FTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 47 DOCTOR/HOSPITAL Bleeding from the mouth IF NO OBVIOUS WOUND IN THE MOUTH: Coughing up blood Vomiting blood TRANSPORT TO HOSPITAL FOR URGENT REVIEW If there is no obvious wound or trauma, consider that the casualty has either coughed or vomited the blood. This is obviously a concern and requires urgent transport to hospital for review. RISK TO LIFE Bleeding from the mouth COUGHING UP BLOOD VOMITING BLOOD AN EGG CUP FULL OR MORE THEN 999’ EMERGENCY - AMBULANCE If the casualty is coughing or vomiting more than an egg cup full of blood, this is an immediate life-threatening situation problem and requires a 999 emergency transfer by ambulance to hospital. FIRST AID MEASURES Bleeding from the mouth DO NOT SWALLOW BLOOD LOOK FOR A WOUND APPLY FINGER-THUMB PRESSURE – 10 MINS TOOTH SOCKET - BITE DOWN ON ROLLED UP GAUZE In terms of first aid, the initial thing is to avoid swallowing blood as this will make the casualty feel unwell and if vomited later, could be confused for blood from the gut. Most wounds will simply stop, but pressure can be applied much like everywhere else in the body. Sit the casualty up and maintain finger pressure for a good 5-10 minutes. If the bleeding is from a tooth socket then the casualty should bite down on a piece of rolled up gauze. Hot drinks should be avoided for at least a few hours after a bleed from the mouth. Bleeding from the mouth Chapter 6: Major Bleeding - B.U.R.P.S

48 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DOCTOR/HOSPITAL Bleeding from bowel IN TOILET BOWEL OR BLOOD ON UNDER CLOTHES LIE DOWN & REASSURE CHECK FOR BLEEDING AGAIN AFTER 15 MINS If still bleeding then refer to hospital If stopped then refer for urgent GP review Bleeding from the gut can also occur at the ‘other end’ where blood may be seen on the toilet tissue or, if of greater volume, in the toilet bowl after the casualty has opened their bowels or on their underclothes. If this occurs, lie the casualty down, reassure them and keep them calm. Has this ever happened before? If there is no further bleeding after 15 minutes, ask them to go and check for any further bleeding. They should be escorted to the cloakroom, where they can check themselves. If there is no further bleeding, recommend that they see their doctor as soon as possible. However, if bleeding does continue, the casualty needs an urgent transfer to hospital. Bleeding from bowel Chapter 6: Major Bleeding - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 49 RISK TO LIFE Bleeding from bowel LARGE VOLUME OR SOAKING CLOTHES LIE DOWN & REASSURE LOOK FOR SIGNS OF SHOCK ELEVATE THE LEGS CALL 999 AMBULANCE Lie the casualty down where they are and make them comfortable. Monitor them for signs of shock and consider elevating the legs if this occurs. Ensure that the ambulance is on its way. Do no leave the casualty unless you have to, keep them warm and preserve their dignity. Bleeding can also occur in pregnancy. This can take the form of small amounts of ‘spotting’ through or larger amounts which is more serious and raises concerns about both the mother and baby. Ask the casualty how many weeks pregnant she is. In the early weeks of pregnancy this may be alright, but it can suggest early signs of miscarriage. Have there been any problems in the pregnancy? How much blood has been lost and are there any associated pains? First aiders should have a very low threshold for midwife or hospital review. Bleeding in pregnancy MAJOR BLEED: MOUTH OR BOWEL? If bleeding from either end of the gut, mouth or bowel is severe, or if it is not stopping, this is an emergency situation and requires an immediate 999 call. Bleeding from bowel Chapter 6: Major Bleeding - B.U.R.P.S

50 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Major bleeding can be distressing for both the casualty and the first aider, but the amount of blood does not always reflect the true severity of the injury. The classic medical phrase is that a little goes a long way. Major bleeding - Trauma Chapter 6: Major Bleeding - B.U.R.P.S RISK TO LIFE Major bleeding NEEDS IMMEDIATE ACTION DIRECT PRESSURE WILL CONTROL 90% OF BLEEDS CALL 999 AMBULANCE Any major bleed, especially with arterial ‘spurting’ or venous pouring, needs immediate action to stop or reduce the blood loss and to preserve the pressure and circulating volume of blood. The wound and source of the bleeding must be exposed and identified. Effective direct pressure must be applied wearing suitable protective equipment. (If protective gloves are not available, use clothing to cover your hands or even kneel on the wound. However, unless a first aider has open wounds, the risk of catching a blood borne infection from blood on the hands is very low). No matter how major the bleed, well positioned and firm direct pressure will control up to 90% of bleeds.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 51 For many years tourniquets have been avoided in first aid as they were considered dangerous and risked the loss of a limb from lack of blood supply. However, during the military conflicts of the last decade or two we have learnt that many casualties with major trauma can die from bleeding before airway, lack of oxygen and other problems. In such cases, if the bleeding is from a limb, then the effective application of a tourniquet can be life-saving and the limb involved is rarely lost or damaged in any way by the tourniquet. The recent increase in global terrorism has resulted in far more ‘combat’ type injuries in the civilian setting and as a result we all need to be best prepared for such major bleeding. The crucial issue to consider with tourniquets is to ask will it be ‘effective’ ? - research has shown that improvised or home made tourniquets, such as belts, cords or bandages, as we can see on the slide, are slow to apply and often ineffective, resulting in serious loss of precious blood, before the bleeding is controlled or slowed. Medical and military experience would suggest that exposing the wound and firm direct pressure is a far more effective first aid measure. However: • When the bleeding point cannot be reached • There are multiple injuries or multiple casualties • You have to leave the casualty to get help • You do not have protective gloves Then a ‘windlass’ based improvised tourniquet may be of some value and certainly worth considering. We will demonstrate this in the class. Chapter 6: Major Bleeding - B.U.R.P.S Tourniquets Haemostatics? You may have heard of a new generation of bandages that have been developed. They are called ‘haemostatics’ as they are designed to stop bleeding. They are very effective when packed into heavily bleeding cavity wounds and then direct pressure is applied, much like packing a wound with a standard bandage. They are far more expensive than a standard ambulance dressing, which is why they are unlikely to reach mainstream first aid. However, for organisations that face the risk of serious or life threatening bleeding eg tree surgeons, glass workers, farmers then the cost may be justified. For the majority of major bleeding, effective packing with a standard ambulance dressing, followed by firm direct pressure will control the majority of bleeds.

52 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Major bleeding ALL MAJOR BLEEDS NEED CONTROLLING THEN URGENT TRANSFER TO HOSPITAL Anyone with a major bleed needs urgent transfer to hospital, even if the bleed has been controlled as it may restart. The casualty may have lost a significant amount of blood and have signs of shock. Any bleed that cannot be controlled needs the immediate attention of ambulance staff, but keep trying until such help arrives. Keep checking that you are applying direct pressure in the right place, press harder and do not be tempted to remove the dressing to keep checking if bleeding has stopped. Causes of SHOCK Chapter 6: Major Bleeding - B.U.R.P.S Pump = Heart Water = Blood Pipes = Vessels Radiators = Tissues In medical terms, shock is not an emotional state, but actually a serious physiological condition with inadequate blood supply to the essential organs. There are a number of causes, but blood loss is the most common in trauma. It can also be produced by heart problems, sepsis and severe allergic reactions. To understand shock, we must consider how blood flows around the body in the system called ‘circulation’. This consists of the heart as a pump and pipes or blood vessels which are called arteries and veins. Shock results from some failure in one or a number of these parts. CIRCULATION IS LIKE ‘CENTRAL HEATING’ The easiest way to understand shock is to consider the circulation as similar to your central heating system at home. The heart is the pump, the pipes are the blood vessels and the organs and tissues are the radiators. Shock

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 53 Chapter 6: Major Bleeding - B.U.R.P.S BLEEDING – BLOOD LEAKS OUT If we consider the blood leaking out first, this is what occurs during bleeding. Blood is lost outside the body (external bleeding) or inside the body (internal bleeding). Internal bleeding poses an extra challenge as you cannot directly see it and you can lose a considerable amount in this way. The body contains some large cavities such as the chest, abdomen and pelvis. Bleeding into these areas can occur without any obvious signs, until symptoms of shock start to appear. This is usually due to trauma or a serious surgical problem and there is likely to be pain as an early indicator of a problem. In an average size adult the body’s circulation contains just 5 litres of blood. The body can cope with some blood loss by making the heart pump harder or by squeezing the pipes (blood vessels) but eventually the body cannot compensate any further and the shock worsens. After 2.5L or more has been lost the body will start to die, and cannot cope for much longer without a life saving replacement of the lost blood. Pump = Heart Water = Blood Radiators = Tissues External Bleeding 5 litres of blood In the body If we lose more than 2.5 Litres then we can die Causes of SHOCK In shock, blood can leak out, the heart can fail or the vessels can open too wide. HALF EMPTY WE ARE IN TROUBLE! It can be difficult to appreciate how much volume this is, but if we consider a typical container of screen wash from the garage is typically 5 litres, it is actually not very much when considered in this way. However, any blood lost onto a wet surface such as tarmac will always look more in quantity then it actually is. The reverse is true for blood lost into grass or sand as this can appear to be less than the amount actually lost. Pump = Heart Water = Blood Radiators = Tissues Internal Bleeding

54 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 6: Major Bleeding - B.U.R.P.S Causes of SHOCK It is important to identify the signs of shock as quickly as possible as once they occur they can rapidly progress and the casualty can deteriorate rapidly and ultimately die. Blood loss is usually the first sign of potential shock, but if the bleeding is internal then other signs may be the noticed first. If we use BURPS, we can identify these signs: B – Obvious or likely blood loss from the injuries U – Confusion, agitation and ultimately a fall in conscious levels R – As shock develops the respiratory rate will increase P – Pain will usually be associated with or point to the site of the injury S – Increasing shock will appear as pale, clammy, cold and mottled skin Any or all of these suggests that there is developing shock. RISK TO LIFE BURPS – Signs of Shock B OBVIOUS BLOOD LOSS U FALLING CONSCIOUS LEVEL OR CONFUSION R FAST RESPIRATORY RATE (>20-30/MIN) P FROM BLEEDING, DISTRESSED S PALE, CLAMMY, COLD, MOTTLED FIRST AID MEASURES Shock LIE CASUALTY FLAT ATTEMPT TO CONTROL BLOOD LOSS ELEVATE LEGS If these symptoms are noticed, first aid should consist of lying the casualty down and reassuring them. Attempt to identify any bleeding points and then control them with effective direct pressure. If the casualty starts to feel faint, make sure that they are lying flat. If there is no potential back or pelvic injury, consider elevating the legs onto a small stool or chair. (This will tip some of the blood from the legs, back into the torso and head, where all of the essential organs lie). This may temporarily improve the shock, but keep the casualty in the same position.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 55 RISK TO LIFE Shock ANY SIGNS OF SHOCK OBVIOUS MASSIVE BLOOD LOSS If there are immediate obvious signs of shock or obvious massive blood loss, then immediately request a 999 ambulance and stress the severity of the situation. Make all best efforts to control the bleeding whilst waiting. Always check the casualty and consider that there could be multiple injuries or wounds. Elevation of the legs may help if there are no pelvic or spinal injuries. B.U.R.P.S – Signs of shock Chapter 6: Major Bleeding - B.U.R.P.S

56 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Unconscious / Very Drowsy – B.U.R.P.S This chapter considers the ‘U’ of B.U.R.P.S, which represents any casualty that is unconscious, has a reduced conscious level or is abnormally drowsy. There are a number of key reasons why a casualty may have a reduced level of consciousness and we will split these into: • Physical/Mental exhaustion • Substance Abuse • Medical • Trauma.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 57 PHYSICAL / MENTAL EXHAUSTION Drowsiness is not something that will usually be referred to a first aider unless something has happened, such as an incident, a safety at work issue or the individual develops signs of illness or their work performance is being significantly affected. This may not always suggest that the individual is at fault. For example, imagine a young female member of staff with a new baby. She is noted to be falling asleep during the day at her computer. Colleagues and managers may feel entirely sympathetic, understanding that she has a demanding new baby, but this is not a solution for anyone. What if she has a crucial job such as an Air Traffic Controller? Falling asleep could have catastrophic effects, but even for a job with lesser responsibility employers and colleagues have a responsibility to ensure the welfare of staff and to identify any issues. FATIGUE Fatigue can also lead to incidents or injuries, especially in repetitive or monotonous work e.g. motorway driving or night time working. For some individuals, there is another cause. They are sleep deprived because of a condition called sleep apnoea. This typically occurs in overweight individuals whose airway is obstructed when they fall asleep at night. They start to turn blue owing to a lack of oxygen, and the brain tells them to wake up before any damage occurs. This sounds fine, until you realise that this can occur repeatedly throughout the night, every night. As a result, these individuals are exhausted during the following day and may often find themselves drifting off to sleep at work. One group which could be at a significant risk are those carrying out relatively inactive jobs which involve danger, such as HGV drivers. In its most extreme form, sleep apnoea can seriously affect the heart, but this can be treated and managed by referral to a GP. Drowsy/unconscious Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

58 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ALCOHOL OR DRUG SUBSTANCE ABUSE Other potential reasons for poor performance and drowsiness at work includes alcohol or drug dependence and employers, managers and first aiders must be aware of this problem. Despite what many believe, there is no stereotypical individual or personality defining someone with a dependence problem, but severe alcohol and even drug addiction can occur across all professions and classes. As first aiders, we need to consider if someone is ‘not right’ at work on a recurrent basis. They may also have increased levels of sickness, lateness, irritability etc, but this could also be a result of stress or other problems and specialist help is needed to sensitively investigate such cases. Drowsy/unconscious Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 59 The Medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The Traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. A faint can result in loss of consciousness in an otherwise healthy individual and can be triggered by a number of things, including emotional stimuli, heat, blood loss, palpitations or even a sudden change of position e.g. standing up too quickly. On some occasions the individual will have some warning and may be able to lie or sit down to prevent a full faint, but on other occasions it can occur very quickly with little warning. The cause of a faint is reduced blood supply to the brain and it is believed that the mechanism is a natural body defence system, whereby low blood supply to the brain results in a faint. This usually means that the individual falls to the floor, allowing the blood in the body to distribute evenly, like liquid in a bottle. As a result, there is more blood supply to the brain and consciousness is restored. This effect is classically seen with the soldier who faints on parade. As he stands motionless, blood starts to collect in his legs. Normally as we walk, the muscles in our legs ‘pump’ the blood back up to the heart, but when standing still, especially for prolonged periods then this does not happen and the brain becomes starved of blood and ‘shuts down’ causing the individual to faint. This diagram demonstrates this effect in simple terms, with blood pooling in the legs and feet as a result of gravity. As there is only a fixed amount of blood in the body, there is insufficient for the brain as described above and this results in the faint. Fainting Brain Feet Feet Brain We can now consider the main causes of unconsciousness which are Medical or Trauma related. Unconsciousness - potential causes? Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

60 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com As soon as the casualty lies down, the blood redistributes horizontally, the blood supply to the brain is restored and the casualty regains consciousness. The redistribution of blood can be enhanced or accelerated by gently elevating the legs, which promotes blood flow back into the torso from the limbs. Lie them flat – blood evens out – they then recover If they don’t come around in a few seconds, raise the legs too shift some blood out of the legs back to the brain. FIRST AID MEASURES Faint LAY THE CASUALTY DOWN CONTROL MAJOR BLEEDING CHECK THE AIRWAY/ BREATHING ELEVATE THE LEGS RECOVERY POSITION This is the basis of managing a faint, in terms of assisting and protecting the casualty as they drop to the floor. Fainting in a position that restricts the casualty’s movement and stops them lying down. This presents a serious risk as the normal protective process is lost and the brain can be starved of essential blood supply. As such, anyone stuck in an upright position, must be rescued and moved to a lying position as a matter of urgency. Once lying down, check for any massive bleeding, check the airway and breathing (see later) and if they are present and a faint is suspected, elevate the legs or simply place in the recovery position. Fainting Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S Brain Feet Feet

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 61 RISK TO LIFE Faint - Serious DO NOT QUICKLY REGAIN CONSCIOUSNESS (1-2 MINS) MEDICAL CAUSE E.G. CARDIAC, DIABETES, TRAUMA REMAIN ‘NOT RIGHT’ AFTER 5-10 MINS SEIZURES OR WEAKNESS (FACE, ARMS, LEGS) Faints are considered more serious (RED call) when the casualty: • Does not quickly regain consciousness (after 1-2 minutes) despite no sedation • Medical causes are evident e.g. cardiac, diabetes or trauma • Regains consciousness but are clearly far from right after 5-10 minutes • Evidence of weakness or seizures affecting face, arms or legs. RECOVERY POSITION The safest ‘first aid’ position for an unconscious patient is known as the ’Recovery position.’ This aims to keep the airway open, with the tongue forward in the mouth, allowing saliva or vomit to drain effectively and preventing the patient from rolling back on to their back or front. If the casualty is unconscious and likely to be in this position for more than 20-30 minutes, they should be gently rolled into the mirror image position on the opposite side after this period. This should be repeated as often as required to avoid the development of ‘pressure areas’ and skin breakdown, as when we are unconscious our normal protective pressure reflexes. A patient lying on their back can be shifted into the recovery position with minimal effort. In fact, the smallest candidate will be able to roll and position the largest candidate as it does not involve lifting or heavy dragging. THE SIMPLE ACRONYM HELLO (raise arm as if saying hello), Prior to rolling we should consider checking pockets so as not to roll them onto hard contents which may produce pressure sores (always use care when searching pockets). CHEEKY (place other hand across the face against the opposite cheek). FANCY A KNEES UP (bend leg that will be uppermost to 90 degrees and lay it across other leg. Then position yourself on the side of the raised arm, take hold of the patient’s upper leg at the knee and gently pull it towards you. This will quickly reach a tipping point and the weight of the leg and then the body will bring it over. Fainting Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

62 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DIABETES Can produce very high or very low blood sugars. For some, this is easily controlled with diet, whilst others need tablets or even insulin. Many people will be unaware they have diabetes or alternatively their diabetes can be very unstable or ‘brittle’ which means that their blood sugars can change rapidly and even dangerously without warning. Even patients with stable diabetes may be unwell with an infection or have their medication changed, resulting in considerable instability in their blood sugars and even coma in extreme cases. Without medication or diet, the blood sugars in diabetics can go very high, or even dangerously high. This is something that must usually be managed in hospital. Far more common and far more serious for the first aider are dangerously low blood sugars when a diabetic has not eaten, has taken too much of their medication or had their medication adjusted. Such low blood sugars can rapidly lead to death if not managed. The brain needs sugar to survive and then the blood sugar gets very low, commonly described as a ‘HYPO’ for hypoglycaemia. MED-ALERT? Upon first approaching an unconscious casualty, ask if anyone knows any details about them, are they on medication or unwell? You may also find a Medic-Alert bracelet or necklace providing information on the patient. These come in many forms and show medical conditions, medication, allergies and DNARs. Diabetes The Medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The Traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. Let us consider some the other more serious causes of unconsciousness. These are broadly split into Medical and Trauma conditions Causes of unconsciousness Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 63 FIRST AID MEASURES Diabetes SUSPECT DIABETES LOOK FOR CONFIRMATION - DIABETIC TREAT ALL AS ‘HYPO’ – LOW BLOOD SUGAR STILL AWAKE – SWEETS, CHOCOLATE, SWEET DRINK If your casualty has a reduced level of consciousness with no traumatic injury it is acceptable to suspect diabetes if there is no obvious other cause. ASK and LOOK for confirmation. This may include bracelets or even medication they are carrying. As hypo or low sugar starves the brain of sugar and the brain cells are dying, it MUST be treated very quickly. If the sugar level turns out to be high, giving sugar will not make it worse. Therefore, we treat all diabetics with a reduced level of consciousness as low in our first aid care. If the casualty is able to eat or drink safely (just feeling drowsy but able to verbalise) they can be given a sugar containing sweet to suck or a sweet drink or even chocolate. They should rapidly start to recover. RISK TO LIFE Diabetes SEMI-CONSCIOUS/UNCONSCIOUS 999 AMBULANCE DO NOT TRY AND FEED OR GIVE DRINKS SUGAR, JAM, HONEY UNDER LIPS INTO GUMS If they are very drowsy, semi-conscious or unconscious they must not be given food or liquids to swallow as they may choke. A safe alternative is to rub small quantities of jam, honey or sugar into the gums, outside of the teeth (safety issue) – this should rapidly improve the casualty’s condition, but if it doesn’t, consider other problems that may be the cause. All these patients are RED and require a 999 ambulance. Diabetes Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

64 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There are two types of stroke, which result in a lack of blood supply to the brain. This can be as a result of a bleed in the brain, or from a blood clot cutting off blood supply. Strokes can affect both the old and young and typically cause effects on one side of the body. These effects are typically weakness or numbness which can be quite subtle or catastrophic with severe paralysis down one side or even coma or death. F.A.S.T A stroke is a medical emergency which is the reason for the Nationwide ‘Health promotion campaign called FAST. FAST is an acronym for the easy to recognise features of a developing stroke: Stroke The medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. The next medical condition that may lead to reduced conscious level is a stroke. Causes of unconsciousness A key part of making the diagnosis is to compare both sides of the body or any major change in behaviour such as weakness or confusion. F FACE: look for facial weakness, suggested by one side of the face drooping, or an unequal smile, or dropped eyelid or inability to puff out the cheeks equally. A ARMS: ask the patient to raise both arms at the same time and look for any differences, can they keep them up there normally for them. S SPEECH: is the speech slurred or abnormal? This will often be noticed by the family and can be quite subtle or very obvious and can include an inability to speak or express what they want to say. T TIME: this stresses the fact that time is of the essence in terms of identifying the problem and getting the patient to hospital immediately. Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 65 RISK TO LIFE Stroke CHECK FOR SIGNS OF LIFE & BREATHING ‘FAST’ ASSESSMENT CALL 999 REASSURE, RE-ASSESS AND RECOVERY The emergency medical management is based on early recognition of the FAST signs, essential supportive measures if the conscious level is reduced, and then calling for an emergency ambulance – 999. Whilst waiting for the ambulance, reassure the patient, continually re-assess, and if the conscious level is reduced significantly then place them into the recovery position. Stroke Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

66 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Seizures, or fits can be caused by a number of things which result in an insult to the brain. In children, the commonest cause is fever and are usually less serious than they look, but always warrant hospital attendance. Other causes include epilepsy, head injuries, low blood sugars, excessive water drinking, recreational drugs and infection. The cause may or may not be obvious, but the priority is to protect the casualty during the seizure and care for them if they remain unconscious or semi-conscious afterwards. SEIZURES – WARNING SIGNS Prior to a seizure there may be warning signs such as repetitive movements, a vacant period/absence or an aura. Alternatively there may be an obvious cause such as a head injury. Key issues in looking after someone who is having a seizure. • DO NOT ever forcibly restrain them or try to force the mouth open • The priority is to protect them from harm • Time the seizure with a watch • Cushion head and remove glasses • Loosen tight clothing • Turn on side • Offer help as seizure ends. Seizures The Medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The Traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. The next cause of reduced consciousness to consider is seizures or convulsions known as a fit. This can occur during or after a seizure. Causes of unconsciousness Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 67 FIRST AID MEASURES Seizures MAKE THE ENVIRONMENT SAFE PROTECT FROM INJURY RECOVERY POSITION ONCE STOPS SURFACE COOLING FOR ANY HIGH FEVER Move furniture and other objects away and create a safe area around the casualty to prevent any injury during the seizure. Once the seizure stops the patient should be placed gently into the recovery position. If there is evidence of high fever, especially in children, remove excess clothing and apply cool flannels to face and wrists. An ambulance should be called in most circumstances. DOCTOR/HOSPITAL Seizures – Trained help FAMILY MEMBERS, CARERS GP MAY BE VERY FAMILIAR WITH SEIZURES MAY HAVE ANTICONVULSANTS TO USE However, if there are family members, a carer or GP present who can explain that the seizures are due to epilepsy and not unusual for the casualty, they may be left in their care if the seizure has resolved. The family may also be trained to give some anti-seizure/ anti-convulsant medication and this will often be given rectally, which is an excellent and rapid way to deliver these drugs. Seizures Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

68 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Unconscious - Seizures HEAD INJURY OR NEW MEDICAL CAUSE SEIZURES >2-3 MINUTES/RECURRENT STOPS BREATHING VERY HIGH TEMPERATURE We should be more concerned about seizures in the following circumstances: • Associated with a head injury or obvious medical cause • Seizures which last longer than 2-3 minutes or keep recurring • The patient has stopped breathing and does not resume after the seizure ends • There is very high temperature. ‘RECREATIONAL’ DRUGS Seizures can also be caused by recreational drugs. These agents can be entirely unpredictable in their constitution and the effects on individuals. All seizures, reduced conscious level and grossly abnormal behaviour should be taken seriously. Manage the casualty’s problems as you see them, in terms of maintaining their airway, protecting them from harm and managing seizures. One sign that often indicates a serious abnormal reaction is a very high temperature (they will feel burning hot to touch). They may also have a racing pulse and agitation. This is a serious reaction and requires urgent hospital review. Attempt to reassure them, keep them calm and actively cool them by removing heavy clothing and applying tepid sponges. RISK TO LIFE Drink/drugs/OD - Unconscious CHECK FOR SIGNS OF LIFE CONSIDER INJURIES E.G. NECK, HEAD OPEN THE AIRWAY/ CHECK BREATHING RECOVERY POSITION & MONITOR 999 AMBULANCE Seizures Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 69 When we talk about the heart we imagine that chest pain will usually be the presenting problem, typical of a heart attack. However, if the heart is not pumping properly, blood supply to the brain is reduced, and if not quickly restored then the conscious level will fall rapidly. This can occur for a number of reasons such as abnormal heart rhythms and clots on the lung as well as heart attacks. When such unconsciousness occurs, the normal signs of life will rapidly be lost and this then becomes a cardiac arrest. This is covered in the cardiac arrest ‘no signs of life’ section of FTACC. ALWAYS CONSIDER WHETHER THERE ARE ACTUAL SIGNS OF LIFE If at any stage there appears to be no signs of life e.g. movement or normal breathing, this must be considered as a cardiac arrest. If you encounter any unconscious individual, quickly look for signs of life. The easiest way to do this in an unconscious individual is to look at their breathing. Ask yourself, does it look NORMAL? If it is just gasping, absent or obviously abnormal, assume that they are in cardiac arrest and commence resuscitation. Cardiac (including cardiac arrest) The Medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The Traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. The next cause of reduced consciousness to consider are seizures or convulsions. These can occur during or after a seizure. Causes of unconsciousness Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

70 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A direct blow to the head can produce concussion, resulting in the individual being dazed, disorientated in time place or person, or actually unconscious. This may last no more than a few seconds or can be for much longer which could indicate a significant brain injury. Blood loss can occur from the body, either externally or internally, as discussed already in this manual. We only have five litres of blood in our body and once we have lost more than a litre we can start to feel faint or light-headed. By the time that blood loss reaches 2-2.5 litres we will be getting very confused and even starting to lose consciousness. This is a very serious situation and any further blood loss can result in death. If a casualty is losing blood rapidly, urgent action should be taken to attempt to control the bleeding and get urgent medical help (999). This is covered extensively in the SHOCK section of the manual. UNCONSCIOUS CASUALTY We have clearly identified a number of causes of unconsciousness and described how serious these are, but not fully explained the reasons. For each individual cause there are specific risks which we have mentioned, but the biggest risk when someone first falls unconscious is as a result of loss of airway control. In view of all these issues, ALL unconscious casualties are TIME CRITICAL and require immediate action to help or call an ambulance and usually both. Cardiac arrest must be rapidly identified, any airway obstruction must be addressed and then any effects of the underlying cause must be managed. The first two are open to good first aid control, but the third may be far more challenging and is likely to require hospital intervention. Head injury, blood loss/shock and falls The Medical causes include: FAINT DIABETIC HYPO STROKE SEIZURES CARDIAC PROBLEMS. The Traumatic causes include: HEAD INJURY BLOOD LOSS/SHOCK FALLS. These will be considered in further detail in the rest of the chapter. The final section of the reduced conscious level chapter considers trauma related causes. Causes of unconsciousness Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 71 UNCONSCIOUS – THE AIRWAY PROBLEM? • Exclude Cardiac arrest – signs of life? • Airway obstruction – usually the tongue • Loss of muscle tone in the throat. THE TONGUE! Despite public misconception, the tongue cannot be ‘swallowed.’ It is a large lump of muscle, like a fist in the throat, with a projection into the mouth. As the muscle tone in the upper airway is lost, the body of the tongue drops back against the back of the throat and obstructs the flow of air into and out of the lungs. This obstruction can be partial, making the breathing noisy, or complete with no air movement and silence. All first aid airway manoeuvres aim to move the tongue forward off the back of the throat to ‘open’ the airway and to allow air in and out. • Approach Safely • Look in the mouth • Consider the tongue. JAW THRUST – ‘OPENING’ THE AIRWAY Fortunately, the tongue is attached to the jaw. If we take hold of the jaw and move it forward, the tongue will move with it and we only need several millimeters of movement to let the air through. In the practical stations we will learn how to do this, with a JAW THRUST manoeuvre. CHIN-LIFT/HEAD TILT A key advantage of the jaw thrust is that is does not involve any neck movement, which is better for trauma patients who may have a neck injury. However, if they are not traumatically injured or if the jaw thrust does not work, an alternative technique for opening the airway is to extend the neck with a HEAD TILT/CHIN-LIFT. This can be combined with a jaw thrust for even more effect. AIRWAY – POSITION! Whenever managing an unconscious casualty, be aware of the potential for neck injury. The simplest method is to avoid moving the casualty. However, if they are in a dangerous position or if the airway is compromised by a chin on chest position, the casualty may have to be moved, gently supporting the head with as little movement as possible, especially avoiding any ’chin to chest ‘movement. Head injury, blood loss/shock Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S

72 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RULE #1 DO NO HARM – DOESN’T SAY DO NOTHING As stated previously, the likelihood of causing serious harm with gentle movement is virtually nil and is no different to the likely actions of the paramedics who will follow. If movement is essential to preserve life, do it. RECOVERY POSITION Once moved to a clear space, if the casualty is not showing early signs of recovery, is still unconscious but breathing, place them in the recovery position and continue to monitor their airway and breathing. In this position the casualty should be gently turned onto their opposite side every 20-30 minutes if an ambulance has not arrived. Head injury, blood loss/shock Chapter 8: Unconscious / Very Drowsy - B.U.R.P.S RISK TO LIFE Unconscious casualty NO NORMAL SIGNS OF LIFE HEAD INJURY OR MEDICAL CAUSE SEIZURES LONGER THAN 5 MINUTES UNCONSCIOUS LONGER THAN 5 MINUTES Any unconscious or unresponsive casualty is TIME CRITICAL until proved otherwise. First aiders must call for help early (unless this obviously a faint) and check that signs of life are present. If no signs of life are present, immediately commence basic life support. If the casualty is alive but unresponsive, managing the airway is the priority. Look for an obvious cause. If they are having prolonged or multiple seizures or remain unconscious for more than five minutes, this is a serious life-threatening emergency and needs a 999 ambulance, even if they normally have seizures. Summary

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 73 No Signs of Life In this chapter we will focus on cardiac resuscitation, which has many different names such as BLS, CPR, ALS, chest compressions etc. ‘You can help someone in Arrest’ even with minimal training.

74 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The key to saving someone in cardiac arrest is to identify it quickly, to call for medical help and then to start chest compressions. In the UK the average survival from cardiac arrest out of hospital is around 10%, but in some parts of the world it can be as high as 60% or more. The key to this success is not fancy medical care or advanced paramedic skills, but is actually down to bystander and first responder efforts. The reasons why are demonstrated clearly in this diagram which shows how survival falls by about 10% every minute without chest compressions and as such within 6 minutes of the arrest occurring the chances of survival falls to 40%. However, even an untrained bystander who attempts to do chest compressions, can significantly improve this situation and at 6 mins improve survival by over 20%. We also now know that for the best chances of overall survival with a good outcome bystander chest compressions can be as important as any of the advanced resuscitation that takes place later. Simply by ‘having a go’ the bystander gives the paramedics the best chance to save a patient. The bottom line is clear – get hands on the chest early and start your compressions hard and fast. Cardiac arrest 0 20 40 60 80 100 1min 2min 3min 4min 5min 6min Percentage Survival The effects of By-stander CPR on Survival By-stander CPR No By-stander CPR Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 75 So consider a typical scenario. Here is a 69yr old man who is playing golf with his friends when he suddenly complains of feeling short of breath, with some tightness in his chest. Seconds later he collapses on the floor, initially clutching his left arm, but then he becomes unresponsive. He will not answer any of your questions and even with a firm but gentle shake he does not respond and he is looking blue around his lips. NO SIGNS OF LIFE • Quickly recheck, ask him loud and clear ‘Are you alright?’ • Look at his chest and feel with your hand over the mouth – is he breathing? GASPING IS NOT BREATHING When we saying breathing, we mean breathing normally. In other words, gasping or very slow breaths are not ‘normal breathing. If in doubt then assume that it is not normal. HELP ME One of the most important factors in any successful resuscitation is early recognition and that is why we simply limit the decision to identifying that the casualty is unresponsive and not breathing normally. • As soon as you suspect a cardiac arrest then call for help • Shout the people around you and then call for an ambulance. If there are people around then get them to make the 999 call and to state ‘CARDIAC ARREST’ and the exact location. Remember all the things that we discussed about the call for help in the earlier chapter. No signs of life Chapter 7: No Signs of Life

76 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Immediately get the casualty onto a firm flat surface in a safe environment. Do not spend more than a few seconds on this as every second counts and ‘hands on the chest’ are what is needed. In other words any interruption or delay to starting chest compressions reduces the chances of survival. If you know where there is an AED (defibrillator) then send someone to get it. If you have a smartphone, it may be worth considering the GoodSAM app which will not only allow you to call the emergency services or other providers but also will tell you where the nearest AED is located and also where you are when you check. Get the casualty onto a firm surface Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 77 Start chest compressions – Do not delay! START CHEST COMPRESSIONS DO NOT DELAY! Keep thinking ’hands on the chest’ Expose the chest of the casualty and locate the breast bone or sternum. We don’t waste time counting ribs etc now, we simply get the heel of the hand on in the middle of the breast bone. Interlock the fingers of the other hand on top and then comence compressions ’Hard and fast’ For the majority of Adult Cardiac Arrest we are not going to provide ventilations, just compressions or ‘hands only resuscitation’ as this will give your casualty the best chance of survival. It is well documented that in inexperienced hands ventilations are unlikely to be effective and will seriously compromise the far more important compressions and defibrillation. Be aware that most AEDs (Defibrillator) will advise you to do 30:2 compressions and ventilations, but as a first aider, you will be far more likely to resuscitate the casualty successfully if you stick to compressions only in most adult cardiac arrests. The only exception were we will provide Compressions and ventilations are cardiac arrests in children, any case of drowning, prolonged arrest (>15 mins) or when experienced help arrives. (see ventilation support below and in ‘R’ section) Expose the chest Lock your hands together and place them on the centre of sternum (Breast Bone). Lean over the casualty with straight arms and push downwards hard and Fast at 100-120 per min. Press down 5-6 cm and take your heal of your hand and weight off the chest after each compression. (this will all be practised at the Skill Station) NEVER, NEVER, NEVER GIVE UP Resuscitation is hard work, and if possible swap over however is doing compressions every 2 minutes with minimal interruption. You may quickly get exhausted or tired but it is essential to remember that you are saving someone’s life and you are making a difference, so keep going, give it your all and do not give up. However if you absolutely cannot carry on then take a short rest and resume compressions as soon as possible this is not ideal but better than nothing. Chapter 7: No Signs of Life

78 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com MOUTH TO MOUTH VENTILATION Mouth to mouth or mouth & nose ventilation is a way to support the breathing of a casualty if no other equipment is available, with exhaled air from your lungs which will continue 16-18% oxygen. This technique does carry a risk of infection from saliva, vomit or blood of the casualty, but this risk is very variable. For example, a child or family member may be deemed low risk when compared to an unknown intravenous drug user found unconscious in the street. As such, we would not normally recommend using this technique for casualties or first aid work. If you do then apply the following methods: • Wipe the face of the casualty • Take a breath • Tilt the casualties head back to open the airway • Pinch the nose and seal you mouth over the casualties’ • Gently but rapidly blow into the casualties’ mouth, the chest should rise • Only blow enough in to see the chest rise • Remove your mouth and let the chest fall • Repeat once more. If doing this as part of resuscitating a cardiac arrest then immediately resume chest compressions then after 30 compressions, repeat the 2 ventilations Advanced first aiders will use 15 compressions to 2 ventilations, but stick to the adult ratio in most situations. POCKET MASK VENTILATION The pocket mask is a small device that can be easily carried in a pocket or first aid kit. The device consists of a face mask, which will fit most adults or children (rotated upside down – see picture). The mask includes a one-way valve and filter which protects the rescuer from vomit and saliva from the casualty. Many pocket masks also have a built-in oxygen intake tube, allowing for administration of 50-60% oxygen. Once sealed onto the casualty face, the rescue blows through the non-return valve to inflate the lungs and the chest is seen to rise and fall. The mask must be held firmly onto the face or the breaths will leak out around the mask and ventilation will not work. This can be very difficult and time should not be wasted on this, when a patient is in cardiac arrest. Chest compressions are the most important focus and MUST be your priority. However, if the casualty is a child, has arrested from lack of oxygen e.g. drowning, or has been in arrest for >15 minutes then attempt pocket mask ventilation and use 30 compressions for every two breaths. Ventilation support Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 79 Chest compressions will keep the person alive, they buy time, but what is really needed is a defibrillator and these are now located in many public areas and they are designed for anyone to use as they are automatic. Automated External Defibrillator – AED. They are very safe and will give clear instructions and will not let you shock anyone who is ‘alive’ accidentally. Make sure that you are aware of your local or workplace defibrillators, just like fire exits. WHERE IS YOUR NEAREST AED? Charities and emergency services as well as shops and schools etc are all placing defibrillators in high profile locations that can be rapidly accessed in an emergency. Some just require you to break the glass, whereas others require you to obtain the code from the ‘999’ emergency operator once you give your location. – which is written on the locked cupboard. AEDs come in all sorts of shapes, sizes and colours, but their operation is largely the same, which is usually a lid that opens, which turns the device on. A voice prompt should then follow. Some require you to press a sequence of numbered buttons, but overall they are the same and will each tell you exactly what to do. Automatic External Defibrillator (AED) Chapter 7: No Signs of Life

80 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DON’T BE AFRAID SIMPLE AS 1,2,3 & VERY SAFE Don’t be afraid of these devices as it is as simple as 1-2-3 and they are very safe and certainly life-saving. The device will not suddenly deliver a shock without warning so do not worry, get those pads onto the chest of casualty as soon as possible, ideally without interrupting the chest compressions. Remove all of the clothing and underwear off the front of the chest with scissors or by ripping it, do not delay with buttons and fasteners. The AED will contain a sealed pack which contains the pads that stick to the chest. The pads attach to the machine by a wire which may need to be plugged in (the AED will tell you to do this if necessary). Peel the pads off the backing to expose the sticky surface which attaches to the chest and prepare to attach them as shown. When applying the pads, try hard to not stop the chest compressions and work around whoever is doing them. Some pads such as the Zoll, are ‘Z’ shaped and include a marker for compressions, which also gives feedback on the depth and rate of your compressions. (see image below). Automatic External Defibrillator (AED) Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 81 Before applying the pads to the chest take a quick look for: Jewellery – this must not be under the pads or it will burn or ‘brand’ the patient when the shock is delivered. Body hair: if the casualty is very hairy then the pads will not get a good contact and either look for an adjacent area of the chest with less hair or they will have to be shaved before application of the pads. A razor is usually supplied with AEDs for this purpose. Remember you only need to shave the area the pad will attach to. Do not use the pads to ‘wax’ the patient as this affects the adhesion of the pads when re-applied. Piercing: if anyone has body or nipple piercings then these also need to be avoided to prevent burns under the pads, however do not waste time trying to remove these. Just avoid them. Pacemakers: these are implanted in some patients under the skin, usually on the left side of the upper chest. We should always avoid shocking over them as they can be damaged and theoretically injure the patient. However if you place the pads as per the previous diagram you should easily avoid the pacemaker. Look for a short straight scar just under the left collarbone and if present then try and avoid it, but if there is no other suitable area then don’t worry and apply the pads and deliver the shock. Patches: Avoid placing pads over nicotine, nitrate or other medical patches. If necessary remove the patch and wipe the underlying skin dry with a gloved hand before the application of pads. Things to avoid - Patient Chapter 7: No Signs of Life

82 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Once chest compressions have started, applying the pads and delivering the life-saving shock is our biggest priority, but ensure that it is safe to do so. Through extensive testing by the AED manufacturers such as Zoll, we know that metal surfaces and wet floors are not a problem as long as everyone has their hands off the casualty when the shock is delivered. The device will ask you to stop compressions and tell everyone to not touch the patient every two minutes in order to assess the heart rhythm. The device will either say SHOCK ADVISED or NO SHOCK ADVISED. If no shock is advised, immediately resume chest compressions and follow further instructions or until signs of life. However, if a shock is advised, the defibrillator will start to charge or ask you to press the charge button. Once fully charged the shock button will illuminate. It is crucial that whenever using an AED, ensure that everyone is clear and not in contact with the casualty before pressing the shock button. Similarly, oxygen must be disconnected and removed to a safe distance (eg an arm’s length away) if in use. In FTACC we strongly recommend, wherever possible, that the person doing the compressions is last to take hands off the chest and is the person who actually delivers the shock. This is probably the safest way to deliver the shock, but vigilance and a quick check that all hands are off the patient before pressing the button are essential, especially when the adrenaline is pumping and people are rushing. Whilst it should never happen if correct safety procedures are followed, if a shock is delivered whilst someone is in contact with the patient, this is unlikely to cause serious harm. However, this cannot be guaranteed and should not happen. Things to avoid - You Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 83 THE ELECTRICITY IS GONE IN A FRACTION OF A SECOND Within fractions of a second after the shock being delivered and the patient jolting, the electricity is gone and the chest compressions should restart immediately. High performing resuscitation teams hover above the chest to avoid any delay in resuming compressions, but for the less experienced resuscitators we would stick with the chest compressor coming off the chest and pressing the shock button to maximise safety. Start chest compressions – Immediately after shock! Chapter 7: No Signs of Life

84 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com WE ARE OFTEN ASKED – HOW WILL WE KNOW IF THE HEART RESTARTS? Remarkably, the casualty may actually start to wake up, especially if this has been a short cardiac arrest or with good quality CPR. However, in many other cases, the first thing you may notice is the patient starting to breathe or cough and their colour starting to improve. Should this occur, place the casualty into the recovery position and await the arrival of the paramedics. If the casualty is NOT breathing normally or showing signs of life such as moving, simply continue with the chest compressions. NEVER, NEVER, NEVER GIVE UP You may start to fatigue or consider the process futile after a while, but as long as you continue good quality compressions there is still hope of survival. So keep going. Never give up! However, if you are working alone and simply cannot continue compressions because you are exhausted, take a short break, get your breath and then resume compressions. If you cannot continue, do not worry. You will have done your best and we cannot save everyone. If you do manage to continue and the casualty survives, you cannot begin to imagine how good that will feel as you will have saved a life. Early recognition and call for help Early defibrillation Post resuscitation care Early CPR - to prevent cardiac arrest - to buy time - to restart the heart - to restore quality of life Return of Spontaneous Circulation (ROSC) - Recovery Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 85 INFANT AND CHILD CPR It is a sad fact that research shows many children do not receive CPR as potential rescuers fear harming them. It is always better to attempt treatment rather than not doing anything, even though treating children can be highly stressful and emotional. We define an infant as birth to one year of age, and a child from one year old to puberty. You can gauge puberty by the size of the child with a good rule of thumb being that if you need to use two-handed adult chest compressions to depress the chest successfully, treat the casualty as an adult. The theory of infant and child CPR is the same as for an adult, it is only the techniques which change. It is crucial to give ventilations as well as compressions to infants and children requiring CPR, as it far likely that a lack of oxygen due to choking for example, is the cause of the cardiac arrest. Just relate the force of compressions and depth of breath to the size of the child. INFANT CPR As with adult CPR, if the infant is not breathing normally summon help via 999 immediately. Try to get someone else to do this to enable you to assist the infant. If no one else can summon help, carry out resuscitation for at least a minute before leaving the infant to call for help. Place the infant on a firm flat surface and unlike adult CPR, keep the head in a neutral position. Do not tilt it back as this does not assist an infant’s airway. • Seal your mouth around the infant’s mouth and nose (or use a pocket mask) and give five initial rescue breaths – blowing in just enough to make the chest rise, and then allow it to fall. If there are no signs of life or improvement in the next 10 seconds, immediately commence life support: • Compress the lower half of the chest • Compress to a depth of a third of the chest at the same rate as adults 100-120/min (i.e. about 2 compressions a second) After 30 compressions give two breaths quickly (30:2 is the same as adults,. Paramedics and others may use a different ratio for children) • Use two fingers only to depress the chest, aiming for 1/3 of the depth of the chest. Continue rotating rescue breaths and compressions as for an adult, giving 30 compressions to two breaths. Resuscitation children – Special circumstances Chapter 7: No Signs of Life

86 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com CHILD CPR As with adult CPR, if the child is not breathing normally summon help via 999 immediately. Try to get someone else to do this to enable you to assist the child. If no one else can summon help, carry out resuscitation for at least a minute before leaving the child to call for help. Place the child on a firm surface and open the child’s airway with the head and chin tilted, as you would do with an adult. Pinch the nose and seal your mouth around the child’s mouth. Give five initial rescue breaths – blowing in just enough to make the chest rise. Then use one hand to depress the chest, aiming for 1/3 of the depth of the chest. Give 30 compressions at a rate of 100-120 per minute. Return to the head and give two further rescue breaths. Continue then as per adult giving 30 compressions to two breaths. AED USE AND CHILDREN AEDs should not be used on infants under one year of age. For children from one to puberty, AEDs can be used, but care must be taken when placing the pads to make sure that there is at least a 3cm gap between the AED pads. If the child is too small to achieve a 3cm gap between pads, they can be placed to the front and back of the child as shown in the diagram. CONFUSED? If you are confused and cannot remember the correct technique for children and babies, simply provide adult BLS and do not worry about doing the wrong rate etc. Similarly, if you feel uncomfortable doing rescue breaths, simply carry out hands only CPR, like adults... Doing something is better than doing nothing. Resuscitation – Special circumstances Chapter 7: No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 87 DROWNING AND NEAR DROWNING Any casualty who is either face down in water or under the surface of the water, must be removed from the water as quickly as possible, as long as it is safe for the rescuer to do so. Once out of the water check if they are breathing normally. • If they are breathing normally, but have swallowed and / or breathed in any water then they must be taken to hospital to be checked out for further complications. Keep the casualty warm and calm whilst waiting for professional help, or are transporting them the Accident and Emergency Department. • If the casualty is unconscious but breathing normally, then place them into the recovery position and call an ambulance. Again try to keep the casualty warm, but do not attempt to ‘pump their stomach’ or ‘empty water from their lungs’ as doing so will not help, and is likely to cause the casualty to vomit and complicate matters. • If the casualty is not breathing normally, turn them onto their back and commence CPR as already described earlier in the chapter. In this situation casualties of any age should receive five initial rescue breaths followed by 30 compressions, and then continued resuscitation with two breaths and 30 compressions. To supply rescue breaths to an adult, open the airway using head-tilt / chin lift, pinch the nose and seal your mouth around the adult’s mouth. Give five initial rescue breaths – blowing in just enough to make the chest rise. If face shields or pocket masks are to hand, use them as a protective barrier between you and the casualty. If not, and you are comfortable to do so, you can supply rescue breaths without a barrier. Resuscitation – Special circumstances Chapter 7: No Signs of Life

88 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FTACC AED – Life Support Protocol (Based on UK/ERC Guidelines 2015) Chapter 7: No Signs of Life ASSESSMENT CHECK PATIENT NO RESPONSE CHECK PULSE AND BREATHING (max. 10 secs) • ABNORMAL BREATHING • NO MAJOR PULSE COMMENCE Hands Only CPR 100-120/min continuous OR 30:2 (See adjacent note) AED AVAILABLE • APPLY PADS • TRY NOT TO INTERRUPT COMPRESSIONS ANALYSE RHYTHM SHOCK ADVISED IMMEDIATELY RESUME CPR FOR 2 MINS 1 SHOCK DELIVERED NO SHOCK ADVISED RESUME CPR FOR 2 MINS RETURN TO CONSCIOUSNESS SIGNS OF WAKING UP e.g. MOVING, BREATHING NORMALLY CALL FOR HELP CALL FOR AED RING 999/112 or GoodSAM app COMPRESSIONS DEFIBRILLATION ASAP Provide ventilations (30:2) in: • Paediatrics • Drowning • Hypoxic Arrests • Experienced Responder

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 89 Respiratory Distress – B.U.R.P.S The next step in the B.U.R.P.S assessment is respiratory distress or difficulty in breathing.

90 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 9: Respiratory Distress - B.U.R.P.S Respiratory distress is typically demonstrated in two obvious ways: • Difficulty in breathing. • Fast breathing. In fact, a fast breathing rate (eg >20/min) is a reliable sign that someone is unwell. Once it reaches 30—40/min we should be very concerned, unless there is an obvious cause, such as exercise or severe pain. If we consider difficulty in breathing first, there are a number of typical causes including: • Obstructed breathing e.g. at the mouth or somewhere in the airway. • Lung conditions e.g. asthma, bronchitis, emphysema. • Heart conditions or failure. • Trauma resulting in shock or chest injury. Respiratory distress These will be considered in turn: • Blocked airway: The airway can be obstructed for a number of key reasons. The commonest causes are: • Foreign body (choking): This is most commonly food but can be children’s toys, pen tops, sweets or other items. • Tongue: This occurs as we have seen earlier most commonly when the casualty loses consciousness and muscle tone, but it can also occur if the tongue swells. • Swelling: can affect not only the tongue but also the lips, the throat and whole airway and tracheal (windpipe) lining as may be seen in a serious. Obstructed breathing - blocked airway

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 91 Choking from a foreign body can cause partial obstruction of the airway where some breathing is still possible but with difficulty, or the obstruction can be complete. The casualty is likely to look terrified and very distressed. They may be trying to cough and will usually be holding their throat. RISK TO LIFE Choking IF JUST ABOUT ABLE TO BREATHE, ENCOURAGE THEM TO COUGH UNABLE TO BREATHE, SPEAK OR COUGH – Back blows – Abdominal thrusts This is clearly a life-threatening emergency. If possible encourage them to cough and this may well clear the obstruction. If they are unable to speak or cough, this is more serious and suggests that no air can get into the lungs. The obstruction needs to be cleared mechanically as the casualty will be unable to do it themselves. Adults FIVE Back blows – check mouth after each blow FIVE abdominal thrusts – check mouth after each Hands above the umbilicus (belly button) and thrust backwards and upwards. REPEAT Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 9: Respiratory Distress - B.U.R.P.S

92 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com CHECK THE MOUTH BACK-BLOWS X5 IN TOTAL CHECK THE MOUTH The first action is to check the mouth for any obvious foreign body. We do not encourage finger sweeps as this may push the object further back and also involves putting your fingers into their mouth which is always risky if they bite down. BACK-BLOWS Stand to the side or behind the casualty and bend them forward slightly. Feel for the space between the shoulder blades and with the heel of your hand deliver five firm blows to the back, checking each time to see if the object has dislodged or has come out of the mouth. Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 9: Respiratory Distress - B.U.R.P.S

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 93 ABDOMINAL THRUSTS If the back blows fail to clear the obstruction, move behind the casualty and wrap your arms around their waist. Make a fist and grip it with the other hand. Move your hands into a position in the upper abdomen, just under the ribs, in the middle. When in position, pull your hands sharply towards you - backwards and upwards. The aim is to use air in the stomach and lungs to forcibly expel the obstruction upwards and outwards. Repeat this until the object is cleared or up to FIVE times, checking for the object in the mouth between attempts. CHECK THE MOUTH ABDOMINAL THRUSTS X5 Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 9: Respiratory Distress - B.U.R.P.S

94 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com CHILDREN >1YR - TREAT AS FOR ADULTS Children over 1 year of age are managed in exactly the same way as adults. Repeat this until the object is cleared or up to five times, checking for the object in the mouth between attempts. Small children can be led head down over a lap to allow gravity to assist the process. UNDER ONE YEAR OLD For younger children or infants less than one year of age, use back slaps as shown. If there is no success after five slaps switch to chest compressions. The reason for this is that in such young children there is a risk of damage to internal abdominal organs if the abdomen is compressed. It may be easier to position the child along the length of your arm or on your knee as shown in the photograph above. Keep rotating 5 and 5 until the obstruction is cleared or the child loses signs of life. Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 9: Respiratory Distress - B.U.R.P.S Do not give up, keep trying to clear the obstruction rotating your methods every five attempts. Repeat until the obstruction is cleared If casualty collapses then commence Basic Life Support.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 95 Tongue: Respiratory distress relating to the tongue occurs most commonly when the casualty loses consciousness and muscle tone, but it can also occur if the tongue swells. UNCONSCIOUS A famous trauma myth is that someone can ‘swallow their tongue.’ In reality, this does not happen as the tongue is actually a large lump of muscle attached to the floor of the mouth and extending down the throat, with a flap like projection that we all describe as the tongue in our mouth. Rather than being swallowed, an unconscious casualty loses all the normal muscle tone in the throat, and the muscle of the tongue, like all muscles becomes relaxed and floppy. As a result, if the casualty is lying on their back, the tongue falls backwards with gravity and closes the narrow gap at the back of the throat, restricting the flow of air as shown in the diagram on the following page. Respiratory distress - Continued Chapter 9: Respiratory Distress - B.U.R.P.S

96 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The diagram shows that air can enter the throat through both the nose and the mouth, but has to pass through the area behind the tongue on its way down to the lungs. As the tone is lost in the tongue muscle, it falls backwards into the area marked with the ‘X’. The tongue is attached in the mouth to the jaw bone. If we can move the jaw forwards (or upwards if lying on the back) we can re-open the gap at the back of the throat and even a millimeter or two will be sufficient to open the airway and to allow air through. This is the basis of the ‘jaw thrust’ manoeuvre. RECOVERY POSITION Alternatively, place the casualty in the recovery position as this will often encourage the tongue to fall forward, the opposite way, keeping the airway open. This is why this position is favoured if you need to leave an unconscious casualty to call for help. Obstructed breathing - Blocked airway TONGUE Chapter 9: Respiratory Distress - B.U.R.P.S