic seal that can be easily broken. The seals are used to identify whether the kit has been opened. A broken seal indicates that the first aid box must be inventoried and restocked. The standard first aid box has three compartments. Each compartment should have a plastic bag that is complete with the basic first aid supplies. Take one of these bags with you on your way to the casualty. Failure to take a bag to the scene may result in you having to go back for supplies. The box does not contain needles, syringes, or medications; but does contain the proper supplies needed to render first aid until medical assistance arrives. First aid boxes are for emergency use only! Report all broken seals to medical personnel as soon as possible. It is important that you know the contents and locations of these boxes. Dressings A dressing is a protective covering for a wound and is used to control bleeding and prevent contamination of the wound. A compress is a sterile pad that is placed directly on the wound. A bandage is material used to hold a compress in place. When applying a dressing, ensure that it remains as sterile as possible. The part of the dressing that is placed against the wound must never touch your fingers, clothing, or any un-sterile object. If you drop, a dressing across the casualty's skin or it slips after it is in place, the dressing should not be used. Battle Dressings Battle dressings are used most often aboard ship and in the field. Each dressing is complete (no other materials are needed) with four tabs which help in applying and securing the dressing. They have "other side next to wound" marked on the outer side. This will help you in (Fig. 5-2) placing the sterile side against the wound. Unless contraindicated, to assist in controlling the bleeding, tie the knot of the dressing over the wound.
Figure 5-2 Battle Dressing Compresses Emergencies may occur when it is not possible to obtain a sterile compress. During these situations, use the cleanest cloth available, a freshly laundered handkerchief, towel, or shirt. Unfold the material carefully so that you do not touch the part that will be placed against the wound. The compress should be large enough to cover the entire wound and extend at least 1 inch beyond its edges. If a compress is not large enough, the edges of the wound will become contaminated. Materials that will stick to a wound or may be difficult to remove should never be used directly on a wound. Absorbent cotton, adhesive tape, and paper napkins are examples of materials that should never come in contact with a wound. Bandages Bandages are strips or rolls of gauze or other materials that are used for wrapping or binding any part of the body and to hold compresses in place. It is not necessary to take time to ensure that the bandage resembles the textbook pictures. However, it is important that the dressing controls the bleeding, prevents further contamination, and protects the wound from further injury. Some of the most commonly used bandages are the roller bandage and the triangular bandage. Roller Bandages The roller bandage (Fig. 5-3) consists of a long strip of material (usually gauze, or elastic) that is rolled and is available in several widths and lengths. Most are sterile, so pieces may be used as a compress on wounds. A strip of roller bandage can be used to make a four-tailed bandage (Fig. 5-4A), by splitting the cloth from each end, leaving as large a center as needed. This type of bandage is used to hold a compress (Fig. 5-4B) on the chin, or (Fig. 5-4C) the nose.
Figure 5-3 Roller Bandages
Figure 5-4 Four Tailed Bandage Triangular Bandages Triangular bandages (Fig. 5-5) are usually made of muslin. They are useful because they can be folded in a variety of ways to fit almost any part of the body. Padding can be added to areas that may become uncomfortable.
Figure 5-5 - Triangular Bandage
Figure 5-6 Cravat Bandage The triangular bandage can be folded to make a cravat bandage, which is useful in controlling bleeding from wounds of the scalp or forehead. To make a cravat bandage, bring the point of the triangular bandage (Fig. 5-6) to the middle of the base and continue to fold until a 2-inch width is obtained. If specially prepared bandages are not available, use whatever material you can find. Remember that the basic purpose of a bandage is to hold the sterile compress in place. Any material or method of application that does not cause further injury to the casualty will be acceptable. Material used as a bandage does not have to be sterile, since it will not come in direct contact with the wound. However, it should be as clean as possible. Cloth bandages should be fastened by tying the ends with a square knot or by tacking the ends with safety pins. If you use a knot to fasten the bandage, be sure to use a square knot. This knot is easy to tie, will not slip, and can be untied quickly. Place the knot so it will cause the least amount of discomfort to the casualty and where it can be removed easily and quickly. Bandages should be applied firmly but not too tight. A loose bandage will slip off the wound. A bandage that is too tight can cut off the blood supply to the injured part and cause damage to the blood vessels and tissues. When you fasten a bandage around an arm or leg, leave the fingers or toes uncovered. If they become blue or swollen, you will know that the bandage is too tight and should be loosened. Figures 5-7 through 5-12 show some of the uses of the roller, triangular, and cravat bandage.
Figure 5-7 - Roller Bandage for the Hand and Wrist
Figure 5-8 - Roller Bandage for the Ankle and Foot
Figure 5-9 - Triangular Bandage for the Head
Figure 5-10 - Triangular Bandage for the Chest
Figure 5-11 - Cravat Bandage for the Elbow or Knee
Figure 5-12 - Cravat Bandage for the Arm, Forearm, Leg, or Thigh Top Chapter Five-Bones, Joints and Muscles Accidents cause many different types of injuries to bones, joints and muscles. When rendering first aid, you must be alert for signs of broken bones (fractures), dislocations, sprains, strains, and bruises (contusions). Injuries to the joints and muscles often occur together, and it is difficult to tell whether the injury is to a joint, muscle, or tendon. It is difficult to tell joint or muscle injuries from fractures. When in doubt, always treat the injury as a fracture. The primary process of first aid for fractures consists of immobilizing the injured part to prevent the ends of broken bones from moving and causing further damage to the nerves, blood vessels, or internal organs. Splints are also used to immunize injured joints or muscles and to prevent the enlargement of severe wounds. Before learning first aid for injuries to the bones, joints, and muscles, you need to have a general understanding of the use of splints. Splints In an emergency, almost any firm object or material will serve as a splint. Thus, umbrellas, canes, rifles, sticks, oars, wire mesh, boards, cardboard, pillows, and folded newspapers can be used. A fractured leg can be immobilized by securing it to the uninjured leg. Whenever possible, use ready-made splints such as the pneumatic or traction splints. Splints should be lightweight, padded, strong, rigid, and long enough to reach the joint above and below the fracture. If they are not properly padded, they will not adequately immobilize the injured part. Articles of clothing, bandages, blankets, or any soft material may be used as padding. If the casualty is wearing heavy clothes, you may be able to apply the splint on the outside, allowing the clothing to serve as a part of the required padding. Fasten splints in place with bandages, adhesive tape, clothing, or any suitable material. One person should hold the splints in position while another person fastens them. Splints should be applied tight, but never tight enough to stop the circulation of blood. When applying splints to the arms or legs, leave the fingers or toes exposed. If the tips of the fingers or toes turn blue or cold, loosen the splints or bandages. Injuries will probably swell, and splints or bandages that were applied correctly may later be too tight. Fractures A break or rupture in a bone is called a fracture. There are two basic types; open and closed. A closed fracture does not produce an open wound in the skin, also known as a simple fracture (Fig. 6-lA). An open fracture produces an open wound in the skin, also known as a compound fracture (Fig. 6-1B). Open wounds are caused by the sharp end of broken bones pushing through the skin; or by an object such as a bullet that enters the skin from the outside. Open fractures are usually more serious than closed fractures. They involve extensive tissue damage and are likely to become infected. Closed fractures can be turned into open fractures by rough or careless handling of the casualty. Always use extreme care when treating a suspected fracture.
Figure 6-1 - Types of Fractures It is not easy to recognize a fracture. All fractures, whether open or closed, can cause severe pain or shock. Fractures can cause the injured part to become deformed, or to take an unnatural position. Compare the injured to the uninjured part if you are unsure of a deformity. Pain, discoloration, and swelling may be at the fracture site, and there may be instability if the bone is broken clear through. It may be difficult or impossible for the casualty to move the injured part. If movement is possible, the casualty may feel a grating sensation (crepitus) as the ends of the bones rub against each other. If a bone is cracked rather than broken, the casualty may be able to move the injured part without much difficulty. An open fracture is easy to see if the end of the bone sticks out through the skin. If the bone does not stick out, you might see a wound but fail to see the broken bone. It can be difficult to tell if an injury is a fracture, dislocation, sprain, or strain. When in doubt, splint. If you suspect a fracture, do the following: 1. Control bleeding with direct pressure, indirect pressure, or tourniquet only as a last resort. 2. Treat for shock. 3. Monitor the airway, breathing, and circulation (ABCs). 4. Remove all jewelry from the injury site, unless the casualty objects. Gently cut clothing away so that you don't move the injured part and cause further damage. 5. Check the distal pulse of the injured part, if pulse is absent, gently move injured part to restore circulation. 6. Cover all wounds with sterile dressings, including open fractures. Do not push bone ends back into the skin. Avoid excessive pressure on the wound. 7. Apply splint - Do not attempt to straighten borken bones.
8. Request medical assistance - All suspected fractures require professional medical treatment. Fracture of the Forearm There are two long bones in the forearm, the radius and the ulna. When both are broken, the arm usually appears to be deformed. When only one is broken, the other acts as a splint and the arm retains a more natural appearance. Fractures usually result in pain, tenderness, swelling, and loss of movement. In addition to the general procedures above, apply a pneumatic (air) splint if available; if not, apply two padded splints; one on the top (backhand side), and one on the bottom (palm side). Make sure the splints are long enough to extend from the elbow to the wrist. Once the forearm is sprinted, place the forearm across the chest. The palm of the hand should be turned in with the thumb pointing up. Support the forearm in this position (Fig. 6-2) with a wide sling and cravat bandage. The band should be raised about 4 inches above the level of the elbow.
Figure 6-2 - Sling Used to Support a Fractured Forearm Fracture of the Upper Arm There is one bone in the upper arm, the humerus. If the fracture is near the elbow, the arm is likely to be straight with no bend at the elbow. Fractures usually result in pain, tenderness, swelling, and loss of movement. In addition to the general procedures above, do the following: If the fracture is in the upper part of the arm, near the shoulder, place a pad or folded towel in the armpit, bandage the arm securely to the body, and support the forearm in a narrow sling. If the fracture is in the middle of the upper arm, you can use one well padded splint on the outside of the arm. The splint should extend from the shoulder to the elbow. Secure the arm firmly to the body and support the forearm in a sling (Fig. 6-3). If the fracture is at or near the elbow, the arm may be either bent or straight. Regardless what position you find the arm, do not attempt to straighten or move it. Gently splint the arm in the position in which you find it.
Figure 6-3 - Splint and Sling for a Fractured Upper Arm Fracture of the Rib Make the casualty as comfortable as possible so that the chances of further damage to the lungs, heart, or chest wall is minimized. A common finding in all casualties with fractured ribs is pain at the site of the fracture. Ask the casualty to point to the exact area of pain to assist you in determining the location of the fracture. Deep breathing, coughing, or movement is usually painful. The casualty should remain still and may lean toward the injured side, with a hand over the fracture to immobilize the chest and ease the pain. Simple rib fractures are not bound, strapped, or taped if the casualty is comfortable. If the casualty is more comfortable with the chest immobilized, use a sling and swathe (Fig. 6-4). Place the arm on the injured side against the chest, with the palm flat, thumb up, and the forearm raised to a 45-degree angle. Immobilize the chest, using wide strips of bandage (ace wrap) to secure the arm to the chest.
Figure 6-4 - Swathe Bandage for Fractured Rib Victim Fracture of the Thigh There is one long bone in the upper leg between the kneecap and the pelvis, the femur. When the femur is fractured, any attempt to move the leg results in a spasm of the muscles that causes severe pain. The leg is not stable, and there is complete loss of control below the fracture. The leg usually assumes an unnatural position, with the toes pointing outward. The injured leg is shorter than the uninjured one due to the pulling of the thigh muscles. Serious bleeding is a real danger since the broken bone may cut the large (femoral) artery. Shock usually is severe.
Figure 6-5 - Boards Used as Emergency Splint for Fractured Thigh In addition to the general procedures above, gently straighten the leg, apply two padded splints, one on the outside and inside of the injured leg. The outside splint should reach from the armpit to the foot, the inside splint from the groin to the foot. The splint should be secured in five places: (1) around the ankle, (2) over the knee, (3) just below the hip, (4) around the pelvis, and (5) just below the armpit (Fig. 6-5). The legs can then be tied together to support the injured leg. Do not move the casualty until the leg has been splinted. Fracture of the Lower Leg There are two long bones in the lower leg, the tibia and fibula. When both are broken, the leg usually appears to be deformed. When only one is broken, the other acts as a splint and the leg retains a more natural appearance. Fractures usually result in pain, tenderness, swelling, and loss of movement. A fracture just above the ankle is often mistaken for a sprain. In addition to the general procedures above, gently straighten the leg, apply a pneumatic (air) splint if available; if not, apply three padded splints, one on each side and underneath the leg. Place extra padding (Fig. 6-6) under the knee and just above the heel. The splint should be secured in four places: (1) just below the hip, (2) just above the knee, (3) just below the knee, and (4) just above the ankle. Do not place the straps over the area of the fracture. A pillow and two side splints also work well. Place a pillow beside the injured leg, then gently lift the leg and place it in the middle of the pillow. Bring the edges of the pillow around to the front of the leg and pin them together. Then place one splint on each side of the leg, over the pillow, and secure them in place with a bandage or tape. Fracture of the Kneecap The kneecap is also known as the patella. Although fractures of the kneecap do occur, the more common injuries are dislocations and sprains. In addition to the general procedures above, gently straighten the leg, apply a pneumatic (air) splint if available; if not, apply a padded board under the injured leg. The board should be at least 4 inches wide and should reach from the buttock to the heel. Place extra padding under the knee and just above the heel. The splint should be secured in four places: (1) just below the hip, (2) just above the knee, (3) just below the knee, and (4) just above the ankle. Do not place the straps directly over the kneecap.
Figure 6-6 - Immobilization of Fractured Kneecap Fracture of the Collarbone The collarbone is also known as the clavicle. When standing, the injured shoulder is lower, and the casualty is unable to raise the arm above the shoulder. The casualty attempts to support the shoulder by holding the elbow. This is the typical stance taken by a casualty with a broken collarbone. Since the collarbone lies near the surface of the skin, you may be able to see the point of fracture by the deformity and tenderness. In addition to the general procedures above, gently bend the casualty's arm and place the forearm across the chest. The palm of the hand should be turned in, with the thumb pointing up. Support the arm in this position (Fig. 6-7) with a wide sling. The hand should be raised about 4 inches above the level of the elbow. A wide roller bandage (or any wide strip of cloth) may be used to secure the casualty's arm to the body.
Figure 6-7 - Sling for Imobilizing Fractured Clavicle Fracture of the Jaw The lower jaw is also known as the mandible. The casualty may have difficulty breathing, difficulty in talking, chewing, and swallowing, and have pain of movement of the jaw. The teeth may be out of line, and the gums may bleed, and swelling may develop. The most important consideration is to maintain an adequate open airway. In addition to the general procedures above, apply a four-tailed bandage (Fig. 6-8), be sure the bandage pulls the lower jaw forward. Never apply a bandage that forces the jaw backward, since this may interfere with breathing. The bandage must be firm enough to support and immobilize the lower jaw, but it must not press against the casualty's throat. The casualty should have scissors or a knife to cut the bandage in case of vomiting.
Figure 6-8 - Four Tailed Bandage for a Fractured Jaw Fracture of the Skull The skull is also known as the cranium. The primary danger is that the brain may be damaged. Whether or not the skull is fractured is of secondary importance. The first aid procedures are the same in either case, and the primary intent is to prevent further damage. Some injuries that fracture the skull do not cause brain damage. But brain damage can result from minor injuries that do not cause damage to the skull. It is difficult to determine whether an injury has affected the brain, because symptoms of brain damage vary. A casualty who has suffered a head injury must be handled carefully and given immediate medical attention. Signs and symptoms that may indicate brain damage include:
If you suspect a head injury, do the following: 1. Position the casualty flat, stabilize the head and neck as you found them by placing your hands on both sides of the head. 2. Establish and maintain an open airway - jaw-thrust maneuver. Note that the head is not tilted and the neck is not extended. Check the airway, breathing, and circulation (ABCs). 3. Finger sweep to remove any foreign bodies from the mouth. 4. Maintain neutral position of head and neck and, if possible, apply a cervical collar or improvised (towel) collar. 5. Apply dressing - Do not use direct pressure or tie knots over the wound. Apply ice or cold packs if available. (For blood or clear fluid from the nose or ears, cover loosely with a sterile dressing to absorb but not stop the flow). 6. Treat for shock - Casualties with suspected head and neck injuries are to remain flat. Do not raise the casualty's feet. If they are vomiting or bleeding around the mouth, place them on their side keeping the neck straight. Do not give anything to eat or drink. 7.Request medical assistance immediately - Time is critical. Head and neck injuries should be treated by professional medical personnel, if possible. Do not attempt procedures that you are not trained to do. Fracture of the Spine The spine is also known as the backbone or spinal column. If the spine is fractured, the spinal cord may be crushed, cut, or damaged so severely that death or paralysis may occur. If the fracture occurs in a way that the spinal cord is not damaged, there is a chance of complete recovery. Twisting or bending of the neck or back, whether due to the original injury or careless handling, is likely to cause irreparable damage. The primary symptoms of a fractured spine are pain, shock, and paralysis. Pain may be acute at the point of fracture and radiate to other parts of the body. Shock is usually severe, but the symptoms may be delayed. Paralysis occurs if the spinal cord is damaged. If the casualty cannot move the legs, the injury is probably in the back; if the arms and legs cannot move, the injury is probably in the neck. A casualty who has back or neck pain following an injury should be treated for a fractured spine. If you suspect a fractured spine, do the following: 1. Position the casualty flat, stabilize the head and neck as you found them by placing your hands on both sides of the head. 2. Establish and maintain an open airway - jaw-thrust maneuver. Note that the head is not tilted and the neck is not extended. Check the airway, breathing, and circulation (ABCs). 3. Finger sweep to remove any foreign bodies from the mouth. 4. Maintain neutral position of head and neck and, if possible, apply a cervical collar or improvised (towel) collar. 5. Keep the casualty comfortable and warm enough to maintain normal body temperature. 6. Treat for shock - Casualties with suspected spinal injuries are to remain flat. Do not raise the casualty's feet. If the casualty is vomiting or bleeding around the mouth, place them on their side keeping the neck straight. Do not give anything to eat or drink. 7. Request medical assistance immediately - Time is critical. Do not move the casualty unless it is absolutely necessary. Do not bend or twist the casualty's body. Do not move the head forward, backward, or sideways. Do not allow the casualty to sit up. Fracture of the Pelvis Fractures often result from falls, heavy blows, and crushing accidents. The greatest danger is damage to the organs that are enclosed by the pelvis. There is danger that the bladder will be ruptured or that severe internal bleeding may occur, due to the large blood vessels being torn by broken bone. The primary symptoms are severe pain, shock, and loss of the ability to use the lower part of the body. The casualty is unable to sit or stand and may feel like the body is "coming apart." Treat for shock, but do not raise the casualty's feet. Do not move the casualty unless absolutely necessary. Request medical assistance immediately. Dislocations A dislocation occurs when a bone is forcibly displaced from its joint. Many times the bone slips back into its normal position; other times, it becomes locked and remains dislocated until it is put back into place (reduction). Dislocations are caused by falls or blows and occasionally by violent muscular exertion. The joints that are most frequently dislocated are the shoulder, hip, finger, and jaw. A dislocation may bruise or tear muscles, ligaments, blood vessels, and tendons. The primary symptoms are rapid swelling, discoloration, loss of movement, pain, and shock. You should not attempt to reduce a dislocation. Unskilled attempts at reduction may cause damage to the nerves and blood vessels or may fracture a bone. You should leave this treatment to professional medical personnel and concentrate your efforts on making the casualty comfortable. If you suspect a dislocation, do the following: 1. Loosen clothing from around the injury. 2. Place the casualty in the most comfortable position. 3. Support the injured part with a sling, pillow, or splint. 4. Treat for shock. 5. Request medical assistance as soon as possible. Sprains A sprain is an injury to the ligaments that support a joint. It usually involves a sudden dislocation, with the bone slipping back into place on its own. Sprains are caused by the violent pulling or twisting of the joint beyond its normal limits of movement. The joints that are most frequently sprained are the ankle, wrist, knee, and finger. Tearing of the ligaments is the most serious aspect of a sprain, and there is a considerable amount of damage to the blood vessels. When the blood vessels are damaged, blood may escape into the joint, causing pain and swelling. If you suspect a sprain, do the following: 1. Splint to support the joint and put the ligaments at rest. Gently loosen the splint if it becomes so tight that it interferes with circulation. 2. Elevate & rest the joint to help reduce the pain and swelling. 3. Apply ice or cold packs, with cloth to prevent damage to the skin, the first 24 hours, then apply warm compresses to increase circulation. 4. Request medical assistance as soon as possible. Treat all sprains as fractures until ruled out by x-rays. Strains A strain is caused by the forcible over-stretching or tearing of a muscle or tendon. They are caused by lifting heavy loads, sudden or violent movements, or by any action that pulls the muscles beyond their normal limits. The primary symptoms are pain, lameness, stiffness, swelling, and discoloration. If you suspect a strain, do the following: 1. Elevate & rest the injured area to help reduce the pain and swelling. 2. Apply ice or cold packs, with cloth to prevent damage to the skin, the first 24 hours, then apply warm compresses to increase circulation. 3. Request medical assistance as soon as possible. Treat all strains as fractures until ruled out by x-rays. Contusions A contusion (bruise) is an injury that causes bleeding into or beneath the skin, but it does not break the skin. The primary symptoms are pain, tenderness, swelling, and discoloration. At first, the injured area is red due to local irritation; as time passes the characteristic "black and blue" (ecchymosis) mark appears. Several days after the injury, the skin becomes yellow or green in color. Usually, minor contusions do not require treatment. If you suspect a contusion, do the following: 1. Elevate & rest the injured area to help reduce the pain and swelling. 2. Apply ice or cold packs, with cloth to prevent damage to the skin, the first 24 hours, then apply warm compresses to increase circulation. 3. Request medical assistance as soon as possible. Top Chapter Six-Envirnomental Injuries Exposure to temperature extremes, whether heat or cold, causes injury to the skin, tissues, blood vessels, vital organs, and in some cases, the entire body. Burns, heat cramps, heat exhaustion, and heat stroke are caused by exposure to heat. Hypothermia (general cooling), frostbite, and (trenchfoot)immersion foot are caused by exposure to the cold. Burns and Scalds Burns are caused by dry heat, and scalds are caused by moist heat. Treatment is the same for both. Contact with an electric current also causes burns, especially if the skin is dry. The seriousness of the burn can be determined by its depth, extent, and location and by the age and the health of the casualty. You must take all these factors into consideration when evaluating burns. Burns are classified (Fig. 7-1) according to their depth as first-degree, second-degree, and third-degree. First-degree Burns First-degree burns involve only the first (epidermal) layer of the skin. The skin is red, dry, warm, sensitive to touch, and turns (blanches) white with pressure. Pain is mild to severe, swelling (edema) may occur. Healing occurs naturally within a week. Second-degree Burns Second-degree burns involve the first and part of the second (dermis) layer of the skin. The skin is red, blistered, weeping, and looks (spotted) mottled. Pain is moderate to severe, swelling often occurs. Healing takes 2 - 3 weeks, with some scarring and depigmentation. Third-degree Burns Third-degree burns involve all layers (full thickness) of the skin, penetrating into muscle, connective tissue, and bone. The skin may vary from white and lifeless to black and charred. Pain will be absent at the burn site if all the nerve endings are destroyed and the surrounding tissue will be painful. There is considerable scarring, and skin grafting may be necessary. Third-degree burns are life threatening.
Figure 7-1, First-, Second-, and Third-degree Burns It is important to remember that the extent (size) of the burned area (Fig. 7-2) is more important than the depth of the burn. A first-degree burn that covers a large area of the body is usually more serious than a small third-degree burn. The "rule of nines" is used to give a rough estimate of the surface area burned and aids in deciding the correct treatment. Shock can be expected in adults with burns over 15 percent or in small children with burns over 10 percent of the body surface area (BSA). In adults, burns involving more than 20 percent of the body surface area endanger life and 30 percent burns are usually fatal if adequate medical treatment is not received. The third factor in burn evaluation is the location: burns of the head, hands, feet, or genitals may require hospitalization. The causes of burns are classified as thermal (heat), chemical, electrical, or radiation.
Figure 7-2-Rule of Nines Thermal Burns Thermal (heat) burns are caused by exposure to hot solids, liquids, gases, or fire. If the casualty has thermal burns, do the following: 1. Monitor the airway, breathing, and circulation (ABC's). Always expect breathing problems when there are burns around the face or if the casualty has been exposed to hot gases or smoke. 2. Control bleeding using direct pressure, elevation, indirect pressure, or tourniquet if indicated. 3. Remove all jewelry from the area, unless the casualty objects. Swelling may develop rapidly. 4. Apply cool water to the affected area or submerge in cool water. Do not use ice or ice water. 5. Remove clothing gently from the burned area. Do not remove clothing that is sticking to the skin. 6. Cover area with dry, sterile dressings, if possible. Cover large areas with clean, dry sheets. Do not break blisters or apply ointments of any kind. 7. Treat for shock - Keep the casualty comfortable and warm enough to maintain normal body temperature. Elevate the burned area above the heart. 8. Request medical assistance for all burns. If possible, before transport, inform medical personnel of the degree, location of the burn, and percentage of the body area affected. Chemical Burns When acids, alkalies, or other chemicals come in contact with the skin, they can cause injuries that are generally referred to as chemical burns. These injuries are not caused by heat but by direct chemical destruction of the tissues. The areas most often affected are the arms, legs, hands, feet, face, and eyes. Alkali burns are usually more serious than acid burns; alkalies generally penetrate deeper and burn longer. If the casualty has chemical burns, do the following: 1. Flush area immediately with large quantities of fresh water, using an installed deluge shower or hose, if available. Avoid excessive water pressure. Continue to flush the area for at least 15 minutes while removing the clothes, including shoes, socks, and jewelry. Dry lime powder (alkali burns) creates a corrosive substance when mixed with water; keep the powder dry and remove it by brushing it from the skin. Acid burns caused by phenol (carbolic acid), should be washed with alcohol. Then wash the area with large quantities of water. If alcohol is not available, flush the area with large quantities of water. Cover chemical burns with a sterile dressing. 2. If available, follow the first aid procedures provided in the Material Safety Data Sheet (MSDS) for the chemical. 3. Flush the eyes with fresh water immediately using an installed emergency eye/face bath or hose on low pressure for at least 20 minutes. Ask casualty to remove contact lenses. Use your hands to keep the eyelids open. Never use a neutralizing agent, mineral oil, or other material in the eyes. 4. Monitor the airway, breathing, and circulation (ABCs). 5. Warning - Do not attempt to neutralize any chemical unless you are sure what it is and what substance will effectively neutralize it. Further damage may be done by a neutralizing agent that is too strong or incorrect. Do not apply creams or other materials to chemical burns. 6. Treat for shock - Keep the casualty comfortable and warm enough to maintain normal body temperature. 7. Request medical assistance for all chemical burns. If possible, before transport, notify medical personnel of the name and other pertinent information about the chemical involved, location of the burn, and percentage of the body area affected. Send the container to medical personnel with the casualty. Electrical Burns Electrical burns may be more serious than they first appear. The entrance and exit wounds may be small, but as electricity penetrates the skin, it burns a large area (Fig. 7-3) below the surface.
Figure 7-3. Electrical Penetration of the Skin If the casualty has electrical burns, do the following: 1. Shut off the power. If you cannot shut off the power, remove the victim immediately. Stand on a well-insulated object, and use a dry rope, wooden pole, or other non-conductive material to either push or pull the wire away from the casualty, or the casualty away from the electrical source. Do not attempt to administer first aid or come in physical contact with an electrical shock casualty before shutting off the power. If you cannot shut off the power immediately, remove the victim from the live conductor before touching them. 2. Maintain a neutral position of the head and neck, apply a cervical collar or improvised (towel) collar. (Casualty is usually thrown). 3. Establish and maintain the airway, breathing, and circulation (ABCs). 4. Begin CPR/rescue breathing - Electrical burns are often accompanied by respiratory or cardiac arrest. If necessary start CPR (Chapter 2) immediately and continue until successful. 5. Cover burn areas with a moist, preferably sterile, dressing. 6. Treat for shock - Keep the casualty comfortable and warm enough to maintain normal body temperature. 7. Request medical assistance for all electrical injuries. If possible, before transport, inform medical personnel of the electrical source involved and the location of the entrance and exit wounds. Sunburn Sunburn results from prolonged exposure to the ultraviolet rays of the sun. First- and second- degree burns similar to thermal burns may develop. Treatment is essentially the same as for thermal burns. Unless a major percentage of the body is affected, the casualty will not require more than first aid attention. Commercially prepared sunburn lotions and ointments may be used. Prevention through education and the proper use of sunscreens and sunblocks is the best way to avoid this condition. White Phosophorous Burns A special category of burn, which may affect military personnel in a wartime or training situation, is that caused by exposure to white phosphorous (WP or Willy Peter). First aid for this type of burn is complicated by the fact that white phosphorous particles ignite upon contact with air. Superficial burns caused by simple skin contact or burning clothes should be flushed with water and treated like thermal burns. Partially embedded white phosphorous particles must be continuously flushed with water while the first aid provider removes them with whatever tools are available, such as tweezers or pliers. Do this quickly but gently. Deeply embedded particles that cannot be removed must be covered with a saltwater (saline) soaked dressing that must remain wet until the casualty receives professional medical attention. When rescuing casualties from a closed space where white phosphorous is burning, protect your lungs with a wet cloth over your nose and mouth. Heat Exposure Excessive heat affects the body in a variety of ways. When a person exercises in a hot environment, heat builds up inside the body. The body automatically reacts to get rid of this heat through the sweating mechanism. If the body loses large amounts of water and salt from sweating, heat cramps and heat exhaustion may develop. If the body becomes too overheated, the sweat control mechanism of the body malfunctions and shuts down. The result is heat stroke (sunstroke). Heat exposure injuries are a threat in any hot environment, especially in desert or tropical areas and in the boiler rooms of ships. Heat Cramps Heat cramps are muscular pains and spasms resulting from the loss of water and salt from the body. Excessive sweating may result in painful cramps of the muscles of the abdomen, legs, and arms. Heat cramps also may result from drinking ice water or other cold drinks either too quickly or in too large a quantity after exercise. Heat cramps are often an early sign of approaching heat exhaustion. Signs and symptoms of heat cramps include:
If you suspect heat cramps, do the following: 1. Move the casualty to a cool or air conditioned area. 2. If the casualty can drink, give him or her one-half glassful of cool water every 15 minutes. If the casualty vomits, stop giving water. Do not give salt tablets. 3. Gently stretch or massage the muscle to relieve the spasm. 4. Request medical assistance if the casualty has other injuries or does not respond to the above procedures. Heat Exhaustion Heat exhaustion is caused by the excessive loss of water and salt (sweating). It is the most common condition from exposure to hot environments (Fig. 7-4).
Figure 7-4. Symptoms of heat stroke and heat exhaustion. Signs and symptoms of heat exhaustion include:
If you suspect heat exhaustion, do the following: 1. Move the casualty to a cool area, apply cold, wet compresses, and fan the casualty. 2. Treat for shock. 3. Remove the casualty's clothing, do not allow the casualty to become chilled. 4. If the casualty is conscious and can drink, give him or her one-half glassful of cool water every 15 minutes. If the casualty vomits, stop giving water. Do not give salt tablets. 5. Request medical assistance for heat exhaustion casualties as soon as possible. Heat stroke Heat stroke, also known as sunstroke, is a life-threatening emergency. It is not necessary to be exposed to the sun for it to develop. It is less common but more serious than heat exhaustion. The casualty experiences a breakdown of the sweating mechanism (Fig. 7-4) and is unable to eliminate excessive body heat. If the body temperature rises too high, the brain, kidneys, and liver may be permanently damaged. Signs and symptoms of heat stroke include:
If you suspect heat stroke, do the following: 1. Move the casualty immediately to a cool area, place them in a cold water bath. If this is not possible, give a sponge bath by applying wet, cold towels to the entire body. If available, place cold packs around the neck. 2. Monitor the airway, breathing, and circulation (ABCs). 3. Treat for shock. 4. Remove the casualty's clothing, do not allow the casualty to become chilled. 5. If the casualty is conscious and can drink, give him or her one-half glassful of cool water every 15 minutes. If the casualty vomits, stop giving water. Do not give salt tablets. 6. Request medical assistance for heat stroke casualties as soon as possible. Cold Exposure When the body is exposed to extremely cold temperatures, the blood vessels constrict and body heat is gradually lost. As the body temperature falls, tissues are easily damaged. The extent of damage depends on such factors as wind speed, temperature, type and duration of exposure, and humidity. Fatigue, smoking, drugs, alcohol, stress, dehydration, and the presence of other injuries increase the harmful effects of the cold. General Cooling (Hypothermia) Hypothermia, an abnormally low body temperature, is a medical emergency. It is caused by continued exposure to low or rapidly falling temperatures, cold moisture, snow, or ice. Individuals exposed to low temperatures for long periods may suffer harmful effects, even if they are protected by clothing, because cold affects the body slowly, almost without notice. Signs and symptoms of hypothermia include:
If you suspect hypothermia, do the following: 1. Move the casualty immediately to a warm place. 2. Monitor the airway, breathing, and circulation (ABCs). 3. Rewarm by applying external heat to both sides of the casualty. Natural body heat (skin to skin) from two rescuers (buddy warming) is the best method. Do not place heat source next to bare skin. Since the casualty is unable to generate body heat, placing him/her under a blanket or in a sleeping bag is not sufficient. 4. If the casualty is conscious and can drink, give warm liquids. Do not give hot liquids, coffee, or alcohol or allow casualty to smoke. 5. Request medical assistance for hypothermia as soon as possible. Immersion Hypothermia Immersion hypothermia, is the lowering of the body temperature due to prolonged immersion in cold water. It is often associated with limited motion of the extremities and water-soaked clothing. Temperatures range from just above freezing to 50 degrees F (1O degrees C). Signs and symptoms of immersion hypothermia include:
If you suspect immersion hypothermia, do the following: 1. Move the casualty immediately but gently to a warm, dry area. 2. Monitor the airway, breathing, and circulation (ABC's). 3. Remove wet clothing carefully, keep casualty warm and dry. Do not rub or massage affected area. 4. Do not rupture blisters or apply ointment to affected area. 5. If the casualty is conscious and can drink, give warm liquids. Do not give hot liquids, coffee, or alcohol or allow casualty to smoke. 6. Request medical assistance for immersion hypothermia as soon as possible. Frostbite Frostbite is damage to the skin due to continued exposure to severe cold. It occurs when ice crystals form in the skin or deeper tissue after exposure to a temperature of 32 degrees F (0 degrees C) or lower. The areas most commonly affected are the hands, feet, ears, nose, and cheeks. Frostbite is classified as incipient, superficial, or deep. Incipient Frostbite (Frost Nip) Incipient frostbite affects the tips of the ears, nose, cheeks, toes, and fingers. Casualties normally are unaware of the injury. Initially, the affected skin reddens, then becomes (blanched) white and painless. Move the casualty to a warm area. Warm the affected areas with a buddy's body heat, or by immersing in warm water. Do not rub or massage affected areas. Frostbite requires professional medical attention as soon as possible. Superficial Frostbite Superficial frostbite affects the surface of the skin and the tissue beneath. The skin will be firm and white, but the underlying tissue will be soft. The affected area may become blue, tingle, swell, and burn during thawing. Move the casualty to a warm area. Hands can be rewarmed by placing them under the armpit, or against the abdomen. Feet can be rewarmed by using a buddy's armpit or abdomen, other areas can be rewarmed by immersing in warm water. Do not rub or massage affected areas. Frostbite requires professional medical attention as soon as possible. Deep Frostbite Deep frostbite is a medical emergency that affects the entire tissue layer. The skin feels hard and is white to blue in appearance. The purpose of first aid is to protect the affected area from further damage, to thaw the affected area, and to monitor the airway, breathing, and circulation. Move the casualty to a warm area. Rewarm affected areas by immersion in water at 100 degrees F to 105 degrees F (30 degrees C to 41 degrees C). Gently dry the area with a soft towel, place cotton between the toes and fingers to avoid their sticking together. Do not rub or massage affected areas. Frostbite requires professional medical attention as soon as possible. Do not allow the affected area to be exposed to the cold. Top Chapter Seven-Chemical, Biological and Radiological Casualities Biological and chemical substances for military use are primarily antipersonnel agents; they are intended to produce casualties without the destruction of buildings, ships, or equipment. There is still a possibility that a chemical, biological, or radiological (CBR) attack may occur in the future. Although the physical damage to a ship or station may be minimal, the possibility that dangerous levels of contamination will remain after an attack is real. All personnel should understand the nature of such attacks, the methods of reducing their effects, and the handling of casualties resulting from such attacks. Defense against an attack is both an individual and a group responsibility. What an individual does before, during, and after an attack will affect both their own and the command's chances of survival. Individuals are responsible for first aid and self aid, proper use of the protective mask, clothing, and personal decontamination. Group responsibilities include the setting of proper material conditions, detection of agents, isolation of contaminated areas, and decontamination and restoration of the ship or station and equipment. Chemical Warfare The use of chemical agents in warfare, frequently referred to as "gas warfare," may be defined as the deliberate use of a variety of chemical agents in gaseous, solid, or liquid states for the purpose of harassing personnel, producing casualties, or contaminating food and water. Chemical agents produce harmful physiological reactions when applied to the body externally, inhaled, or swallowed. They can be spread by aircraft, projectiles, bombs, grenades, pots, candles, land mines, and missiles. These principal factors determine the method by which a chemical agent is spread: the quantity of the agent required to accomplish specific objectives, the nature of the agent being used, the distance to the place of attack, and the way in which the agent must be used. Nerve Agents Nerve agents are not quickly and easily detected. Small quantities can quickly cause casualties and deaths. They may be colorless gases with little or no odor or colorless to light brown liquids. These agents radically disturb the chemical processes of the nervous system, impairing or stopping other bodily functions. Nerve agents can enter the body by inhalation, ingestion, and absorption through the skin and eyes. Entry through the skin is extremely effective. This means that the protective mask alone is not adequate protection because the agent can enter through any exposed skin. There are now two series or groups of nerve agents: The G series and the V series. The G series is composed of the following agents: tabun (GA) "faintly fruity odor," sarin (GB), and soman (GD) "fruity camphor odor," the V series is composed of agent VX "odorless." Signs and symptoms:
Blister Agents Blister agents, also known as vesicants, are odorless and vary in duration of effectiveness. In the pure state, mustard is a yellowish, oily liquid. Most blister agents are insidious in action; there is little or no pain at the time of exposure except with lewisite (L) "geranium odor," and phosgene oxime (CX), which causes immediate pain on contact. Wet skin absorbs more mustard than dry skin. Protection from blister agents is extremely difficult, because they attack any part of the body that comes in contact with the liquid or vapor agent. The primary blister agents, distilled mustard (HD) "garlic odor," and nitrogen mustard (HN), are most effective for general use. The newer blister agents include the nitrogen mustards (HN-1) "fishy or musty odor," (HN-2) "soapy to fruity odor," (HN-3) and the mixed blister agent (HL) "garlic-like odor." Signs and symptoms:
Incapacitating Agents Incapacitating agents, also known as psycho-chemical agents, are the latest discovery. Most agents are colorless, odorless, and tasteless. They enter the body by inhalation and interfere with mental processes that control bodily functions. Many are still in the research, development, and testing stage; much remains to be learned. These agents are used to wage and win a war without resorting to the massive killing, enormous destruction of property, and immense monetary cost. An agent of this type is benzilate (BZ), a slow-acting aerosol. Although there are many unanswered questions concerning the physiological action of these compounds and much research remains to be accomplished, they offer many advantages. 1. They are flexible. The effects can range from drowsiness to complete withdrawal. 2. They are economical. They are less expensive to produce. 3. They are not destructive. Buildings will remain standing. 4. They are less injurious. Will cause less loss of life, maiming, crippling, and less permanent after-effects. 5. They are a simpler weapons system. They are easily stored, loaded into munitions, and delivered on target. 6. They are difficult to detect. They are colorless, odorless, and tasteless. Signs and symptoms:
Blood Agents Blood agents are chemicals that are in a gaseous state at normal temperatures and pressures. They are systemic poisons and casualty producing agents that interfere with vital enzyme systems of the body. They can cause death in a very short time after exposure by interfering with oxygen transfer in the blood. Although very deadly, they are non-persistent agents. The most common blood agents are hydrogen cyanide (AC) "bitter almond odor" and cyanogen chloride (CK). Although AC is one of the most deadly poisons, it is one of the least effective chemical agents because it evaporates rapidly. CK deteriorates the chemical canisters in protective masks within a short period of time. Death or recovery takes place rapidly. Signs and symptoms:
Choking Agents Choking agents, also known as lung irritants, primarily affect the respiratory tract (nose, throat, and lungs), causing pulmonary edema. Their concentrations in the air are reduced fairly rapidly by water condensation (rain and fog) and by dense vegetation. Unlike nerve and blister agents, choking agents have no poisonous effect upon foods; they are too readily destroyed. The two most common choking agents are phosgene (CG) "new mown hay odor" and diphosgene (DP) "new mown hay odor." Signs and symptoms:
Vomiting Agents Vomiting agents are dispersed as aerosols and produce their effects by inhalation. The symptoms may be delayed for several minutes after initial exposure. Therefore, effective exposure may occur before the presence of the smoke is suspected. If the protective mask is then put on, symptoms will increase for several minutes, despite adequate protection. At high concentrations, effects may last for several hours. Because of their arsenical properties, these agents make foods poisonous. The most important agents of this type are diphenylchlorarsine (DA), diphenylchanosarsine (DC), and adamsite (DM). Signs and symptoms:
Tear Agents Tear agents, also known as lacrimators, are riot-control agents. They may be solids or liquids and may be dispersed in the air as vapors or smokes. This agent is highly successful in quelling riots. An individual is incapacitated for 20 to 60 seconds after exposure. Effects last 5 to 10 minutes after the individual is removed to fresh air. Tear agents include CN, CNC, CNB, BBC, and CS. Of these, CS is the newest and most effective. It produces immediate effects even in extremely low concentrations. Signs and symptoms:
Self Aid and First Aid At the first sign of a chemical agent in the atmosphere, put on your protective mask immediately. If a liquid nerve or blister agent gets on your skin or clothing, take immediate action. If your clothing is contaminated, put on new clothing and resume your duties. Treat contaminated skin with the M258A1 skin decontaminating kit. Do not get any chemicals from the kit in your eyes or mouth. The treatment requires the use of two packets: Decon 1 wipe and Decon 2 wipe, which are found in the kit. Use these packets according to the instructions on the M258A1 carrier. After use, you should occasionally examine the contaminated areas for local sweating and muscular twitching. If none develops in the next half hour and you have no tightness in your chest, your self aid was successful. If these symptoms do occur, immediately use your atropine and 2 Pam-Chloride injectors. These injections should be self-administered, through your clothing and into the outside of your thigh. If no other symptoms develop, one injection each of atropine and 2 Pam-Chloride is enough. Dryness of the mouth is a good sign indicating that you have had enough atropine. If nerve agent symptoms persist, you may give yourself up to two more injections of atropine and 2 Pam-chloride at 10 to 15 minute intervals. More than three injections may be given only under the direct supervision of medical personnel or under the direction of the petty officer or officer in charge of the battle station. If liquid nerve agent gets into your eyes, immediately flush your eyes for 30 seconds or more. This must be done in spite of the presence of nerve agent vapor. Hold your breath as long as possible during this procedure. After taking several breaths with the mask on, again remove the mask and complete decontamination. Watch the pupil of the contaminated eye, if it gets smaller, inject into your thigh one of your atropine automatic injectors at once. Do not use atropine until you are sure that the symptoms are those of nerve agent poisoning. Severe nerve agent exposure may rapidly cause unconsciousness, muscular paralysis, and loss of breathing. When this occurs, atropine and 2 Pam-chloride alone will not save a life. Begin rescue breathing immediately and continue until breathing is restored or the casualty can be taken over by medical personnel. An atropine injection increases the effectiveness of rescue breathing. It should be administered as soon as possible, preferably by someone who is not performing rescue breathing. Whenever liquid or vaporized blister agents are known to be present, be sure to wear your protective mask. Liquid blister agents in the eyes or on the skin must be dealt with immediately. If liquid blister agent gets into your eyes, immediately flush the eyes for 30 seconds to not more than 2 minutes. The risk of leaving blister agents in the eye is much greater than the risk of exposure to blister agent vapors. Therefore, the decontamination procedure must be performed in spite of the presence of vapor. Phosgene oxime reacts rapidly, decontamination will not be entirely effective after pain has started. The contaminated area should be flushed immediately with large amounts of water. If you notice any stimulation of breathing, an odor of bitter almonds, or any irritation of the eyes, nose, or throat, mask at once. Within a few seconds after exposure, you probably will not be able to put on the mask by yourself. There is currently no self-aid or buddy-aid for blood agent symptoms. Affected personnel should seek medical attention immediately. Irritation of the eyes or a change in the taste of a cigarette might indicate the presence of phosgene. Smoking may become tasteless or offensive in taste. If any one of the signs occur, hold your breath and put on your protective mask immediately. Unless you have difficulty breathing, experience nausea or vomiting, or have more than the usual shortness of breath on exertion, continue your normal combat duties. If any of these symptoms occur, you should rest quietly until you are evacuated by medical personnel. Biological Warfare Biological warfare is the use of living agents such as bacteria, viruses, and other pathogenic microorganisms to produce disease or death of humans, animals, or plants. Biological agents are a threat that must be recognized and prepared for by all personnel. A large part of the defense against biological agents depends upon self-protection and the ability to carry out duties in the presence of such agents. Biological agents may be spread in various ways. They may be used as fillings in bombs or shells or dispersed through aerial or surface spray tanks. They may be released from munitions such as aerosols. The aerosols are cloud like formations of solid or liquid particles in which the biological agents are held suspended. There are no simple and rapid methods to detect biological agents such as those used to detect chemical agents and nuclear radiation. The positive detection and identification of a pathogen can be obtained only by taking samples of the organisms, growing a culture of the organisms under laboratory conditions, and then subjecting the culture to a variety of biochemical and biological tests. Obviously, the final identification of pathogens is a problem for medical personnel. Effects Biological agents may be selected to produce various strategic or tactical goals. These goals range from brief but crippling diseases to widespread serious illnesses with many deaths. The effects of biological agents vary widely, depending upon the agent or agents selected. The mere presence of a disease-producing organism on or in the body of a host does not guarantee infection or illness. In fact, pathogenic organisms are frequently present and cause no harm in the human body for long periods of time. Microorganisms Microorganisms are minute living organisms, which can usually be seen only with the aid of a microscope. Each organism is composed of a single cell or a group of associated cells capable of carrying on all functions of life, including growth and reproduction. They do not have a digestive tract, organs of sight, or a heat regulating system. Many of them resemble plant life and are regarded as being in the vegetable kingdom. Some, such as the protozoa, have characteristics that place them in the animal kingdom. Microorganisms are universally distributed in the air, water, and soil. Those capable of producing disease are known as pathogens. Most of these pathogens are parasites and live on or within another living organism, called a host, which provides shelter and nourishment. Bacteria are very small single-cell organisms. They may be spherical, rod-shaped, or spiral in form. They are visible through an ordinary microscope. They are present everywhere in nature, in air, soil, water, and animal and plant bodies, both living and dead. Many types of bacteria can cause infection. The powerful toxins produced by some could be used alone for biological warfare. Diseases caused by bacteria are typhoid fever, meningitis, and tuberculosis. Rickettsiae are usually smaller than bacteria, but they are still visible through an ordinary microscope. They grow only within living cells, and they are potent disease producers in man and animals. Many of them are transmitted by insect bites. Diseases caused by rickettsiae are Rocky Mountain spotted fever and typhus. Viruses are even smaller than rickettsiae and are not visible with the ordinary microscope. Some have been photographed through the electron microscope. Like the rickettsiae, they will grow only within the living cell. Viruses and rickettsiae are probably less well distributed than bacteria because they are more particular in their growth requirements. However, it is known that they can survive for short periods of time in the air. Diseases caused by viruses are mumps, smallpox, and influenza. Fungi include such plants as yeasts, molds, and mildews. These organisms are known for their ability to spoil foods and fabrics. Generally speaking, diseases caused by fungi in humans are less severe than those produced by other microorganisms. They usually produce low-grade, mild, and often chronic diseases. A few fungi are capable of producing serious diseases. Diseases of plants caused by fungi are potato blight, cotton root rot, corn smut, and wheat rust. Protozoa are single-celled, animal-like forms that occur in a variety of shapes and often have complicated life cycles. Some protozoa cause diseases in both man and animals. Problems of production and transmission limit their application in biological warfare, but it must not be assumed that these problems could not be solved. Protozoa infections of humans are amoebic dysentery and malaria. Self Aid and First Aid Since symptoms caused by pathogenic biological agents may not appear for some time, you may not know that a biological attack has occurred. If you suspect biological contamination, put on your protective mask and observe the basic principles of preventive medicine. These include individual hygiene, sanitation, and physical check-ups. Report any illness to medical personnel immediately. If there is a possibility that you have been contaminated, take the following actions: Carefully remove your clothes to avoid spreading any contamination, and take a thorough soap and water shower as soon as possible. Change your clothes and dispose of contaminated clothing as directed. Pay careful attention to your face and hands. Use a fingernail brush to remove dirt under your nails. Brush your teeth and gums frequently, including the roof of your mouth and your tongue. Some biological agents take effect with great speed. You should apply self aid or first aid immediately if you think you may have been exposed. Radiological Warfare When a nuclear device is detonated in space, in the atmosphere, or at or below the surface of the earth or ocean, many characteristic effects are produced. Some effects, such as nuclear radiation and expanding debris, are common to all of these environments, though varying in degree. Other effects, such as cratering, blast, and water shock, are peculiar to certain environments. Effects such as light and heat are visible or tangible. Others, like nuclear radiation, are not directly apparent and can only be discerned by instruments or secondary effects. Some effects occur in and last only micro-seconds, whereas others occur in micro-seconds but linger for days, months, or even years. Meteorological conditions such as atmospheric pressure, temperature, humidity, winds, and precipitation can affect some of the observed phenomena. All nuclear detonations, however, produce effects that can damage equipment and injure personnel. Airburst An airburst is a burst where the point of detonation is below an altitude of 100,000 feet and the fireball does not touch the surface of the earth. Air blast, thermal radiation (heat and light), an electromagnetic pulse, and initial nuclear radiation (neutron and gamma rays) are produced around the point of detonation. There will be no significant residual nuclear radiation (gamma and beta radiation from airborne or deposited radioactive material) unless rain or snow falls through the radioactive cloud. High-altitude Burst A high-altitude burst is an airburst where the point of detonation is above 100,000 feet. The high-altitude burst produces air blast, thermal radiation, an electromagnetic pulse, initial nuclear radiation, and atmospheric ionization. At such high altitudes, the proportion of energy appearing as blast decreases considerably, and at the same time the proportion of radiation energy increases. Surface Burst A surface burst is a burst where the point of detonation is on, or above, the surface of the earth and the fireball touches the surface of the earth. The surface burst produces air blast, thermal radiation, and an electro-magnetic pulse. Surface bursts over water will also produce underwater shock and surface water waves, but these effects will be of less importance except to submarines. Overland, earth shock will be produced but will not be an important effect at any significant distance from the point of detonation. Underwater Burst An underwater burst is a burst where the point of detonation is below the surface of the water. An underwater burst produces underwater shock and a water plume that then causes a base surge. Bursts with very shallow points of detonation can also produce air blast, initial nuclear radiation, fallout, and possibly some thermal radiation. These effects will be reduced in magnitude from those of a water surface burst and will become rapidly insignificant as the depth of the point of detonation is increased. Underground Burst An underground burst is a burst where the point of detonation is below the ground's surface. An underground burst produces a severe earth shock, especially near the point of detonation. Thermal radiation, air blast, initial nuclear radiation, and fallout will be negligible or absent if the burst is confined below the earth's surface. Early fallout can be significant, and at distances near the explosion, base surge (evidenced by a dust cloud) will be an important hazard. Self Aid and First Aid The blast and heat injuries from a nuclear explosion are treated the same as those from explosive bombs, incendiary weapons, and mechanical accidents. Fractures, concussions, lacerations, contusions, bleeding, burns, shock, and exposure are treated with standard first aid measures. There is nothing that needs to be done immediately for nuclear radiation sickness. Remember that you can receive a dose of radiation even though you are not contaminated with radioactive particles. If there is the possibility that you have been exposed to nuclear radiation, be sure you are examined and treated by medical personnel. If directed, proceed to a personnel decontamination station. Discard your clothing and equipment and take a shower using plenty of soap and warm water. In washing, pay close attention to the hairy parts of your body, body creases, and fingernails, where dirt tends to gather. Decontamination The basic purpose of decontamination is to remove or neutralize CBR contamination so that the mission of the ship or station can be carried out without endangering the life or health of assigned personnel. Decontamination operations may be both difficult and dangerous. Personnel engaged in these operations must be thoroughly trained in the proper techniques. Certain operations, such as the decontamination of food and water, should be done only by experts qualified in such work. However, all members of a command should receive adequate training in the elementary principles of decontamination so that they can assist in emergency decontamination operations. After an attack, data from CBR surveys will be used to determine the extent and degree of decontamination. Contaminated personnel must be decontaminated as soon as possible. Before decontamination of installations, machinery, and gear is undertaken, appraisals of urgency must be made in the light of the tactical situation. Top Chapter Eight-Poisoning Each year in the United States, there are thousands of deaths from suicide or accidental poisonings. In addition to the fatalities, approximately one million cases of nonfatal poisoning occur because of exposure to substances in everyday use such as medications, industrial chemicals, cleaning agents, and plant and insect sprays. Since most poisons act rapidly, professional medical attention or assistance from a poison control center should be obtained immediately. If more than one person is present, one should obtain assistance while the other begins administering first aid. Although the symptoms of poisoning may disappear completely before professional help is obtained, the poison may have harmful or fatal after effects. A poison can be in a solid, liquid, or gaseous state. Poisons can be ingested (swallowed), inhaled, absorbed, or injected into the body. Poisoning should be suspected whenever a sudden unexplained illness develops. The immediate area should be searched for evidence of the cause. Clues such as gases or other chemical odors may be present. Leftover food, drinking glasses, containers, or bottles may also provide clues. Ingested Poisons Ingested poisons are difficult to identify because there are many different kinds. Some substances are fatal in small amounts, while other substances that are safe in small amounts become fatal if large amounts are taken. Poisoning, can result from improperly stored foods, household products, or commercial substances used aboard ship. If you suspect poisoning, do not waste time trying to find the cause or the antidote, poisoning is a medical emergency. Signs and symptoms of ingested poisoning include:
If you suspect poisoning by ingestion, do the following: 1. Monitor the airway, breathing, and circulation (ABCs). Establish and maintain an adequate open airway. 2. Position the casualty sitting and leaning slightly forward, to prevent aspiration of vomit into the lungs. 3. Obtain if possible, all containers the substance was ingested from. If the casualty vomits, obtain a sample. 4. Contact local Poison Control Center or medical personnel immediately. 5. Request medical assistance for Ingestion of poisons immediately. A Material Safety Data Sheet (MSDS) for the material will provide more detailed first aid procedures for ingestion of the chemical. Shellfish and Fish Mussels, clams, oysters, and other shellfish often become contaminated with bacteria during the warm months of March to November. Numerous varieties of shellfish (Fig. 9-1) should not be eaten at all, so wherever you serve in the world, learn which local seafood is known to be safe.
Figure 9-1 - Poisonous Fish Most fish poisoning occurs with fish that are normally considered safe to eat, but which become poisonous at different times of the year from eating poisonous algae and plankton (red tide) that appear in certain locations. Signs and symptoms of shellfish and fish poisoning include:
First aid is directed toward evacuating the stomach contents; if the victim has not vomited, cause him or her to do so. If respiratory failure occurs, give artificial ventilation and treat for shock. Inhaled Poisons In the Navy, many industrial processes produce air contaminants. Workers or passersby could inhale the air contaminants and suffer adverse health affects. Routine cleaning, painting, and preservation produce toxic vapors, gases, and dusts. You can see and smell some toxic air contaminants; however, others are invisible and odorless, like cyanide gas. Other hazardous air contaminants are by-products of certain processes that include exhaust gases from internal combustion engines; fumes or vapors from materials used in casting, molding, welding, and plating; gases associated with bacterial decomposition in closed spaces, and gases that accumulate in voids, double bottoms, empty fuel tanks, and similar spaces. Do not enter any closed compartment or poorly ventilated space until the ship's engineer, or his or her authorized representative, has tested the space and declared it safe to enter. Signs and symptoms of inhaled poisoning include:
You may observe a variety of symptoms, from irritation to asphyxiation. Some air contaminants work slowly to damage the liver, kidneys, and central nervous system. Some materials can cause serious diseases to the same areas. If respiratory problems are not corrected, serious illness or death could occur. If you suspect inhalation poisoning, do the following: 1. Remove the casualty to fresh air immediately. Do not enter a toxic environment without proper respiratory protection or oxygen breathing apparatus. 2. Loosen clothing around the neck and chest. 3. Monitor the airway, breathing, and circulation (ABCs). Establish and maintain adequate open airway. 4. Treat for shock. 5. Position the casualty sitting and leaning slightly forward, to prevent aspiration of vomit into the lungs. 6. Contact local Poison Control Center or medical personnel immediately. 7. Request medical assistance for inhalation poisoning, immediately. The Material Safety Data Sheet (MSDS) for the toxic material gives the symptoms of exposure and first aid measures. Carbon Monoxide Poisoning Carbon monoxide, formed by the incomplete combustion of carbon, is the most common cause of poisoning by inhalation. Carbon monoxide is colorless, tasteless, and odorless. It is usually the result of faulty equipment, improper use of equipment, or poor ventillation of equipment. Signs and symptoms of carbon monoxide poisoning include:
If you suspect carbon monoxide poisoning, do the following: 1. Remove the casualty to fresh air immediately. Do not enter a toxic environment without proper respiratory protection or oxygen breathing apparatus. 2. Loosen clothing around the neck and chest. 3. Monitor the airway, breathing, and circulation (ABCs). Establish and maintain an adequate open airway. 4. Treat for shock 5. Position the casualty sitting, and leaning slightly forward, to prevent aspiration of vomit into the lungs. 6. Contact local Poison Control Center or Medical immediately. 7. Request medical assistance for carbon monoxide poisoning immediately. Absorbed Poisons Many substances enter the body through the skin. The sap or juice of certain plants will cause skin irritation. The most common are poison ivy, oak, and sumac. The poison comes from the leaves, but it also may come from their roots and stems. The smoke from burning brush containing these plants has been known to carry the poison considerable distances. Other substances are insecticides and industrial, lawn, and garden chemicals. Signs and symptoms of poisoning by absorption include:
If you suspect absorbed poisoning, do the following: 1. Remove contaminated clothing carefully, protecting yourself with gloves. do not spread the contamination. 2. Absorb liquid substances on skin, carefully brush off dry substances. 3. Flush area immediately with large quantities of fresh water, using an installed deluge shower or hose, if available. Flush area two separate times. 4. Monitor the airway, breathing, and circulation (ABCs). 5. Treat for shock. 6. Contact local Poison Control Center or medical personnelimmediately. 7. Request medical assistance for poisoning by absorption as soon as possible. Injected Poisons Injection of venom by stings and bites from various insects, while not normally life-threatening, can cause an acute allergic reaction that can be fatal. Any allergic reaction can develop into anaphylactic shock. Poisons also may be injected by snakes and marine animals.
Figure 9-2 - Pit Vipers Found in the U.S. and Their Bite Patterns. Snakebite Poisonous snakes are found throughout the world, primarily in the tropical and temperate regions. Within the United States, there are 20 species of poisonous snakes. They can be grouped into two families, the Crotalidae (rattlesnakes, copperheads, and moccasins), and the Elapidae (coral snakes). Identification The Crotalidae are called pit vipers because of the small, deep pits between the nostrils and the eyes (Fig. 9-2). They have two long hollow fangs, which normally are folded against the roof of the mouth, but which can be extended by a swivel mechanism when they strike. Other identifying features include thick bodies, slit-like pupils of the eyes, and flat triangular heads. Further identification is provided by examining the wound for signs of fang entry in the bite pattern shown (Fig. 9-2). Individual identifying characteristics include audible rattles on the tails of most rattlesnakes and the cotton white interior of the mouths of moccasins. These snakes are found in every state except Maine, Alaska, and Hawaii.
Figure 9-3 - Neurotoxic Snakes and Their Bite Patterns. Coral snakes are related to the cobras, kraits, and mamba snakes in other areas of the world (Fig. 9-3). Corals, which are found in the Southeastern United States, are comparatively thin snakes with small bands of red, black, and yellow (or almost white). Other nonpoisonous snakes have the same coloring, but in the coral snake, the red band always touches the yellow band. Its short, grooved fangs must chew (bite pattern Fig. 9-3) into its victim before the poison can be introduced. Every reasonable effort should be made to kill or positively identify the snake.. Venom Venom is a complex mixture of enzymes, peptides, and other substances. A single injection can cause many different toxic effects in many areas of the body. Some of these effects are felt immediately while the action of other venom components may be delayed for hours or days. A poisonous bite should be considered a true medical emergency until symptoms prove otherwise. The venom is stored in sacs in the snake's head. It is introduced into a casualty through hollow or grooved fangs. An important point to remember is that a bitten casualty has not necessarily received a dose of venom. The snake can control whether or not it will release poison and how much to inject. Signs and Symptoms It is essential that you be able to quickly diagnose a snakebite as being envenomated or not. Normally enough symptoms present within an hour of a poisonous snakebite to eliminate any doubt. The casualty's condition provides the best information as to the seriousness of the situation. The bite of the pit viper is extremely painful and is characterized by immediate swelling around the fang marks, usually within 5 to 10 minutes, spreading and possibly involving the whole extremity within an hour. If only minimal swelling occurs within 30 minutes, the bite will almost certainly have been from a nonpoisonous snake, or from a poisonous snake that did not inject venom. When the venom is absorbed, there is a general discoloration of the skin, followed by blisters and numbness in the affected area. Other signs that may occur are weakness, rapid pulse, nausea, shortness of breath, vomiting, shock, headache, fever, chills, and blurred vision. The eastern diamondback rattler bite is further characterized by numbness and tingling in the mouth and possibly the face and scalp. A metallic taste may be noted. If you suspect a snakebite, do the following: 1. Move the casualty away from (the snake) danger. 2. Calm and reassure the casualty, keep them lying down, quiet, and warm. Do not give the casualty anthing to eat or drink. 3. Immobilize the casualty's affected extremity, keeping the area below the level of the heart. 4. Remove jewelry from affected area, unless the casualty objects. 5. Apply a constricting band (belt, necktie) 2 to 4 inches above the fang marks (Fig. 9-4) between the bite and the heart. It should be tight enough to stop the flow of blood in the veins but not through the arteries. Adjust the band as swelling occurs. Never place a band around a joint, the head, neck, or chest.
Figure 9-4. Constricting Band Properly Applied. 6. Suction the bite over the fang marks, using an extractor from a snakebite kit. Suction by mouth is recommended only as a last resort. Suction after 30 minutes is ineffective, the venom has already diffused. 7. Monitor the airway, breathing, and circulation (ABCs). 8. Treat for shock. 9. Never apply ice to afflicted area. 10. Contact nearest medical facility, if possible, so that the proper antivenom can be made available. 11. Transport the casualty (and the dead snake) as soon as possible. Insect Stings Insects that most commonly cause allergic reactions are honeybees, wasps, yellow jackets, hornets, and fire ants. Individuals with known sensitivities carry medication in commercially prepared kits. Signs and symptoms of insect stings include:
If you suspect an insect sting, do the following: 1. Calm and reassure the casualty, keep them lying down, quiet, and warm. 2. Immobilize the casualty's affected extremity, keeping the area below the level of the heart. 3. Remove jewelry from affected area, unless the casualty objects. 4. Scrape stinger from the skin with a plastic card. Do not use tweezers. 5. Wash the area with soap and water. 6. Place a coldpack to area to reduce swelling and pain. 8. Treat for shock. 9. Transport the casualty for professional medical treatment as soon as possible. Spiders and Scorpions The black widow spider is a small, glossy, jet-black spider. It has a distinctive hourglass-shaped red mark (Fig. 9-5) on the underside of its abdomen. Black widow bites are the leading cause of death from spiders in the United States. Signs and symptoms of black widow bites include:
If you suspect a black widow bite, do the following: 1. Apply coldpacks to affected area, do not apply ice. 2. Monitor the airway, breathing, and circulation (ABCs). 3. Treat for shock. 4. Transport the casualty (and the spider) for professional medical treatment as soon as possible. The brown recluse spider is yellow to dark brown. It has a distinctive violin-shaped marking (Fig. 9-5) on its upper back. Brown recluse bites are non-healing and require skin grafting to repair. Signs and symptoms of brown recluse spider bites include:
If you suspect a brown recluse spider bite, do the following: 1. Monitor the airway, breathing, and circulation (ABCs). 2. Treat for shock. 3. Transport the casualty (and the spider) for professional medical treatment as soon as possible. The scorpion is 2 to 3 inches in length with a long, narrow, segmented tail (Fig. 9-5) that ends in a venomous stinger. Stings can be fatal, most occur on the hands. Signs and symptoms of scorpion stings include:
If you suspect a scorpion sting, do the following: 1. Apply a constricting band (belt, necktie) 2 inches above the sting. It should be tight enough to stop the flow of blood in the veins but not through the arteries. Adjust the band as swelling occurs. Never place a band around a joint, the head, neck, or chest. 2. Apply coldpacks to affected area, do not apply ice. 3. Transport the casualty for professional medical treatment as soon as possible.
Figure 9-5 - Black Widow and Brown Recluse Spiders and a Scorpion. Ticks The tick is 1/4 inch in length with a barbed protruding mouth part (proboscis) for attachment to the skin. They cause Lyme disease, Rocky Mountain spotted fever, and other bacterial diseases. Signs and symptoms of Lyme disease usually occur in three stages that include:
Signs and symptoms of Rocky Mountain spotted fever that develop within 10 days of tick infestation include nausea, vomiting, abdominal pain, and weakness. If the casualty has a tick, do the following: 1. Remove with tweezers, grasp as close to the skin as possible. 2. Wash the area with soap and warm water. 3. Casualty should mark the date of exposure as a reminder if medical care is needed. Marine Life Marine life are not normally aggressive, most injuries occur when people disturb them. Their venom causes more damage to the tissues and is destroyed by heat rather than ice. If the casualty has a large bite (shark), do the following: 1. Remove casualty from the (danger) water. 2. Establish and maintain the airway, breathing, and circulation (ABC's). 3. Control bleeding with direct pressure, elevation, indirect pressure, or tourniquet. 4. Treat for shock. 5. Transport immediately to nearest medical treatment facility. If the casualty has a tentacle sting (Fig. 9-6), do the following: 1. Remove, casualty from the (danger) water. 2. Gently remove tentacles and wash the area with rubbing alcohol or meat tenderizer. 3. Treat for shock.
Figure 9-6 - Stinging Sea Animals. 4. Transport to nearest medical treatment facility. If the casualty has a puncture wound (Fig. 9-7), do the following: 1. Remove casualty from the (danger) water. 2. Control bleeding with direct pressure and elevation. 3. Soak affected area for at least 30 minutes in hot water. 4. Protect the site from movement, the stinger must be removed by a physician. 5. Transport to nearest medical treatment facility.
Figure 9-7 - Stingray. Human and Animal Bites Human and animal bites cause abrasions, lacerations, avulsions, and punctures. Human bites that break the skin can become infected, since the mouth is contaminated with bacteria. Human bites must be treated by a physician. Animal bites, whether domestic (dogs and cats) or wild (bats, raccoons, and rats) present the possibility of rabies in addition to tissue damage and infection. The animal should be captured and confined so it can be observed for signs of rabies. If you must take the animal's life, do not damage the head, it will be necessary to examine the brain. If the casualty has a human or animal bite, do the following: 1. Control bleeding with direct pressure and elevation. 2. Wash the area with soap and warm water, apply a sterile dressing. 3. Transport to nearest medical treatment facility. Top Chapter Nine-Rescue and Transportation If you are faced with the problem of rescuing a person threatened by fire, explosive or poisonous gases, or some other emergency, do not take action until you have had time to determine the extent of the danger and your ability to cope with it. In a large number of accidents the rescuer rushes in and becomes the second casualty. Do not take unnecessary chances! Do not attempt any rescue that needlessly endangers your own life! Protective Equipment The Navy uses a wide variety of special protective equipment. It includes the oxygen breathing apparatus; air-line masks; emergency escape breathing devices; protective (gas) masks; proximity suit; tending lines; and detection devices.
Figure 11-1 - A-4 Oxygen Breathing Apparatus. Oxygen Breathing Apparatus The type A-4 Oxygen Breathing Apparatus (OBA) is a self-contained breathing apparatus (Fig. 11-1) used throughout the Navy. It is particularly valuable for rescue purposes because it enables the wearer to breathe independently of the outside atmosphere. It produces its own oxygen and allows the wearer to enter compartments, voids, or tanks that have a low oxygen content or that contain smoke, dust, or fire. The face-piece contains the eyepiece, the speaking diaphragm, and the head straps. The breathing bag contains the oxygen that is generated by the canister. One breathing tube transports the oxygen from the breathing bag to the face-piece; the other transports the exhaled air back to the canister. Both tubes are made of corrugated rubber. They control the flow and help cool the air. The timer is located so that you can check the amount of time remaining. To set the timer, turn the knob clockwise to 60 minutes, and then turn it counterclockwise to 30 minutes. By setting the timer to 60 first, you fully wind the alarm bell spring. When 30 minutes have expired, the warning bell will sound continuously for 10 or more seconds. All OBA equipment and canisters must be stored in a cool, dry place. The life of an OBA will be lengthened if it is stored under these conditions.
Figure 11-2 - Air-line Hose Mask Components. Air-line Masks The air-line mask (Fig. 11-2) is part of all ship's repair party locker allowance. Never use the air-line mask to fight fires. It may be used to enter smoke-filled spaces to rescue personnel. The air-line mask is a demand-flow, air-line respirator with a speaking diaphragm, monocular lens with adjustable head harness, breathing tube, and belt-mounted demand regulator with male and female (buddy) quick-disconnect fittings. A 25-foot length of hose with male and female quick-disconnect fittings is provided for use with the air-line mask. This hose can be used to connect to the demand regulator fitting and a low-pressure air supply, or to a compressed air cylinder with an intervening air regulator and air filter. The maximum length of hose that may be used with the air-line mask is 250 feet. Tending Lines Tending lines (Fig. 11-3) are used as a precautionary measure to help rescue an individual who is wearing an oxygen breathing apparatus, air-line mask, or similar equipment. A 50-foot nylon covered, steel wire tending line is used aboard ship. The tending line has a stout hook on each end that is closed with a snap catch. The line is pliable and can slide freely around obstructions.
Figure 11-3 - Tending Lines. If necessary, the rescue should be accomplished by having another person equipped with a breathing apparatus follow the tending line to the person to be rescued. Do not drag the casualty out by the tending line. If the rescue is to take place promptly, someone must be equipped with an OBA that is ready for immediate use and must be standing by ready for immediate entry. The tender should wear rubber gloves and shoes when handling steel tending lines and cables. The OBA wearer and the line tender should both know and use the following system of line signals. The OATH code is as follows:
Atmosphere Testing Devices All closed or poorly ventilated compartments, particularly those in which a fire has just occurred, are potentially dangerous. The atmosphere may lack oxygen, contain poisonous gases, or present fire and explosion hazards. Aboard naval ships, no person may enter any closed compartment or poorly ventilated space unless the ship's gas-free engineer, or his or her authorized representative, has tested the space and declared that it is safe to enter. Rescue Procedures If you are faced with the problem of rescuing an individual threatened by fire, explosive or poisonous gases, or some other emergency, do not take any action until you have had time to determine the extent of the danger and your ability to cope with it. In a large number of cases, the rescuer rushes in and becomes the second casualty. Do not take any unnecessary chances! Do not attempt any rescue that needlessly endangers your own life! Phases of Rescue Operations When there are multiple casualties (explosions or ship collisions), rescue operations should be performed in phases. These phases apply only to extrication operations. The first phase is to remove lightly pinned casualties, such as those who can be freed by lifting boxes or removing a small amount of debris. In the second phase, remove those casualties who are trapped in more difficult circumstances but who can be rescued by the use of the equipment at hand and in a minimum amount of time. In the third phase, remove casualties where extrication is extremely difficult and time consuming. This type may possibly involve cutting through decks, or removing large amounts of debris. An example would be rescuing a worker from beneath a large, heavy piece of machinery. The last phase is the removal of the dead. Stages of Extrication The first stage of extrication within the rescue phases outlined above is gaining access to the casualty. Much will depend on the location of the accident, damage at the accident site, and the position of the casualty. The second stage involves giving lifesaving (emergency care) first aid. The third stage is disentanglement. The careful removal of debris from the casualty. The fourth stage is preparing the casualty for removal. The final stage is removing the casualty from the trapped area and transporting to an ambulance or medical facility. Rescue from Fire If you must go to the aid of a casualty whose clothing is on fire, try to smother the flames by wrapping the casualty in a coat, or blanket. Leave the head uncovered. Beat out the flames around the head and shoulders, then work downward toward the feet. If you have no material with which to smother the fire, roll the casualty over slowly and beat out the flames with your hands. If the casualty sits or stands, they may be killed instantly by inhaling flames or hot air. Inhaling flames or hot air can kill you! Do not place your face directly over the flames. Turn your face away from the flames when you inhale! Always use an oxygen breathing apparatus or other protective breathing equipment when you enter a burning compartment. Rescue from Steam-filled Spaces It is sometimes possible to rescue a casualty from a space in which there is a steam line. Since steam rises, escape upward may not be possible. If the normal exit is blocked by escaping steam, move the casualty to the escape trunk, or to the lowest level in the compartment. Equipment that offers protection against fire does not protect against steam! Rescue from Electrical Contact Rescuing a casualty who has received an electrical shock can be difficult and dangerous.You must not touch the casualty's body, the wire, or any object that may be conducting electricity! Look for the switch and turn the power off immediately. Do not waste time hunting for the switch, every second is important. If you cannot find the switch, try to remove the wire from the casualty or the casualty from the wire. Use a dry broom handle, branch, pole, oar, board, or similar non-conducting object. An old favorite is to remove the casualty from an electrical contact using the uniform belt. Be careful, the belt was made of cotton, but is now made of nylon and other conductive material. When you are trying to break an electrical contact, always stand on some non-conducting material. The old drop kick method is extremely dangerous and not recommended. Rescue from Unventilated Compartments Rescuing a casualty from a void, double bottom, gasoline or oil tank, or any closed compartment or unventilated space is a hazardous procedure. Aboard naval vessels and at naval shore activities, no person is permitted to enter any such space or compartment until a gas-free engineer, or his or her authorized representative, has tested the space and declared it safe to enter. Rescue from Water Never attempt to swim to the casualty unless you have been trained in water rescue techniques, and then only if there is no safer way of reaching the casualty. If you do not have the skills, or if the conditions do not warrant rescue by swimming, you should note the exact location (time and any landmarks), and seek help immediately. Many double drownings occur when individuals untrained in water rescue techniques attempt swimming rescues! The casualty may panic and fight you so violently that you will be unable either to rescue the casualty or to save yourself. Even if you are not trained in water rescue techniques, you can rescue the casualty by holding out a pole, oar, or branch for the casualty to grab hold of, throwing a lifeline, or a buoyant object such as a life preserver. Various methods are used aboard ship to pick up survivors in the water. The method used will depend upon the weather conditions, the type of equipment available aboard the rescue vessel, the number of personnel available for the rescue operation, and the physical condition of the casualty. Most rescue operations aboard ship use motor whaleboats (life boats) or helicopters. Transportation In an emergency, there are many ways to move a casualty to safety, ranging from one-person carries to stretchers. The casualty's condition and the immediacy of danger will dictate the appropriate method, but remember to give all necessary first aid before moving the casualty. At times it will be necessary to move the casualty immediately, without regard to the severity of the injuries. Remember, when you move a casualty, you are taking a calculated risk. You may cause further injury or even death! You are justified in taking such a risk only when it is evident that the casualty will die if not moved. General Rules 1. Whenever possible, render first aid before transporting the casualty. Reduce the casualty's pain and make them as comfortable as possible. 2. Use a regular stretcher, with enough people to carry it, so that you will not drop the casualty. 3. Whenever possible, take the stretcher to the casualty, instead of carrying the casualty to the stretcher. 4. Fasten the casualty to the stretcher so that they don't slip, slide, or fall off. 5. Use blankets, clothing, or other material to pad the stretcher and protect the casualty from exposure. 6. Casualties should be lying on their back while being moved. However, in some case, the type or location of the injury will necessitate the use of another position. In all cases, it is important to place the casualty in a position that will best protect them from further injury. 7. Always move the casualty feet first so the rear bearer can watch for signs of difficulty breathing. 8. Always give a complete account of the situation before giving the casualty to other personnel. Include what caused the injury and what first aid procedures have been completed. Also, get the name of the casualty and the person whom you are turning them over to. This is one way of protecting yourself and at the same time ensuring that the patient will be in good hands.
Figure 11-4 - Neil Robertson Stretcher. Neil Robertson Stretcher The Neil Robertson stretcher (Fig. 11-4) is specially designed to remove a casualty from engineering spaces, holds, vertical trunks, and other compartments where hatches or ladders are too small to use other stretchers. It is made of semi-rigid canvas with wooden slats sewn the length of the stretcher. When firmly wrapped around the casualty in a mummy fashion, it provides sufficient support for the casualty to be lifted vertically. A 12-foot length of handling line is spliced on the O-ring at each end to prevent the casualty from swaying against bulkheads while being lifted. Figures 11-5 through 11-10 provide instructions on its proper application. Secure the outer chest straps over the victim's chest and under his arms. Secure the arms to the side by placing the middle chest strap over the upper arms and chest.
Figure 11-5 - Neil Robertson Stretcher. Arrange the stretcher as depicted.
Figure 11-6 - Neil Robertson Stretcher. Remove the hood.
Figure 11-7 - Neil-Robertson Stretcher. Place the hood on the victim. This is easier than trying to place the victim in the hood while it is still attached to the stretcher.
Figure 11-8 - Neil-Robertson Stretcher. Three persons should pick up the victim as depicted. A fourth person should be available to slide the stretcher under the victim. In placing the victim in the stretcher, ensure that the shoulders line up with the arm holes and chest flaps.
Figure 11-9 - Neil-Robertson Stretcher. Place the victim on the stretcher. If the victim is a short person, make sure that his or her armpits are even with the cut-out section of the flap. This will place the casualty in the correct position in the stretcher and prevent them from slipping out. Secure the hood to the stretcher. Place the chest flaps over the patient's chest and under the arms.
Figure 11-10 - Neil Robertson Stretcher. Fold the leg flaps in place over the victim's legs. If the victim is positioned correctly the hands will be under the leg flap and against the thigh. Secure the leg straps. Miller (Full Body) Board The Miller Board is constructed of an outer plastic shell with an injected foam core of polyurethane foam. It is impervious to chemicals and the elements and can be used in virtually every confined space rescue and vertical extrication. The casualty can be turned vertically and laterally with no movement, and the board's narrow design allows passage through hatches and crowded passageways. It fits within a Stokes (basket) stretcher and will float a 250-pound person. The Miller Board will eventually replace the Neil Robertson Stretcher.
Figure 11-11 - Stokes Stretcher Stokes Stretcher The most commonly used stretcher for transporting the sick and injured is called the (Fig. 11-11) Stokes (basket) stretcher. It is essentially a wire basket supported by iron rods. A new version is made of molded plastic. It is adaptable to a variety of uses, since the casualty can be held securely in place even if the stretcher is tipped or turned. It can be used with floatation devices to rescue casualties from the water. The Stokes should be padded with three blankets: two should be placed lengthwise, so that one will be under each of the casualty's legs, and the third should be folded in half and placed in the upper part to protect the head and shoulders. The casualty should be lowered gently into the stretcher and made as comfortable as possible. Cover the casualty with one or more blankets. Fasten the casualty and blanket with the straps provided over the chest, hips, thigh, and lower legs. Do not place the straps over the knees or areas of suspected broken bones! Army (Pole) Litter The Army litter (Fig. 11-12) is collapsible, made of canvas, and supported by wooden or aluminum poles. They are used aboard ship only for mass casualty situations and are not to be used for transporting casualties throughout the ship.
Figure 11-12 - Army Litter Improvised Stretchers Standard stretchers should be used whenever possible to transport casualties. If none are available, it may be necessary for you to improvise. Sometimes a blanket may be used as a stretcher. The casualty is placed in the middle of the blanket on his or her back. Four people kneel (Fig. 11-13) on each side and roll the edges of the blanket toward the casualty. Stretchers may also be improvised (Fig. 11-14) by using two long poles (approx. 7 feet long) and a blanket. Most improvised stretchers do not give sufficient support in cases where there are fractures or extensive wounds of the body!
Figure 11-13 - Blanket used as improvised transport stretcher.
Figure 11-14 - Stretcher made from poles and a blanket. Fireman's Carry The Fireman's Carry (Fig. 11-15) is one of the easiest ways to carry an unconscious casualty. 1 .Place the casualty face down. Face the casualty, and kneel on one knee at the casualty's head. Pass your hands under the armpits; then slide your hands down the sides and grasp them across the back. 2. Raise the casualty to his knees. Take a better hold across the casualty's back. 3. Raise the casualty to a standing position and place your right leg between the casualty's legs. Grasp the right wrist in your left hand and swing the arm around the back of your neck and down your left shoulder. 4. Stoop quickly and pull the casualty across your shoulders and, at the same time, put your right arm between the casualty's legs. 5. Grasp the casualty's right wrist with your right hand and straighten up. The procedure for lowering the casualty to the deck is also illustrated. Do not attempt if the casualty has an injured arm, leg, ribs, neck, or back!
Figure 11-15 - Fireman's Carry
Figure 11-16 - Tied Hands Crawl Tied-Hands Crawl The tied-hands crawl (Fig. 11-16), may be used to drag an unconscious casualty for a short distance. It is particularly useful when you must crawl underneath a low structure, but it is the least desirable because the casualty's head is not supported. 1. Place the casualty face up. Cross the casualty's wrists and tie them together. 2. Kneel astride the casualty and lift the arms over your head so that the casualty's wrists are at the back of your neck. 3. When you crawl forward, raise your shoulders high enough so that the casualty's head will not bump against the deck. Blanket Drag The blanket drag (Fig. 11-17), can be used to move a casualty who, due to the seriousness of the injury, should not be lifted or carried by one person alone. 1. Place the casualty face up on a blanket, and pull the blanket along the deck. 2. Always pull the casualty head first, with the head and shoulders slightly raised, so that the head will not bump against the deck.
Pack-Strap Carry The pack-strap carry (Fig. 11-18), can be used to move a heavy casualty for some distance. 1. Place the casualty face up. 2. Lie down on your side along the casualty's uninjured or less injured side. Your shoulder should be next to the casualty's armpit. 3. Pull the casualty's far leg over your own, holding it there if necessary. 4. Grasp the casualty's far arm at the wrist and bring it over your upper shoulder as you roll and pull the casualty onto your back. 5. Rise up on your knees, using your free arm for balance and support. Hold both of the casualty's wrists close against your chest with your other hand. 6. Lean forward as you rise to your feet, and keep both of your shoulders under the casualty's armpits. Do not attempt if the casualty has an injured arm, ribs, neck, or back!
Figure 11-18 - Pack-Strap Carry Chair Carry The chair carry (Fig. 11-19), can be used to move a casualty away from a position of danger. The casualty is seated on a chair and the chair is carried by two people. This is a good method to use when you must carry a casualty up or down steps or through narrow, winding passageways. Do not attempt if the casualty has an injured neck, back, or pelvis!
Figure 11-19 - Chair Carry
Figure 11-20 - One-Person Arm Carry Arm Carries There are several kinds of arm carries that can be used in emergency situations to move a casualty to safety. The one-person arm carry (Fig. 11-20), should not be used to carry a casualty who is seriously injured. Unless the casualty is considerably smaller than you, you will not be able to carry the casualty very far. The two-person carry (Fig. 11-21), unless absolutely necessary, should not be used to carry a casualty who is seriously injured. An alternate two-person carry (Fig. 11-22) also can be used. 1. Two rescuers kneel beside the casualty at the level of the hips, and carefully raise them to a sitting position. 2. Each rescuer puts one arm under the casualty's thighs; hands are clasped and arms are braced. 3. Both rescuers rise slowly to a standing position. Do not attempt if the casualty is seriously injured!
Figure 11-21 - Two-Person Carry by Arms and Legs
Figure 11-22 - Two-Person Arm Carry Top Near Drowning The drowning victim my be flailing
their arms or lying face down in the water. Near drowning may be classified as either:
Caution: Signs and Symptoms:
Treatment:
If the patient begins coughing or
spurting water from their nose and mouth, you should turn them on their
side. This will aid water removal from the lungs, keeping the patient's head
lower than the rest of the body will reduce the risk of re-inhaling fluid.
Always allow any swallowed water to drain out naturally. All near drowning victims must be seen by a Doctor as soon as possible. Fluid remaining in the lungs will irritate them and may have a detrimental effect on the respiratory system. Complications such as pneumonia can set in or a fatal condition called "late drowning". So call an Ambulance or bring the patient to hospital now. Top Internal Bleeding Internal bleeding should always to be
considered very serious and urgent medical attention is necessary.
Visible bleeding:
Remember, visible internal bleeding is referred to this way because the results of the bleeding can be seen. Concealed bleeding:
Concealed bleeding is harder to diagnose because we can't see it, but if you take a full history from the patient, the patient's family or bystanders at the scene, you should get a better picture of what injuries might be hidden from you. Look at the mechanism of injury. This will also indicate where the patient might be injured. i.e. chest, abdomen or pelvis. Look for clues on the patient's body, like bruising and tenderness. It's important to remember that some critical signs and symptoms may not appear until well after the incident has happened. This is due to the nature and speed of the internal bleed, it can be slow or perfuse. Following the above information should give you the necessary clues as to whether internal bleeding may be present. If you are not sure, assume the worst and treat for internal bleeding, always error on the side of caution. Signs and Symptoms:
Treatment: Top Carbon Monoxide The silent killer that is carbon monoxide poisoning. Carbon monoxide is a toxic gas produced by burning any fuel. It is odourless and colourless. Sources of carbon monoxide are;
Carbon monoxide poisoning
kills. Signs and symptoms:
In high concentrations, carbon
monoxide can cause loss of consciousness and death. Treatment:
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Figure 11-17 - Blanket Drag
