BTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 99 To examine a casualty for abdominal injury: 1. Try and lie the casualty flat if possible 2. Explain what you are going to do to the casualty 3. Expose and visually inspect the abdomen 4. Ask the casualty if they have any pain anywhere 5. Look around the sides of the abdomen 6. Feel along the back on each side of the abdomen, checking for wounds or bleeding 7. If the patient is conscious, starting away from any painful area, apply gentle pressure with the flat of your hand in each of the four quadrants of the abdomen (see figure 6.15) asking the casualty if this causes pain or discomfort, looking for any complaint of pain or grimacing on the casualty’s face. If there is no significant discomfort, then repeat the examination a second time, pressing a little more firmly, keeping your fingers flat on the abdominal wall. Signs and Symptoms of Abdominal Injury Signs and symptoms of abdominal injury include: • Abdominal wounds • Bruising on the abdomen • Abdominal pain • Broken lower ribs • Blood in vomitus • Bleeding from the anus or urinary tract • Distension (bloating of the stomach). Little can be done to care for abdominal injuries on scene, but recognition is very important, as massive internal haemorrhaging can lead to shock. Rapid transfer to hospital is essential. Any efforts to treat abdominal injury should not delay transfer. When abdominal wounds are present and time permits, efforts can be made to control external haemorrhaging with simple pressure dressings, chest seals, or—for larger wounds—cling-film. However, there is also likely to be similar amounts, or even more, internal bleeding, so rapid transport to hospital is the priority, especially if there are features of shock. If any abdominal contents have eviscerated (spilled out of the wounds), they can be gently covered with cling-film or saline-soaked swabs. DO NOT try and push them back into the abdomen. Gently handle or move any casualty with a possible internal injury or bleeding to minimise the bleeding and discomfort. Consider a pelvic strap before any movement, if necessary. Abdominal injury Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.15: 4 Quadrants of the abdomen to examine Left upper quadrant Left LOWER quadrant RIGHT upper quadrant RIGHT LOWER quadrant

100 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 6.16: Diagram to describe depth of skin burns Superficial Superficial dermal DEEP dermal Full Thickness EPIDERMIS DERMIS SUBCUTANEOUS Burns can vary from minor redness to a life-threatening situation, depending on the depth and location of the burn (see figure 6.16). Superficial burns: (first-degree burns) are the most minor type of burn and are characterised by reddened and painful skin, but without blistering, e.g. sunburn or a minor scald. The injury is confined to the outermost layers of skin, and the casualty experiences minor to moderate pain. A superficial burn usually heals in about a week, with or without treatment. Partial-thickness burns, dermal (second-degree burns) are somewhat deeper, do not damage the deepest layers of the skin, but are the most painful. Blistering is typically present, although they may not form for several hours in some cases. There may be some fluid loss and usually moderate to severe excruciating pain because the nerve endings in the skin are fully exposed to contact and the air. Partial-thickness burns require medical treatment and usually heal within two to three weeks and may result in some form of scarring. Full-thickness burns (third-degree burns) damage all layers of the skin. In some cases, the damage is deep enough to injure and destroy underlying muscles and other tissues. There is often less pain than expected because the nerve endings have actually been destroyed. However, there is typically some marginal or associated partial thickness burn too, which will produce severe pain. Without the protection provided by the skin, patients with extensive full-thickness burns lose large quantities of body fluids and are susceptible to shock and infection. All full thickness burns require hospital review. Burns All burn patients should receive high flow oxygen to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the effects of any carbon monoxide poisoning. Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 101 It is not always possible or necessary to determine the exact degree or depth of a burn. Burns should be always considered time critical if they: • Cover more than 10% of an adult’s body surface area or more than 5% of the body surface area of a child (under 16 years) – remember that the casualty’s hand (palm & fingers) = approx 1% of skin area • Affect the airway • Are found in a paediatric or elderly casualty (extremes of age) • Are found in a casualty with other serious medical or trauma conditions • Involve the face, hands, feet, genitalia, perineum or major joints • Are located above the shoulders • Are circumferential ( i.e. go all the way around a limb or body part) • Are electrical or chemical burns • Involve fumes or smoke inhalation. All major or time critical burns patients should receive high flow oxygen (15 L/min) to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the effects of any carbon monoxide poisoning. For time critical burn patients, rapid transport is essential. Burns are also categorised by the source of the injury: • Thermal, • Chemical • Electrical. The signs, symptoms, and treatment of each type vary, as outlined in the following sections. More accurate assessment of burn area: Traditionally burns have been assessed using simple charts such as the Lund and Browder and the ‘Rule of Nines’ but an accurate and far simpler version now exists with the ‘Mersey Burns’ application produced by one of the UK’s leading Burns and Plastics units at Whiston Hospital in Merseyside. This offers a very simply method to record and size the burn based on the size, weight and age of the casualty. Burns Remember to cool the burn effectively for at least 10 minutes, but avoid significant hypothermia if the burn is extensive. Chapter 6: H: Head Trauma and Other Serious Injuries Recommendation: Mersey Burns APP St Helens & Knowsley Teaching Hospitals NHS Trust

102 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Thermal burns are the result of direct contact with flames or thermal energy (heat) on the skin or tissue. In all types of thermal burns, treatment should aim to limit the damage caused by the thermal energy, which may still be present when you reach the casualty, who may even still be on fire. Extinguishing the fire Your safety is clearly paramount and if the fire service are not present, then use appropriate fire extinguishers (see guidance in appendix) ensuring that you protect yourself at all times and avoid being in enclosed spaces with fire. Managing the burn This involves actively cooling the injured area to dissipate the thermal energy which, can remain and cause further damage, even after the direct heat source has been removed. • Place the injured area under clean, cold running water as soon as possible for at least 10 minutes • Only dress the burn once it has cooled completely (see figure 6.17). Immersion in cold water is not as effective as running water, which continues to remove heat energy from the burn. However, if the only water available is in a static container or vessel, then it is better than no cooling. Water does not have to be sterile, but ideally it should be clean. However, if all that you have is tap water, a garden hose or water from the fire engine tank, use it, as the active cooling is the priority and any infection risk is very much a secondary issue, as most burns get infected at some point. Dressing the burn • Cover the burns with ‘burn-film’ (or ordinary cling-firm if nothing else is available) laid on in sheets • Face shield can be used for facial burns • Hands and feet – burn bags or freezer bags • Gel dressings are not ideal as they have a limited heat absorption and are not as effective as running water. The gel can be hard to remove from the raw burn at a later stage in hospital. Burn film keeps the area clean, reduces fluid loss, and significantly reduces pain by covering the exposed nerve endings. Never wrap or wind film around a limb. Always lay strips or sheets on lengthways, as when the limb starts to swell, the dressing will not be tight, constricting the limb. Hands and feet are best managed with clear plastic bags or freezer bags and if possible, with a few millilitres of sterile eyewash/saline added to the bag and then loosely taped around the wrist or ankle. This creates a humidified environment and allows ongoing inspection of the burn, through the bag in hospital. Thermal burns Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.17: Burns are covered with burn-film and plastic bags containing a few millilitres of saline eyewash for the hands and feet.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 103 Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Every effort should be made to identify the chemicals involved to determine the most appropriate form of treatment, as certain chemicals, such as sodium phosphorous may react negatively with water producing more heat. All chemical powders should be brushed off the patient’s clothing or skin, carefully avoiding coming into contact with this substance yourself. Dry decontamination (ideally by the individual themselves) is now the favoured approach. Removing clothing and brushing the agent off with paper towel is recommended, but if it’s burning, irrigate as soon as possible. After you have removed as much of the dry chemical as possible, irrigate the burned area with clean, cold running water. The water washes off remaining chemical residue and residual thermal energy. Flush the affected area for at least 30 minutes. Once it has been decontaminated effectively, cover the area with a burn-film dressing (if there is obvious residual chemical on the skin, avoid dressings) and provide rapid transport to hospital. Diphoterine – This is an emergency agent used on many chemical sites/labs for the immediate management of chemical burns. Some studies have indicated that it may reduce the injury from burns. However, hospital burns units would still recommend the use of cold running water, for at least 10 minutes, especially for more major burns. Diphoterine can be used, but for smaller burns or for immediate management. It is rarely in sufficient volume, especially for larger burns and we should switch to running water when it runs out. See Clinical Update: A.7 Corrosive Attack Phosphorus burns – water was traditionally avoided as there action can generate significant heat but when a sufficient volume of water is used this effect is minimised and it is therefore a safe and effective option. Electrical burns Electrical burns result from direct contact with a live electric energy source. Even small electrical burns, if sufficient to burn the skin (often looking like cigarette burns) can cause a large amount of tissue damage and a great deal of pain. With electrical burns, there is an added risk of cardiac arrest, which requires immediate basic life support and defibrillation (see chapter 7). Before treating an electrical burn, always ensure that the scene is safe and that you are adequately protected from the electrical source. Before you touch or treat a person who has suffered an electrical burn, be certain that the casualty is not still in contact with the electrical power source which caused the burn. If the casualty is still in contact with the power source, anyone who touches him or her may also be electrocuted. If the casualty is touching a live power source, your first act must be to unplug, disconnect, or turn off the power. If you are unable to do this alone, call for assistance and stand clear until help arrives. After the power has been disconnected, examine the casualty carefully, assessing airway, respiration, and circulation before treating visible, external burns. If there is obvious thermal injury (e.g., flames or blistering), the area may be cooled with water only when there is no risk of contact with electricity. However, cooling is less effective in these burns and the wounds should be rapidly dressed with burn-film before immediate transfer to hospital. Even small electrical wounds can hide major tissue injury, or result in cardiac injury. All electrical burn casualties should be referred to hospital. Chemical burns Chapter 6: H: Head Trauma and Other Serious Injuries

104 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Anyone exposed to fire, smoke, or hot gases is at risk of inhalation injury to the lungs and upper airway. In these incidents, the airway can become dangerously swollen and the lungs can become congested with soot and water which is released as a reaction to the damage of the delicate lining of the lungs. Casualties can die from this injury a day or even weeks later, with no external sign of a burn. Signs and Symptoms of Inhalation Injury Signs and symptoms include: • Airway injury: redness or soot around or inside the nose/mouth • Coughing: especially with sooty sputum • Wheezing • Difficulty breathing • Presences of fire, smoke, hot gases or steam at the scene. To treat casualties with inhalation injuries, first move them to a safe distance away from the scene and then assess them in a sitting position, to help them breath, unless they have a reduced level of consciousness level. If so, it may be safer to lay them down in the recovery position until an ambulance arrives. Administer oxygen through a non-rebreathing mask at 15 L/min Remember that the pulse oximeter is not reliable in such cases and will potentially read higher. If the airway starts to swell (lips, tongue, throat, face) or the burn is above the shoulders then consider: • Inserting one or even two fingers into the nasal airway, before the swelling gets too severe, could be life-saving later • Any signs of swelling and the casualty is at significant risk and is clearly time critical. All smoke inhalations should receive 100% oxygen - irrespective of there oxygen saturation on pulse oximeter. If a casualty is asthmatic, they may well benefit from using their blue-grey ‘Ventolin’ inhaler, if their chest is tight or they are coughing a lot. Encourage them to take two puffs of the inhaler, which they can repeat a second time five minutes later if required. Carbon monoxide, cyanide and inhaled poisoning Carbon Monoxide Carbon monoxide is a highly toxic, colourless, odourless and invisible gas that binds to the haemoglobin in blood and prevents the normal carriage of oxygen. • High levels of carbon monoxide can result in coma and death within minutes • Victims may exhibit flu-like symptoms and reduced levels of consciousness • Typically they still appear ‘pink’ as the carboxy-haemoglobin in the blood is cherry red. Following a significant level of exposure to fire or carbon monoxide, e.g. house fire or faulty gas appliance) the ‘poisoned’ blood is very red, the casualty does not appear blue or short of oxygen and even the normal pulse oximeter will be fooled and give a very high saturation reading. In view of this the pulse oximeter should only be relied upon for heart/pulse rate readings and not used to assess the oxygen status of these patients as the reading will be falsely elevated. Smoke inhalation Chapter 6: H: Head Trauma and Other Serious Injuries Do not rely on oxygen saturations from pulse oximeter in smoke inhalation victims

105 The UK Ambulance HART teams and hospitals have a more complex type of oximeter called a Co-oximeter, which will tell the difference between normal and abnormal blood and can indicate the need for oxygen therapy and hospitalisation. Carbon monoxide is released from partial combustion of substances in fires or in faulty household heating appliances. Carbon monoxide poisoning may result from the following scenarios: • Defective domestic gas/oil appliances such as boilers (most common after the onset of inclement weather when these appliances are first turned on are a period of disuse) • Even short exposure to fires or smoke in a closed environment • Prolonged exposure to fire in any environment • Fuel-driven engines in a confined space • Contaminated compressed gas cylinders (e.g. divers). Signs and Symptoms of Carbon Monoxide Poisoning • Reduced level of consciousness or coma • Headache • Fatigue and lethargy • Flu like symptoms • Dizziness • Poor coordination and/or balance • Blurry or double vision • Abnormal, involuntary eye movement (nystagmus) • Ringing in the ears • Shortness of breath • Chest pain • Diarrhoea (especially in children). As you can see, many of these features are nonspecific and vague, which can lead to delayed diagnosis, even when people have sought medical help or guidance for their symptoms but have not linked them to a faulty appliance. A very important prevention message and public education programme has been established by a number of UK Charities, following some tragic deaths in family homes, holiday homes and student accommodation. Always enter any property where there is such a risk with extreme caution, especially after a fire or casualties have been found. This may require breathing apparatus as even a few breaths of carbon monoxide at high level can render you unconscious. Treatment of carbon monoxide poisoning To treat casualties with carbon monoxide poisoning, responders should: • Administer supplemental high flow oxygen (15L/min) to displace the carbon monoxide from the haemoglobin • Severe cases (including casualties with a history of reduced conscious level or neurological symptoms and pregnant or paediatric casualties) may later require referral to a medical hyperbaric unit • Unconscious casualties need rapid assessment and either airway management with oxygen or if there are no signs of life, then immediate basic life support, with high flow oxygen and ventilation (30:2). Cyanide and other toxins House fires, where many synthetic furnishings and materials are burned in an enclosed space, may also release dangerous levels of other toxic gases such as cyanide compounds which can be fatal even at very low levels. In France and other parts of the world, every house fire victim is treated for potential cyanide toxicity at the scene. In the UK this practice is rare, even in emergency departments. Other Hidden dangers and situations Tunnels, sewers, silos, or hoppers may also involve dangerous gases or toxins at very high levels, e.g. methane and carbon dioxide which greatly reduce oxygen levels. Gas analysers and breathing apparatus are essential for safe working or rescue in these environments. Carbon monoxide, cyanide and inhaled poisoning Chapter 6: H: Head Trauma and Other Serious Injuries Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

106 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chemical suicide In recent years there has sadly been a growing trend from the internet for young adults and teenagers to commit chemical suicide alone or even in groups. They typically use cyanide, which is rapidly fatal and can be produced with a simple blend of some household chemicals based on instructions that they find online. There is a typical pattern to these suicides and they usually seal themselves in a locked room, and clearly mark the door outside to protect relatives and the emergency services. It is essential that rescuers DO NOT ever enter such a room without suitable chemical protection, especially as cyanide compounds can: • Be absorbed through the skin • Exhaled by casualties. If we do manage to rescue the casualties they will then require resuscitation during a full decontamination process, which is very challenging and unlikely to be successful. Farm workers Few appreciate the very real risks of inhaled or skin poisoning and sudden death on farms. There are several key areas of risk including: • Slurry pits • Grain stores and silos • Organophosphate Fertiliser and pesticides, e.g. sheep dip. Slurry pits are often adjacent or underneath cow sheds or shippons and very high levels of methane and carbon dioxide can accumulate in these tanks, which can be released in very high levels when they are agitated. A few breaths of this colourless gas will render the casualty unconscious and rapidly lead to death because of the low levels of oxygen. Grain silos carry similar risks from high levels of carbon dioxide, which can rapidly incapacitate a worker or rescuer, rapidly resulting in death. Working or rescuing casualties in any of these situations requires breathing apparatus and ideally gas analysis before entering the scene. Resuscitation to such casualty is unlikely to be successful, unless they have only just collapsed within a few minutes. Organophosphates Many chemicals on farms are based on organophosphates such as fertilisers and pesticides. A typical poisoning could involve excessive skin exposure or ingestion, e.g. falling into a sheep dip or spillage. These agents are closely related to the chemical weapons such as Taban and Saran and result in: • Excessive salivation • Muscle weakness (paralysis at extreme) • Difficulty breathing • Constricted pupils • Slow pulse rate. This can be a life-threatening emergency and rapid decontamination is essential, ideally dry or wet if necessary with copious amounts of water (always consider where the water is running off to, based on the nature of the chemical) If breathing is difficult, then supporting the breathing with a bag valve mask or pocket mask can be life-saving until help arrives. HART paramedics will carry atropine autojet antidotes for chemical terrorism which will help, but hospital will usually be required for management of the paralysis, that will re-occur despite the atropine. Note: Farming accidents are covered in more detail in the BTACC Special Circumstances – Farming section Any casualties brought from a fire or enclosed environment with a reduced level of consciousness should be given high-flow oxygen, assumed to have CO or Cyanide poisoning and be rapidly transported to hospital. Carbon monoxide, cyanide and inhaled poisoning Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 107 • he final step in the MARCH algorithm addresses head trauma and other serious injuries, including spinal injuries, bone fractures, abdominal injuries, and burns • Treatment of head injuries in the field focuses on preventing further damage • The AVPU scale is used to assess casualty responsiveness • Head trauma casualties must be rapidly transported to hospital • All casualties with signs or symptoms of spinal injury should be considered time critical • While there are certain situations in which the spine should not be immobilised, responders should fully immobilise the spine if there is any doubt • Longboards can be used for extrication and immobilisation. A casualty should either be placed on the longboard by logrolling or with an orthopaedic (scoop) stretcher • Fractures should be immobilised by splinting which limits movement, reduces pain, helps control bleeding, and decreases the risk of damage to the nearby nerves and vessels • Many different materials can be used as splints. Splints can be improvised from rigid materials, but commercially available products offer more robust immobilisation • Splints should be applied when there is a doubt about their necessity • For rib fractures, responders should be careful to handle the casualty gently and continually reassess for developing respiratory concerns • Pelvic fractures require immobilisation, since these injuries often involve severe blood loss • Examine casualties carefully for signs of abdominal injury and provide rapid transport to hospital if abdominal injury is suspected • If treating abdominal injuries will not delay transport, wounds should be dressed appropriately • Burns are categorised by depth (superficial, partial-thickness, and full- thickness) and by source (thermal, chemical, electrical) • Thermal burns are the result of direct contact of flames or thermal energy (heat). They should be cooled under running water, dressed in burn-film wrap, and, if time critical, rapidly transported to hospital • Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Chemical burns should be identified, cleaned, washed, and dressed. Casualties should be rapidly transported to hospital • Electrical burns result from direct contact with a live electric source. Safe approach is essential when treating electrical burns. Wounds should be dressed with burn-film before rapid transfer to hospital. All electrical burn casualties should receive supplemental oxygen • When appropriate, pain management drugs such as Entonox and Fentanyl may be used to help stabilise casualties. Summary: Chapter 6: H: Head Trauma and Other Serious Injuries

108 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com AVPU scale: A scale to measure a casualty’s level of consciousness. The letters stand for alert, verbal, pain, and unresponsive. Cervical collar: A neck support that partially stabilises the neck following injury. Full-thickness burns: Burns that extend through the skin and into or beyond the underlying tissues; the most series class of burn. Logrolling: A technique used to move a patient onto a longboard. Partial-thickness burns: Burns in which the outer layers of skin are burned; these burns are characterised by blister formation. Splinting: A means of immobilising an injured part by using a rigid or soft support. Superficial burns: Burns in which only the superficial part of the skin has been injured; for example, a sunburn. Revision: 1. Which of the following scales should be used to assess patient response to stimuli? A ABC B MARCH C AVPU D DiD-iT ANSWERS 1: C 2. True or False? Any casualty who has suffered a serious head injury and has an oxygen saturation of 90% should NOT be given supplemental oxygen. A TRUE B FALSE ANSWERS 2: B Vital vocabulary Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 109 3. When should a rescuer working alone attempt to immobilise the spine in a casualty with suspected spinal injury? A Immediately after securing the airway. B When no other time critical injury needs managing. C Before moving the casualty, under any circumstances. D A single rescuer should never attempt to immobilise the spine. ANSWERS 3: B 4. In the event of a suspected pelvic fracture, rescuers should: A Strap the pelvis, legs, and ankles together and then evacuate the casualty on a longboard or scoop. B Use a traction splint. C Elevate the legs. D “Spring” the pelvis. ANSWERS 4: A 5. Which of the following criteria relating to burns indicates a time critical situation? A The burn has caused blistering on the thigh. B The burn is very painful. C The casualty has sunburn and cannot wear a shirt. D The burn is found on the neck. ANSWERS 5: D Revision: Chapter 6: H: Head Trauma and Other Serious Injuries

110 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com M.A.R.C.H Algorithm Chapter 6: H: Head Trauma and Other Serious Injuries B.L.S. Protocol NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • Cx spine immobilisation RESPIRATO RY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATO RY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Elevate Legs • Head to Toe survey INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing Spinal Injury and Fractures • Immobilise/Splint Burn Injury • Active Cooling • Cling-film/bags Environment • Keep warm • Package for Transport MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air HEAD & OTHER INJURIES • AVPU • Pain or numbness • Burns/Cold • Others, e.g fractures RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 111 Chapter 7: Resuscitation and Basic Life Support 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. Basic Life Support (BLS) and use of AED will also be covered as a shortend refresher in the First Aid & Medical Emergencies Section (see chapter 8).

112 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Cardiac arrest 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 (figure 7.1) 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. 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. No signs of life Chapter 7: Resuscitation and Life Support 0 20 40 60 80 100 1min 2min 3min 4min 5min 6min Percentage Survival By-stander CPR No By-stander CPR Figure 7.1: The effects of By-stander CPR on Survival

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 113 HELP ME One of the most important factors in any successful resuscitation is early recognition and that is why we simplified the process of identifying a cardiac arrests - a casualty 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. Confirm Cardiac Arrest • Open the Airway and feel for breathing on your hand stroke face for 10 seconds (No more) • Feel for a major pulse (Neck, Groin) for 10 seconds (No more) • If there is no breathing or pulse or you are in any doubt then assume Cardiac Arrest. 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: Resuscitation and Life Support

114 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: Resuscitation and Life Support Recommendation: GoodSAM APP Available on App Store and Android

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 115 Place hands over the mid-lower part of the sternum (breast-bone). Do not delay the chest compressions trying to be too exact, but ensure that you are not compressing the soft abdomen If a person is in cardiac arrest, responders should attempt to maintain or restore circulation through cardiopulmonary resuscitation (CPR). CPR is comprised of two components: chest compressions and ventilations. Chest Compressi ons Early Chest compressions are the most crucial part and should be started as soon as possible to give the patient the best chance for survival and keep the patient alive until more advanced medical care can be administered. ADULT CPR commences with compressions only or before any breaths. To perform chest compressions, kneel beside the patient’s chest facing the patient (see figure 7.2). Place the heel of one hand in the centre of the patient’s chest. Place the heel of the other hand on top of the hand on the chest, interlocking your fingers. After you have both hands in the proper position, compress the chest of an adult 5 to 6 cm straight down. For compressions to be effective, stay close to the casualty’s side and lean forward so that your arms are directly over the casualty. Keep your back straight and your elbows locked so you can apply the force of your whole body to each compression, not just your arm muscles. Between compressions, lift the heel of your hand off the patient’s chest allowing the chest to completely recoil. Compressions must be rhythmic and continuous. This takes practice and feedback devices such as the Zoll defib pads really help. Each compression cycle consists of one downward push followed by a rest so that the heart can refill with blood. Compressions should be at the rate of 100 – 120 compressions per minute. Cardiopulmonary Resuscitation (CPR) Chapter 7: Resuscitation and Life Support Figure 7.2: Performing Chest Compressions 1. Kneel beside the casualty’s chest. 2. Place the heel of one hand in the centre of the casualty’s chest. 3. Place the heel of the other hand on top interlocking your fingers. 4. Compress the chest of an adult 5 to 6cm straight down. Then allow chest to completely recoil.

116 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Why ‘Hands-only’ CPR? Chapter 7: Resuscitation and Life Support It may come as a surprise to hear, but for those who are not involved in resuscitation on a very frequent basis, (e.g. monthly) they are likely to have more success with adult cardiac resuscitations by doing chest compressions only. The reasons for this are simple, as we now know that good compressions are the key element of CPR and to interrupt to deliver breaths/ventilations, can actually reduce the chances of survival. This clearly demonstrates that the key focus must be the compressions and even if capable of doing ventilations, they are less of a focus and must be completed without any delay to resuming compressions. The simple diagram below demonstrates why continuous compressions are so important, as they maintain the blood flow or ‘perfusion’ to the brain and organs of the body, but when we stop compressions, the perfusion drops to near zero immediately. When compressions are resumed, it can take up to 18 compressions, to restore the perfusion again, so we should only do ventilations if they are essential and will count. There are a few exceptions where we would always recommend compressions and ventilations. These exceptions are cardiac arrests where there is a lack of oxygen involved e.g: • Drowning • Hanging • Carbon monoxide poisoning • Children (under 18 years) • Greater than 10-15 mins downtime (cardiac arrest). However, if ventilations are difficult or you cannot do them for whatever reason, carry out compression only ‘hands-only’ CPR. If you are doing compression-only (hands-only) CPR but you have oxygen available, then there is theoretically some benefit in delivering the oxygen during the compressions, as some will flow down an open airway and reach the lungs. Theoretically, this may increase the chances of a good outcome. This should not delay or interrupt the compressions, but if multiple rescuers are present then consider: • Starting compressions and during airway procedures below • Inserting nasal (x2 if possible) and oral airway • Applying oxygen 15 L/min via mask (alternatively insert I-gel) • Holding the airway open and maintain during compressions • Performing continuous compressions and following the AED instructions when it arrives.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 117 Use of the pocket mask for ventilation. Keep the casualty’s airway open by using the head tilt–chin lift manoeuvre (or the jaw-thrust manoeuvre for patients with suspected head or neck injuries) and then take a deep breath and blow steadily into the mask for about half a second. Use rapid but gentle, sustained breathing and just enough to make the casualty’s chest rise. Remove your mouth from the mask and allow the lungs to deflate and the chest to fall. If using a Bag valve mask (BVM) squeeze the bag ONLY ENOUGH TO SEE THE CHEST RISE NORMALLY. This allows you to use a large adult bag on small adults or even children. Use of a pocket mask with oxygen attached. The rate of breaths should be 10 to 12 breaths per minute for an adult. If a pocket mask or bag-valve mask is not available and you are unwilling or unable to perform mouth-to-mouth ventilation, continue with chest compressions only at a rate of 120 per minute. (Equivalent to 30: 2). Person Bag-valve-mask (BVM). If the ventilations do not make the casualty’s chest rise and fall, as seen with normal breathing, make sure that the airway opening technique you are using (e.g., head- tilt–chin-lift or jaw-thrust manoeuvre) is being appropriately applied. Check for, and remove any visible obstruction, in the casualty’s mouth, but do not delay further compressions worrying about ventilations – remember that effective life support is far more about chest compressions than ventilations. Provide only two ventilations before returning rapidly to chest compressions, and keep repeating these checks until normal chest rise is seen with ventilation. Ventilations or ‘Rescue breathing’ - Experienced resuscitator If not used to providing ‘ventilations’ on a regular basis, then clinical evidence shows that “hands only” CPR will give better results. Figure 7.3: Performing Ventilations Chapter 7: Resuscitation and Life Support If attending frequent cardiac arrests and skilled in ventilation this allows the rescuer to ‘breathe’ for the casualty, which may improve the outcome in Cardiac Arrest and will improve the likely outcome in Children drowning and Hypoxic (lack of oxygen) Arrests. To perform ventilation, use a pocket mask or a bag-valve mask (see figure 7.3). For the pocket mask, ensure that the airway is clear and open (jaw thrust, chin lift) then seal the mask onto the face.

118 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Although one-rescuer CPR can keep the casualty alive, two-rescuer CPR is preferable because it is less exhausting for the rescuers, and if necessary one person can deliver chest compressions while the other performs ventilation. One, two or more rescuer CPR, delivers 30 chest compressions for every 2 ventilations. Continue this process without stopping unless the casualty starts to breathe properly or more advanced health care professionals arrive. In two-rescuer CPR, the first rescuer should provide 30 chest compressions and then pause just long enough for the second rescuer to provide two ventilations. To avoid rescuer fatigue—which may result in less effective chest compressions—the two rescuers should switch roles after every five cycles of CPR (about every 2 minutes). Two rescuers should be able to switch roles quickly, interrupting CPR for the minimum amount of time. The aim is that under no circumstances, should CPR be interrupted other than to analyse on the AED - especially for longer than 10 seconds. One or two-rescuer CPR is now the same in adults (no difference in compression: ventilation ratio) Chapter 7: Resuscitation and Life Support Automatic External Defibrillator (AED) In Europe, nearly 700,000 individuals die of cardiac arrest each year. Up to 70% of adult patients who suffer a non-traumatic cardiac arrest are in a state of ventricular fibrillation (VF)—a condition in which the heart muscles are ‘quivering’ or ‘fibrillating’ and not effectively pumping blood. It is in this condition that we are most likely to reverse and save them. This irregular heart electrical rhythm can be defibrillated, reorganised or ‘shocked’ into effective heartbeats with the use of an automated external defibrillator which creates a DC electric shock. (AED) (see figure 7.4). Automated external defibrillators (AEDs) are machines which can accurately identify ventricular fibrillation and advise responders to deliver a shock to defibrillate the heart rhythm. Figure 7.4: An Automated or Advisory External Defibrillator (AED)

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 119 Automatic External Defibrillator (AED) Once the AED is brought to the scene, quickly attach the adhesive electrode pads to the casualty. Nearly all AEDs provide accurate and simple voice and screen commands. Follow these and ensure that no one is touching the casualty whilst the AED is analysing the rhythm. Pad placement When sticking the pads to the chest, ensure that the chest is dry and not too hairy (safe hair-removal devices can be kept with the AED). Do not delay defibrillation awaiting a razor. Place one pad just to the right of the sternum, below the collar bone and the other pad on the left side of the chest, just below the nipple (for males) or underneath the breast tissue (for females). If the pads are slightly misplaced, avoid removing and reapplying them, as they may not adhere as well. (see figure 7.5) Additionally, responders should check for the 8 P’s which require special attention before administering attaching pads or delivering shocks: • Piercings • Pacemakers • Pendants • Playtex (bras) • Patches (GTN/ nitrate patches) • Perspiration • Paediatric casualty (requiring special pads) • Personnel in contact with patient Foreign objects listed above should be avoided or removed, without delaying the shock or ongoing CPR. Special paediatric pads may be required for children. No one should be contacting the casualty when a shock is administered. Feedback defibrillator pads The latest generation defibrillator pads, such as those produced by Zoll, provide real time feedback to those that our doing chest compressions about the quality of the compressions in terms of: • Rate • Depth • Release Rescuers may refer to the AED pad packaging for correct placement. Chapter 7: Resuscitation and Life Support Figure 7.5: PAD Placement

120 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Function of the AED/defibrillator The AED will assess the casualty’s status every two minutes and advise when to deliver a shock. (see figure 7.6) When a shock is advised, use the following steps: 1. Stop CPR 2. Disconnect any supplementary oxygen and move bag-valve mask at least 1.5 m away from the casualty 3. Ensure that no one is touching the casualty 4. Shout“Stand clear!” we recommend that the shock is delivered by the chest compressor to ensure their hands are not on it. 5. Press the “shock” button on the AED. (Fully-automatic AEDs will deliver the shock automatically) 6. Stand back while the AED delivers a shock 7. Immediately recommence CPR for two minutes until the AED reassesses the casualty’s need for further shocks. Repeat this sequence until the casualty starts to breathe normally. If no further shocks are indicated, continue CPR until the patient regains spontaneous breathing, or more qualified help arrives. If spontaneous breathing is present, check for a pulse (carotid of femoral). Figure 7.6: Analysing a rhythm using an AED AEDs vary in their operation so learn how to use your specific AED. Practice until you can perform the procedure quickly and safely. Ensure you always follow the most recent Resuscitation Council guidelines. Many AEDs are only equipped with adult sized pads which are suitable to down to eight years of age. For smaller children, if no paediatric pads are available then the adult ones can be used over one year of age, placed on the front and back if necessary. Automatic External Defibrillator (AED) Care should always be taken when using AEDs in certain environments, particularly those that are wet or near water sources. An AED can be safely used in children down to 1 year of age. Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 121 Return of Spontaneous Circulation – ROSC When the casualty starts to breathe or show signs of life put them in the recovery position and observe them. Leave the AED pads attached unless they are shivering or having a seizure and continue to monitor them until help arrives. Whilst it is rare for someone to just wake up immediately intact, this can occur if the arrest has been very short or after a period of recovery. Reassure them and keep them comfortable and warm until the ambulance arrives. Traumatic cardiac arrest In Traumatic cardiac arrests, e.g. at a road traffic collision, VF is rare and CPR and defibrillation are unlikely to be successful. The mortality from blunt traumatic cardiac arrest is close to 100%, but most providers will still wish to try some aspect of resuscitation/CPR, as the cause of the incident may have been the cardiac arrest, although they should be aware their efforts are likely to be futile with 1-2% survival or less. However, penetrating cardiac arrests, e.g. from a stabbing, may be amenable to aggressive surgical control, but this is far beyond the scope of all but the most advanced trauma-medical teams and most will die of blood loss or other effects such as bleeding around the heart. Summary: • When a casualty shows no signs of life, he or she is likely to be in cardiac arrest and should be considered time critical • In cardiac arrest, the heart stops contracting which can lead to organ and brain damage • Chest compressions should be performed on all casualties suffering a cardiac arrest • Chest compressions are delivered by placing one hand in the centre of the casualty’s chest, and placing the other hand on top of the fist, interlocking the fingers. Push down 4-6 cm and allow full recoil • Chest compressions should be given at a rate of 100 - 120 compressions per minute • 30 chest compressions should be given followed by two ventilations. This should continue until the casualty starts breathing normally, more qualified help arrives, or you become exhausted • Hands only CPR is often just as effective, if not more so, for in-experienced resuscitators. Therefore, do not struggle with ventilation and focus on chest compressions and defibrillation • An AED will deliver a shock that stops the heart quivering or fibrillating, allowing it to start again in a suitable rhythm • If an AED is available, it should be applied to the casualty using adhesive pads and the voice prompts followed • Traumatic cardiac arrest casualties rarely survive their injuries. Automatic External Defibrillator (AED) Chapter 7: Resuscitation and Life Support

122 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Automated External Defibrillator (AED): Portable battery-powered device that recognises ventricular fibrillation and advises when a shock is indicated. The AED delivers an electric shock to a casualty in ventricular fibrillation. Basic Life Support (BLS): CPR to treat a casualty who has no signs of life until a defibrillator is available Cardiac Arrest: Ceasing of breathing and a heartbeat. Cardiopulmonary Resuscitation (CPR): The artificial circulation of the blood and movement of air into and out of the lungs. Chest Compressions: Manual chest-pressing method that mimics the squeezing and relaxation cycles a normal heart goes through; administered to a person in cardiac arrest. Hands Only CPR: Resuscitation for those responders who do not do regular ventilations. Outcome is often just as good if not better in in-experienced hands. Ventilations Artificial: Means of breathing for a casualty. Ventricular Fibrillation (V-fib or VF): An uncoordinated muscular quivering of the heart; the most common abnormal rhythm causing no-traumatic cardiac arrest. Revision: 1. Which of the following would indicate that CPR is needed? A Rapid pulse B Dilated pupils C Absent breathing D Shortness of breath. ANSWERS 1: C Vital vocabulary Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 123 2. Which of the following is NOT a key component of basic life support? A Leg elevation B Chest compressions C Ventilations in drowning cases D Automatic external defibrillation ANSWERS 2: A 3. What is the appropriate depth of chest compressions for an adult casualty? A 1 to 2cm B 2 to 4cm C 4 to 6cm D 5 to 7cm ANSWERS 3: C 4. When performing adult CPR, what is the ratio of chest compressions to ventilations A Always do hands only CPR B 15 to 2 C 30 to 2 D 50 to 2 ANSWERS 4: C Revision: Chapter 7: Resuscitation and Life Support

124 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 5. When should rescuers deliver a shock using an AED? A When the device tells you that a shock is advised B When the device indicates that the pulse rate is below 30 beats per minute C Only when the cardiac arrest was witnessed D Only after two cycles of CPR, if no signs of life are present. ANSWERS 5: A Revision: Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 125 M.A.R.C.H Algorithm Chapter 7: Resuscitation and Life Support B.L.S. Protocol NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • Cx spine immobilisation RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATORY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Elevate Legs • Head to Toe survey INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing Spinal Injury and Fractures • Immobilise/Splint Burn Injury • Active Cooling • Cling-film/bags Environment • Keep warm • Package for Transport MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air HEAD & OTHER INJURIES • AVPU • Pain or numbness • Burns/Cold • Others, e.g fractures RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min

126 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com BTACC AED – Life support protocol (Based on UK/ERC Guidelines 2015) 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 IF 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 Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 127 Part 3 Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach Preparing for medical emergencies This section covers first aid and the common medical emergencies that may be encountered by responders and how they recognise and manage these conditions until further help arrives. Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Providing first aid safely? Safety is our greatest priority for both you and the casualty. The first step in delivering effective first aid is to be safe yourself. The last thing that we want is for you to become another casualty. Although, this may sound easy and obvious, in reality when confronted with someone in severe distress, especially someone we know, or perhaps a child, we can forget the simplest and most obvious safety principles. Our world is dominated by health and safety and many of you may feel that we live in a ‘nanny state’ where we wrap people in cotton wool. Signs, rules, restrictions and limits are everywhere but as first aiders we will often face injured people who have ignored the warnings. Sometimes there may not even be any warnings and therefore we have to be extra vigilant to avoid becoming a casualty ourselves. Appreciate the risks Every environment we find ourselves in or face as first aiders has risks, whether it be within a kitchen or in industry. Even simple domestic products found in the kitchen or bathroom, for example, can cause burns, eye injuries, breathing problems from fumes or fires. Similarly, devices and machines can also cause serious injury if they are faulty, misused or safety procedures are ignored. In industry, this is an even greater problem as chemicals can be far more concentrated and machines can be larger and more dangerous. Yet again, for a first aider the appreciation of any such risks is all the more important, especially if called to a place or area where you do not normally work. Following an accident, good health and safety may be even more important to prevent further injuries. LEVEL OF RISK? • Nature of work • Environmental • Personal training & PPE • Failure to follow SOPs Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 128 NATURE OF WORK / ENVIRONMENT If we consider the level of risk, this may be obvious or actually quite subtle, yet still very high. If we consider the nature of work, it is obvious that being a lion keeper and entering the lion’s den each day has very real risks. Similarly, if you work in confined spaces such as a ships engine, then many of the risks are clear and obvious. However, what if you work in a busy coffee shop? Are there any risks? Clearly there are, and although initially you may view them as trivial, bear in mind the fact that you are working with boiling water, steam under pressure, in an environment with wet floors combined with demanding customers from a seemingly never-ending queue. All this plus fatigue and you have the makings of a very dangerous environment. Increased risk? Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com NATURE OF WORK / ENVIRONMENT Even working in an office has risks. These may seem trivial and perhaps they are in comparison to the role of the lion keeper, but they still exist and have the potential to cause real harm. Some of that harm could be minor but cause significant effects, such as repetitive strain injury, but some of it could also be serious, such as the following: • Electrical fires • Falls downstairs • Slips and trips • Broken glass • Office related injuries • Kitchen related injuries. These are all potential hazards that we could face even in an office environment. The key issue here is that whilst the risks may be far lower than in other industries, hazards exist everywhere and are often not marked or obvious. Increased risk? Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 130 Another key factor is the use of safety equipment. Risks may have been identified, clearly defined and safety equipment may have been provided, but if staff don’t have it, don’t use it or are not trained to use it, those risks have not been mitigated and injury or even death is far more likely. You would not expect a steeplejack or rigger to not be wearing all their safety equipment, since the risks of falling are so great. However, they may argue that they are entirely comfortable at height and for a quick and easy job, they does not consider the risk that great. Rules and safety devices are there for a reason, and this is even more important where you may not appreciate the hazards. A crucial part of your safety may be to simply accept that you cannot enter a dangerous area without the necessary training and equipment e.g. a house fire. BASIC LEVEL (PPE) The simplest personal protective equipment (PPE) you will wear as a first aider are gloves, which protect you as well as the casualty. Gloves protect you from contact with blood and body fluids and protect the casualty from the risks of infection from your hands. ADVANCED LEVEL (PPE) At the other extreme, PPE may be there to protect you from some very hazardous materials and therefore must be worn and used correctly with no short cuts or changes. This can be frustrating if the equipment is difficult to wear or work in, or the environment is very warm or humid. In these situations, training can help to better prepare the individuals. A real awareness of rescuer welfare is crucial to avoid exhaustion or excessive fatigue. INFECTION Other than scene related risks, blood and body fluids present the most significant risk to the first aider and everyone needs to be aware of these risks in order to protect themselves adequately. Body fluids can potentially transmit infection. The most significant risks are from blood borne viruses (BBV) such as Hepatitis B, C and HIV. However, the greatest risks occur from needle-stick injuries. Getting blood onto your skin is highly unlikely to cause a serious infection unless you have cuts and open wounds, in which case you should seek medical advice if contaminated. The other risk is called mucous membrane contamination, which is basically any area of your skin that has a moist lining e.g. mouth, eyes. If infected body fluids or blood comes into contact with these areas of your body, you should also seek medical advice. The incidence of BBV infections in the UK population is less than 1%, so the vast majority of casualties will present no serious risk to you. However, it is impossible to predict that risk. We should be aware that IV drug abusers or known infected patients do present a greater risk, but you may not have this information when you reach a casualty. The key is to protect yourself: • Use gloves • Wear eye or face-shields if there is a risk of splash or spurting • Take care when cleaning up contaminated areas • Clear guidance is available on the HSE website which should be read and adapted for the potential risks in your working environment. Increased risk? Personal - Training & PPE Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The following points apply regardless of the scale of the spillage: • Gloves should be worn throughout and should be discarded safely after use • If there is broken glass present, it is essential that the fragments are not gathered up by hand either before or after treatment with disinfectant. Bunches of paper towels or newspaper, pieces of card or a plastic dustpan should be used to remove the fragments to a safe container without risk of injury. Small spots of blood or small spills: • Gloves should be worn and cuts or open wounds on exposed skin covered with a waterproof dressing • Contamination should be wiped up with a paper towel soaked in freshly prepared hypochlorite solution containing 10,000ppm available chlorine • Towels and gloves should be placed in a clinical waste bag for incineration and hands washed. For larger spills other than urine (unless the urine is bloodstained). If spillage is extensive: • Disposable plastic overshoes or rubber boots may be necessary • If splashing is likely to occur while cleaning up, other protective clothing should be worn • Liquid spills should be covered with dichloroisocyanurate granules and left for at least two minutes before clearing up with paper towels and/or a plastic dustpan • Alternatively, the spill may be covered with paper towels and the contaminated area gently flooded with hypochlorite solution containing 10,000ppm available chlorine* (again this should be left for at least two minutes before attempting to clear up) • Towels, gloves, disposable overshoes and contaminated clothing should be placed in a waste bag for incineration and hands washed; (rubber boots may be decontaminated with dilute disinfectant) • Finally, the area should be washed with water and detergent and allowed to dry • In open areas, for example playgrounds and roadways the spillage should be hosed down with large amounts of water. Heavily contaminated clothing should be considered high risk and should be professionally laundered to remove all risk of infection transmission. Useful references and advice: www.hse.gov.uk/pubns/indg342.pdf Immunisation against infectious diseases – ‘The Green Book’, 2006 Edition, HMSO, ISBN 9780113225286. Hepatitis B information is available at link: http://www.dh.gov.uk/ prod_consum_dh/idcplg?IdcService=GET_FILE&dID=11 5985&Rendition=Web) A summary of requirements designed to protect health care workers from BBV exposure is provided in The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections -known as The Hygiene Code Guidance on Personal Protective Equipment at Work Regulations 1992. L25 HSE Books 2005 ISBN 0 7176 6139 3 Health Protection Agency - Reporting of occupational exposure to blood borne viruses – history and how to report Safe Management of Healthcare Waste (2007). Royal College of Nursing. ISBN 978 1 904114 76 5. http://www.rcn.org.uk/__ data/assets/pdf_file/0013/111082/003205.pdf *Note that urine may promote the release of free chlorine from the treated area when hypochlorite or other chlorine-containing compounds are applied. Ventilation of the area will be necessary. Increased risk? Personal - Training & PPE Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 132 Finally, injuries and deaths can occur as a failure to follow standard operating procedures (SOPs), rules or simple safety guidance. These include many of the issues raised above but also involve many of the wider practices at work, which if not adhered to correctly, may result in serious injuries that a first aider may face. APPRECIATE ANY INCREASED RISKS TO YOU At the very least there is a need for a clear appreciation of the risk involved with the work you are doing, especially if working with hazardous materials. Is the containment vessel suitable? Simply washing these materials down the drain is neither appropriate or acceptable as there could be huge environmental and public safety issues somewhere further down the water course. Training plays an essential part in this. If you are untrained or not suitably equipped, do not take on the task. This includes first aid, as discussed above. INDUSTRIAL SPILLAGE Where procedures have not been followed, an incident such as a chemical spillage can occur and a casualty may already have been involved. Here the SOPs and the safety or emergency procedures are even more important to prevent further casualties occurring, and to ensure that any casualties are given the best opportunity of being helped or saved. If in doubt then call the experts in your organisation or call the emergency services. SCHOOL LAB Even a chemical spill on a much smaller scale, such as a school laboratory, can still have huge significance and risk if badly managed. A clear protocol or SOP should exist for any dangerous material to define the response if a spillage or accident should occur. In doing this, the incident can often be managed easily and safely without increased risk to anyone. If in doubt, evacuate the area and call the Emergency Services. SAFE APPROACH As discussed earlier in the chapter, some hazards are obvious and we need little convincing not to rush in, but others may not be so obvious. A good example are water rescues. Every year people die attempting to rescue others who have got into difficulty in lakes or open water. The rescuers, who are often strong swimmers, enter the water confident that they can help, but as a result of the cold water, they often become victims themselves. Being within easy reach of the shore often gives a false sense of safety. DO NOT RUSH IN! Even domestic incidents can involve hazards. If you see someone who has collapsed, hold back for a moment and take a look at the scene. What hazards can you see? Why has this person been injured or collapsed? This should not delay us excessively as we obviously need to reach the casualty, but do not rush in and do not under-estimate the dangerous effects of doing so, even for experienced rescuers, especially if the casualty is a child or a loved one. DO NOT BECOME A CASUALTY YOURSELF - the best you may be able to do for the casualty is to make an emergency call to get professional help quickly. Increased risk? Failure to follow SOPs Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 1950’S STYLE SAFETY The image above is a 1950’s view of a ‘safe approach.’ to demonstrate the dangers of electricity and electrocution and to highlight the risks to any rescuer if the power is still turned on or the casualty is still in contact with the source. Increased risk? Failure to follow SOPs 21ST CENTURY This is a 21st century equivalent safety advertisement, which is typically more graphic and hard hitting. In some ways it appears to be less informative, but it is far more hard hitting in its message about electrical safety in the home and also approaching an electrocution victim on a wet floor, when the power may still be on. Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 134 THE CASUALTY MAY COME TO YOU As a first aider, many of your casualties will approach you and ask for help. This often gives you little time to think or prepare yourself, but if you follow the simple principles shown in this course, you will be able to quickly assess, react and manage the situation confidently. YOU MAY BE CALLED TO THE CASUALTY For other first aid situations you may be called to attend and assist. This may often be in an unfamiliar environment, which may take you out of your comfort zone. In such situations it is all the more important to remain calm and focused on your key principles and methods to avoid missing anything serious that you could identify and manage. INTRODUCE YOURSELF (AND MAKE EYE CONTACT) A crucial element of all first aid is the initial contact with the casualty. Introduce yourself with something such as “Hello, my name is….” and if at all possible make eye contact. Do not simply rush in and grab the casualty. I AM A TRAINED FIRST AIDER Make a clear statement that you are a first aider and that you are there to help. You can open the conversation by asking some general questions and this will also help you to assess what has happened. The following are good examples: • What has happened? • May I take a look at your injury? • Do you have any pain? • Where does it hurt? CAN I TRY TO HELP YOU? Consent can be a confusing area with patients who are injured, combative, disorientated or frightened. It is important that you offer your help and accept that it may be refused. It can come as quite a shock when a casualty refuses help or treatment either if they don’t actually want it, or alternatively because they are confused. It is important to respect the patient’s wishes wherever possible. However, if they refuse your help, but clearly need it for their injuries, you should try and talk them into allowing you to help, whilst awaiting professional support. DO NO HARM - DO SOMETHING A key message from this course is to not be afraid, since with your first aid skills you are highly unlikely to make a situation worse. You are more likely to fail your casualty by not getting involved or missing something potentially serious. In other words, doing nothing is often far worse than doing something. The old first aid mantra of ‘do not move the casualty’ can be appropriate on rare occasions, but in most situations it will hinder their care. Gentle movement will rarely, if ever, cause serious harm, even to a casualty with potential spinal injuries. The casualty Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DO NOT ATTEMPT RESUSCITATION (DNAR) A dilemma that can present when attending a casualty you do not know is DNR or DNAR – ‘do not attempt resuscitation.’ In other words, for whatever reason, this person does not wish to be resuscitated in the event of a cardiac arrest. This can be found on medic-alert type bracelets or necklaces, but may also be found on tattoos. In addition, family members may thrust pieces of paper in front of you or declare that the patient is not for resuscitation etc. This can make the whole situation very stressful and confusing and even create fear about doing the right thing. It is difficult to give rigid guidance on this, as orders may have varying conditions or may not be legally binding. However, if the patient is refusing help or clearly has a medical bracelet or legal document from a solicitor stating that they are DNR/DNAR then this should be respected. However, in most other circumstances or if in doubt, do what feels right. This will usually mean starting resuscitation. Do what feels right, which will usually be the wishes of the patient or the family. DO YOUR BEST Finally, many first aiders hear stories of people being sued or prosecuted for doing the wrong thing. However, as a first aider doing your best with basic skills, you will not get sued. The key part of this is to simply do your best in the situation. No one could ask anything more, and at least you will have tried to help. You will be highly unlikely to ever make things any worse in the time before help arrives. The casualty Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 136 Providing First Aid Calling for Help FTACC approach - Level of response required IMMEDIATE ASSESSMENT OF SITUATION CALL FOR HELP IMMEDIATE ACTIONS LEVEL OF RESPONSE REQUIRED - 999 An essential part of First Aid is to make an effective call for help. However, people are often confused about: • What to do first • How to make the call • What to say • What is needed. There is also the issue of how serious is the injury? Chapter 11: First Aid & Medical Emergencies – Calling for Help MINOR FIRST AID For example, an injury such as this laceration to the hand may look very nasty at first with significant bleeding and pain, but on closer inspection it is actually quite a small wound and quickly stops bleeding. However, there may be other things to consider which could be associated with the injury. In this case we would be concerned that there may be tendon injuries affecting finger movements or nerve injuries affecting sensation in the hand. FTACC will help you to make these decisions. Sometimes these may be obvious but on other occasions they could be more challenging.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com LIFE SAVING FIRST AID – YOU MAY NEED HELP! In some situations it may be immediately obvious that the injury is very serious or even life threatening. FTACC will help you to identify these quickly and then to manage them in tried and tested ways which are known to work. As described above, FTACC will also guide you on how and when to call for help. This is a key element of this course, as unlike others, we will teach things which are effective and known to work, rather than more traditional skills, which we now know offer little true value, but have simply become the normal approach in many first aid courses. CAN SOMEBODY HELP ME PLEASE ? An essential part of asking for help, especially when facing a life-threatening emergency is to shout out to attract the attention of anyone around you. This may mean actually shouting to be heard. HELP Depending upon where you are when the emergency occurs, there may be an emergency button or an automated emergency call such as a Fire Alarm or a cardiac arrest buzzer in the hospital. The emergency button may also stop a machine or halt a process which could prove to be life-saving, such as someone in serious difficulty trapped in a machine, such as an escalator or a lathe. FTACC approach - Level of response required Chapter 11: First Aid & Medical Emergencies – Calling for Help

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 138 FTACC approach - Level of response required Chapter 11: First Aid & Medical Emergencies – Calling for Help One of the challenges for a first aider is what to manage yourself, what requires nursing or medical attention and finally what is a life- threatening situation. These may not always be as obvious as you might think. To help with this, throughout the course we will have colour coded slides. Green slides usually do not require hospital treatment and can usually be managed with first aid skills. FIRST AID MEASURES GREEN SLIDES USUALLY DO NOT REQUIRE AMBULANCE OR HOSPITAL Yellow slides indicate the need for medical or nursing review. This may be a GP, a walk-in centre or hospital, but does not require a ‘999’ emergency response. You may be able to provide transport yourself, eliminating the need for an ambulance. Remember you can also call the ‘111’ NHS Helpline for advice. You may receive additional guidance and advice about the best place for the situation you are managing. DOCTOR/HOSPITAL YELLOW SLIDES SUGGEST WHEN TO CONSIDER TRANSPORT TO HOSPITAL/GP - 111 RISK TO LIFE RED SLIDES INDICATE WHEN THERE IS AN IMMEDIATE OR REAL RISK TO LIFE ‘999’ Ambulance Call Finally, we have red slides, which suggest a life-threatening problem requiring immediate action or a ‘999’ emergency ambulance call, such as someone with severe chest pain.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FTACC approach - Level of response required RISK TO LIFE Chapter 11: First Aid & Medical Emergencies – Calling for Help To request an ambulance we have two choices, we can either call ‘999’ or call ‘112’ - both will immediately connect you to an emergency operator who will ask which service you require. Remember that you can even make an emergency call on anyone’s mobile phone, even if it is blocked.’ CALLING AN AMBULANCE Before actually making the call, take a second or two to compose your thoughts. • Which service do you require? Police, Fire or Ambulance • What has happened – explain in a short, concise fashion • When you ring they will usually know what number you are ringing from and they will usually repeat it to confirm your identity • Make sure that you know where you are and be as specific as possible • Be prepared for the operator to ask you questions which may appear to be unnecessary They are working through a well-defined process • Do not hang up unless they tell you to and do not be surprised if they ring you back. EVERYONE FEELS ANXIOUS Do not worry about feeling anxious. This is perfectly normal as people rarely ring the Emergency Services, and it will usually be a stressful situation that makes the call necessary. You may also feel like this when handing over to the ambulance paramedic or crew. Adrenaline will help you to respond to such an emergency but it will also make you shaky or anxious and you may feel your heart racing, but do not worry as this is normal.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 140 FTACC approach - Level of response required RISK TO LIFE Chapter 11: First Aid & Medical Emergencies – Calling for Help ISBAR HANDOVER One way to perform the handover of the casualty details is to use something generally used in hospitals, called the SBAR handover. This sometimes extends to ISBAR with the ’I’ being included for ‘I am… To give your name and status’ The ISBAR acronym stands for: I – Introduce yourself S – The situation, as in what is the problem? B – What is the background, in terms of the preceding events or any known medical problems? A – Your assessment of the current situation? R – What response do you require? Consider an example of an elderly gentleman with crushing central chest pain who is clearly distressed. Let’s prepare our ISBAR message. SPECIFIC QUESTIONS? As discussed earlier, the ambulance control room staff will ask you a number of specific questions and may also give you specific advice. Listen carefully and if necessary put the phone on to ‘speaker mode,’ so that you can do as they request. AN AMBULANCE CAR WILL OFTEN COME FIRST The first ambulance to arrive for a serious emergency may be a car or ‘rapid response vehicle’ which will usually be driven by an experienced paramedic. This vehicle will not carry a casualty but will provide some immediate response for any serious emergency. It is essential that you have considered how the ambulance will find you, how they will access your building, and even your site if there is security controlled access. You may need to assign someone the role of meeting the ambulance and then escorting them to the incident. AN AMBULANCE The main ambulance will arrive with a crew of two and the stretcher etc. Ideally provide access so that it can get as close as possible to the incident. Even at the scene, make room for them to work, remove any unnecessary staff or witnesses and provide some privacy and dignity for the patient. HELP THE AMBULANCE CREW • Inform main gates, security or reception • Arrange for someone to meet them • Ensure doors or access points are open • Make space for them to work. ISBAR - Handover (Example) I INTRODUCE: I am our First Aid Trainer S SITUATION: I have a 63 year old man with severe chest pain B BACKGROUND: History of angina for several years, he is also a diabetic. Collapsed rushing up the stairs. A ASSESSMENT: Conscious, but says angina is worse than normal, he looks unwell & has vomited with the pain. R RESPONSE / RECOMMENDATION: I have reassured him, called an ambulance, encouraged him to use his Angina spray. I also have our AED here.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SBAR Scenario 1 – Severe stomach pain S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 25YR OLD LADY WITH SEVERE LOWER ABDOMINAL PAIN B BACKGROUND: She is normally fit and well but this started 2 hrs ago A ASSESSMENT: She looks unwell, has vomited and feels very hot. Her pain score is 5 out of 5 R RESPONSE: I have reassured her, called an ambulance and laid her down here in the first aid room Skill Session Call for an ambulance / handover scenario SBAR SCENARIOS This session will be followed by a series of short exercises which can be conducted individually or in groups of up to four people. As a group, we would like you to assess the casualty outside, formulate an SBAR handover (one element each if in a group of four) and then come back in and handover to the rest of the candidates. THREE INCIDENTS TO REPORT. GROUPS OF 4 • Each group assess one casualty with SBAR • Take a minute to prepare • Give SBAR hand over to group. Chapter 11: First Aid & Medical Emergencies – Calling for Help

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 142 Skill Session Call for an ambulance / handover scenario Chapter 11: First Aid & Medical Emergencies – Calling for Help SBAR Scenario 3 – Patient Fitting S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 18YR OLD MALE CASUALTY WHO HAS HAD A 2 MINUTE SEIZURE B BACKGROUND: He just collapsed in the reception area A ASSESSMENT: He has a Med-alert bracelet confirming epilepsy. He is breathing and un-injured R RESPONSE: I have put him into the recovery position SBAR Scenario 2 – Fallen Downstairs S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 30YR OLD FEMALE WHO FELL DOWN A FLIGHT OF STAIRS B BACKGROUND: She is apparently normally fit and well A ASSESSMENT: She was unconscious for 30s but is awake and complaining of pain in her lower back. She can feel her legs & move her toes R RESPONSE: I have not moved her and she is safe here

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Immediate Assessment – B.U.R.P.S A key part of providing first aid is how we assess the casualty, especially if the problem is not immediately obvious or we are unsure how serious it is. NEW METHOD TO ASSESS A CASUALTY. Courses traditionally talk of primary surveys, ABC, MARCH and many similar approaches to casualty assessment. However, these are not based on conditions, but rather body systems such as airway, breathing, circulation. We are going to offer you an alternative approach, which rather than confuse things further, will actually offer a far more practical and simple assessment process to rapidly identify problems and their likely causes. B.U.R.P.S – Immediate assessment We will be using the acronym ‘BURPS’ which allows immediate assessment, simply and quickly to identify serious problems and also avoids missing injuries or signs. In other words, when we approach the casualty we ask: B – Bleeding: Is there any sign of bleeding? Each element will be further broken down to identify the serious from minor. U – Unconscious: Is the person unconscious or very drowsy? R – Respiratory Distress: Is the patient having difficulty breathing? P – Pain or Numbness: is there any pain or altered sensation. Pain is obviously very variable in its intensity and this spectrum will be considered in the pain section later in the course. S – Skin Changes: Are there any rashes, heat, blisters or skin changes? In the skin section we will highlight the important signs to look for, such as: • RASH • TEMPERATURE - HOT • TEMPERATURE - COLD • WOUNDS & ABRASIONS • BURNS & BLISTERS. BURPS B BLEEDING U UNCONSCIOUS OR SEMICONSCIOUS R RESPIRATORY/BREATHING DIFFICULTY P PAIN, DISTRESS OR NUMBNESS S SKIN CHANGES Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 144 B.U.R.P.S supporting questions Once the B.U.R.P.S assessment is completed, additional supporting questions may prove useful, depending upon the problem. These include: • Do you have any health problems? • Has this ever happened before? • Are you taking any medication? • Do you have any allergies? B.U.R.P.S assessments DOCTOR/HOSPITAL BURPS – Hand wound with nerve injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAIN FROM WOUND & NUMB LITTLE FINGER S WOUND Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS Consider these first aid problems and apply the B.U.R.P.S assessment and the colour coded triage for the recommended level of response required.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FIRST AID MEASURES BURPS – Isolated Headache B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P BAD FRONTAL HEADACHE S NO SKIN CHANGES RISK TO LIFE BURPS – Severe chest pain B NO MAJOR BLEEDING U FULLY CONSCIOUS R SHORT OF BREATH P SEVERE CHEST PAIN S SWEATY AND PALE B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 146 DOCTOR/HOSPITAL BURPS – Significant ankle injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAIN & UNABLE TO WEIGHT BEAR S BRUISING & SWELLING DOCTOR/HOSPITAL BURPS – Toe Injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAINFUL BUT BEARABLE S MILD SWELLING & REDNESS B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE BURPS – Dislocated shoulder B NO MAJOR BLEEDING U FULLY CONSCIOUS R BREATHING QUICKLY P SEVERE PAIN FROM SHOULDER S SWEATING WITH SEVERE PAIN RISK TO LIFE BURPS – Bacterial Meningitis B NO BLEEDING U DROWSY, IRRITABLE CHILD R INCREASED BREATHING RATE P IRRITABLE, HEADACHE S SKIN RASH – NON BLANCHING B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS