BTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 148 Bleeding – B.U.R.P.S Working from the B.U.R.P.S assessment we are going to considering bleeding. Now in traditional approaches to first aid, this would come much later, but as trauma care has progressed there has been an increasing realisation that in the most severe injuries blood loss can be the biggest preventable killer. As such, with early recognition of such major bleeding and prompt action, we may well be able to save that person, but if we get bogged down in airway and breathing assessments then it may well be too late. The majority of bleeding injuries will not be too severe. We will therefore be able to temporarily dismiss them and move on to assess the other essentials such as airway and breathing. Minor bleeding, major bleeding and shock We need to quantify what we mean by bleeding and in simple terms we can split it into MINOR and MAJOR. The latter is clearly of more concern and can ultimately result in elements of shock and even death. That said, we must also appreciate that even a small and relatively minor bleed, if left unattended for a prolonged period, may eventually become major, much like a dripping tap or leaking pipe. BLOOD IS ESSENTIAL TO LIFE Blood is essential to life and we only have a limited amount of it, which in a typical adult is 5 litres. This is equivalent to 15 cans of Coke or one gallon of petrol. Smaller adults and children have significantly less blood and are at even greater risk from blood loss as a result. Once the blood is gone, we cannot quickly replace it and make more of it. MINIMISE BLOOD LOSS Traditionally we think of people simply having a blood transfusion, but there are problems associated with this. Firstly, we have to have transfused blood immediately available, blood has to be of the correct blood type and it will still never be the same or as good as the patient’s own blood. In emergencies, the paramedics will use saline as a ‘temporary fix’ but this is just ‘salty water’ and doesn’t have the special properties as blood and may actually create more problems. As a result, the best way of managing blood loss is the most obvious, and that is to control or reduce it, preserving your own precious blood in your body. Your blood is the best blood to have in your circulation. Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Stopping bleeding can be very simple or from a more major wound it can be hugely challenging. There are two things to remember: • Firstly you may well be saving that persons life • Their body will help you to try and stop bleeding, it just needs a chance to form a blood clot • REMEMBER YOUR OWN SAFETY FIRST – what caused the injury and are you protected from the casualty’s blood? With effective pressure in the right place, 90% of bleeding will stop, but to do this we must first expose the wound and find out where the bleeding is coming from. In a serious bleed, simply pressing on blood soaked clothing or generally in the direction of the bleeding may mean the difference between life and death. However, for most first aid bleeding, we need to find the wound and use simple measures such as: • Applying direct pressure • If bleeding is from a limb, elevate it where possible • Only move to bandaging or dressings once the bleeding is controlled. In other words, bandaging is fiddly and awkward if you are not doing this regularly. If you add in the ‘gloves of panic,’ inevitably you will be all fingers and thumbs. Even experienced providers can drop a bandage or get it tangled etc, but more importantly, this won’t be providing effective direct pressure. FIRST AID MEASURES Bleeding DIRECT PRESSURE WILL CONTROL 90% OF BLEEDS FIND THE SOURCE ELEVATION OF LIMBS ONLY ‘BANDAGE’ ONCE BLEEDING CONTROLLED Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS Minor bleeding, major bleeding and shock

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 150 As with many things, the simple measures work well. Sit them down and make sure they are calm Encourage them to lean over a sink or bowl without stretching or straining and to spit out any blood in the back of the throat which has trickled down the back of the nose. Get them to gently pinch the uppermost soft part of the nose firmly but comfortably and to keep hold for 10 minutes – stress that they must not let go or they may have to start again. Tell them to avoid talking, coughing or moving and especially to not release their hand early ‘just to see.’ Reassure them about the blood and tell them not to swallow it as it will make them feel unwell. The majority of bleeds will simply stop. Nose bleeding DELICATE VESSELS SNEEZING FOREIGN OBJECTS These are one of the commonest first aid presentations and many patients will have suffered from them previously. They may be as a result of a bang to the nose, foreign body insertions such as toys, but in other cases it can be as simple as sneezing, picking their nose or even spontaneously for no reason. The lining of the nose has a rich blood supply and delicate blood vessels and trauma to these vessels can result in bleeding. This bleeding will usually just stop by itself, but sometimes can continue and be distressing. In children especially, a persistent nose bleed can result in the loss of a significant amount of their blood and should not be ignored. FIRST AID MEASURES Nose Bleeding – Treatment CALMLY LEAN OVER A SINK OR BOWL PINCH SOFT PART OF NOSE – 10 MINS AVOID COUGHING, TALKING, MOVING REASSURE (ESP CHILDREN) – MAJORITY WILL STOP We will now consider bleeding further but separating minor bleeding from the more major bleeds which are mentioned later in this chapter. Minor bleeding Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If the bleeding is more severe it may be a recurrent problem or the patient may be on blood thinning medication (e.g. Warfarin or similar drugs for a previous thrombosis or embolism) which impairs their blood clotting process. Anything more than a tea-cup full, or bleeding for more than 30 minutes with the first measures followed, becomes YELLOW and needs to be seen by a nurse or doctor. This could be a medical walk-in centre, GP or failing that, the Accident and Emergency Department of the hospital. DOCTOR/HOSPITAL Nose Bleeding SEVERE BLEEDING (CUP FULL OR MORE) BLEEDING MORE > 30 MINUTES SHOULD BE SEEN BY A NURSE OR DOCTOR If the nose bleed is related to a major trauma, such as a head injury and is associated with a period of unconsciousness, loss of memory or confusion, the casualty warrants an emergency transfer to hospital. The other emergency group are those with torrential and uncontrollable bleeding, where the nose, which is literally pouring or pumping blood out. This is very unusual, but simple measures are usually effective. RISK TO LIFE Nose Bleeding ASSOCIATED WITH MAJOR HEAD INJURY – Period of unconsciousness – Loss of memory/confused MASSIVE/TORRENTIAL BLEEDING Bleeding from the ear OUTSIDE THE EAR Bleeding from outside the ear will usually be as a result of trauma, a scratch or possibly an infected spot or blister. This is unlikely to be serious. Simply apply gentle pressure with a dressing and then a plaster or bandage once the bleeding is controlled. Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 152 If we now consider when we would be more concerned about bleeding from the ear canal which requires professional medical review. The factors are bleeding from the ear canal with: • Any recent history of head injury. Or association with any of the following: • Sickness or vomiting • Worsening dizziness • Visual disturbance • Drowsiness/seizures. DOCTOR/HOSPITAL Bleeding from ear canal HISTORY OF MAJOR HEAD INJURY SICKNESS, VOMITING DIZZINESS VISUAL DISTURBANCE DROWSINESS/SEIZURES Bleeding from the ear INSIDE THE EAR Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Bleeding from the eyes is relatively uncommon and should be taken seriously in all cases. The default position must be ‘if in doubt,’ seek expert advice. SMALL BLEED – NO TREATMENT Small amounts of bleeding like this are probably the most common bleeds seen in the eyes and can occur spontaneously or following trauma. They are small and are located in a small part of the ‘white’ of the eye. They do not affect vision and only require medical review if they fill the white of the eye or occur on a regular basis. This is not an emergency. INFLAMED EYE A similar appearance can occur with eye infections where the eye is described as ‘injected,’ looking as though red dye has been injected into all the small blood vessels in part, or more frequently, in all of the eye. There may be yellow pus coming from the tear duct or other parts of the eye. This can lead to ‘sticky eye’, where the eye is difficult to open. The eye will usually be sore or irritated and it is essential to avoid rubbing with the hand as this may then lead to the infection spreading to the other eye. This is not a medical emergency but it does require treatment, which could be obtained at a Pharmacy, Walk-in centre or the GP. Bleeding from the eyes Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 154 DEBRIS OR FOREIGN BODIES A similar appearance can occur far more rapidly when dust or foreign material gets in to the eye. The material can produce an abrasive effect on the surface of the eye, or it can cause a chemical or inflammatory reaction. These need to be managed urgently, will be very uncomfortable and if left untreated may cause further problems later. The key is to remove the irritant. This may initially mean moving it out of the contaminated environment and then by irrigating the eye with saline eye wash (if this isn’t available then cold tap water will do). When doing this it is essential to have the infected side down over the sink or bowl to allow contaminants to wash way rather than simply run into the unaffected eye.’ Never wipe objects off the surface of the eye but instead persevere with copious amounts of washout. Ask the patient to look up, down and to the sides while you wash out and then ask them to pull back their eyelids to look for further debris. If there are stubborn objects, ask them to close the eye and then to look around with the lid closed, using their natural tears to help remove the debris. If there are stubborn particles, a medical review will be needed. DOCTOR/HOSPITAL Eyes – when to go to Hospital METALS, GLASS FRAGMENTS OR IRRITANT DUST CHEMICALS / THERMAL INJURIES PENETRATING OBJECTS OR DO NOT WASH OUT BLOOD / FLUID LEAKING FROM EYE LOSS OF VISION DOCTOR/HOSPITAL Bleeding from eyes OFTEN ASSOCIATED WITH FOREIGN BODY/TRAUMA LIGHT PAD DRESSING – AVOID PRESSURE TRANSFER TO HOSPITAL DO NOT USE PRESSURE OR PUT DRESSING IN EYE Bleeding from the eyes BLEEDING FROM EYES If larger foreign bodies are stuck in the eyes, these must never be removed. Dress the eye if necessary without applying pressure to the object or the eye and then arrange immediate transfer to the Accident and Emergency Department at the hospital. Whilst this isn’t a red slide, as it is not a life-threatening situation, it is vision threatening and requires a real degree of urgency in transport to hospital. Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Bleeding from the scalp can be trivial and superficial or it can be major and even life threatening, from slow and often insidious bleeding, especially from the back of the scalp. If we consider the wounds in our typical GREEN, YELLOW and RED perspective then: FIRST AID MEASURES GREEN Small wounds, no history of confusion or reduced conscious level, although the casualty may be upset or slightly shaken up DOCTOR/HOSPITAL YELLOW Actively bleeding open wound, may be a little dazed, but no history of being unconsciousness RISK TO LIFE RED Extensive major bleeding, soaked hair, ground or carpet or a period of unconsciousness The scalp Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 156 Green injuries e.g. small wounds simply need the bleeding to be controlled with pressure. Wash out any gravel or debris with saline or water (may increase bleeding for a short while, so may require further pressure). Apply a dressing or head bandage (diagonally from top under the skull, rather than simply round and round the head, to avoid it slipping off). FIRST AID MEASURES Scalp & head wounds CONSCIOUS LEVEL – OK APPLY PRESSURE TO BLEEDING POINT WASH OUT DEBRIS – STERILE WATER/SALINE DRESSING & BANDAGE Anyone who is either unconscious, been unconscious, vomiting, has a severe headache or has a seizure following a head injury needs an immediate 999 ambulance. RISK TO LIFE Head Injury UNCONSCIOUS/SEMI-CONSCIOUS CONFUSED VOMITING HEADACHE SEIZURES CALL 999 AMBULANCE The scalp Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com MINOR CUTS AND LACERATIONS Minor cuts and lacerations from various parts of the body can be managed with some simple principles based upon our colour coding. FIRST AID MEASURES Minor cuts & lacerations EXPOSE THE WOUND APPLY PRESSURE IF BLEEDING CLEAN THE WOUND – SALINE WASH APPLY A PLASTER OR SMALL BANDAGE It is essential to fully expose all wounds in order to assess the full extent of the injury. This may simply mean looking, or involve the removing or even cutting of clothing. Do not be afraid to look. Explain to the casualty what you are doing and reassure them. Many deaths as a result of bleeding have occurred because the casualty’s carers simply didn’t find or fully expose the bleeding point, so they were unable to effectively manage it. GREEN INJURIES – simply apply pressure to control the bleeding. If necessary wash any contaminants such as dirt and gravel out of the wound and apply further pressure. Finally, apply a suitable dressing or bandage. Cuts & lacerations Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 158 Puncture wounds and holes to the torso Any holes in the trunk or torso, such as stab and gunshot wounds appear alarming, but they are not always immediately life threatening. Often simple measures and emergency transport to hospital will be sufficient to ensure that the casualty is safe. DOCTOR/HOSPITAL Bleeding - Lacerations INDICATION FOR ‘STITCHES’ • More than skin depth • >2cm in length • Continues to bleed through dressings. LOSS OF FUNCTION OR NUMBNESS A ROUND WOUND FOREIGN MATERIAL IN WOUND E.G. GRAVEL, GLASS Decisions about needing medical advice are usually based upon several factors: • Nature of the wound – more than skin depth, >2cm long or ongoing bleeding despite effective pressure • Possible tendon or nerve damage: loss of function or numbness related to the injury • Contamination of the wound which is difficult to clean. These all require effective medical review and potential intervention such as thorough cleaning, debridement or closure (e.g. stitches) which also requires a local anaesthetic. Cuts & lacerations Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE BURPS – Stab wound to chest B BLEEDING U CONSCIOUS R BREATHING QUICKLY P SEVERE PAIN FROM WOUND S SWEATING WITH SEVERE PAIN If we consider our B.U.R.P.S assessment, then puncture wounds can manifest in the following way: B – Bleeding: There may be external bleeding, but we must also consider that internal bleeding into the body cavities is very common. This can rarely be seen or appreciated externally unless we recognise the signs of worsening shock. Remember that we can quietly bleed to death internally with little or no external signs other than shock. U – Unconscious: whilst the wound will not affect conscious level, as any internal blood loss increases the features of shock may lead to a reduction in conscious level. R – Respiratory Distress: The respiratory rate may be increased as a result of either injuries to the lung or worsening shock (It is interesting to note that in an otherwise fit individual a collapsed lung from a stabbing to the chest is rarely fatal and often just creates breathlessness and pain – this does not mean that we should delay getting expert help and emergency transport to hospital). P – Pain or Numbness: Pain associated with the wound. S – Skin Changes: Wounds in the skin, which can be very small such as a small knife wound or bullet hole, through to much larger holes. Even larger holes are not always immediately life threatening and all holes or wounds in the torso need emergency 999 transport to hospital. Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS Puncture wounds and holes to the torso

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 160 If a wound is into the abdomen or back, that does not mean it has not gone up or down into the chest or pelvis. It is always difficult to predict the extent of damage simply from an entry wound and as first aiders it is unimportant. The type of weapon used can cause very variable damage and any information that you can get may help. Once a hole is identified in the torso or trunk, the casualty requires emergency attention and transfer to hospital as soon as possible. In the meantime apply some simple first aid measures which may help them: • Approach safely (especially if this is a victim of an assault or gunshot) • Expose the wound and check for any others as best you can (pain and blood on the clothes may help you locate other wounds and always check the back and sides of the torso • If possible get the casualty to place their hand over the wound and keep it there. For wounds on the back, you need to cover them with your hand or that of a passer-by • Press firmly if there is any obvious external bleeding • Do not try to create improvised dressings e.g. a three-sided dressing, as these rarely work well and waste time) • Call for help including 999, for an ambulance • If the casualty is losing consciousness or feeling faint, lie them down and consider elevating their legs • Ideally lie them with the INJURY SIDE UPPERMOST (this contradicts many old school first aid courses, but allows you to monitor the wound and physiologically is far better for the patient) • If the casualty is having difficulty breathing, sit them up and ensure that the hole is being covered, using your hand if necessary • Reassure the casualty as they are likely to be very anxious. Other major bleeding will be considered further in the next section. In the final section we will consider a series of typical minor wounds and injuries and how we may address them based on the principles of: • Approaching the casualty • Introductions and consent • Exposing and finding the wound • Controlling major bleeding • Cleaning the wound • Checking that bleeding is controlled • Applying a dressing • Seeking expert advice when required. Minor injury care Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS Puncture wounds and holes to the torso

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Major Bleeding – B.U.R.P.S The previous section discussed minor bleeds. We will now consider bleeds which may be more major or potentially life threatening. MOUTH BOWEL/RECTAL VAGINAL As a starting point, any bleeding coming from ‘inside’ the body should raise concern. Although this is not always serious, it must be Investigated. Bleeding from the mouth is most commonly a result of trauma. Cuts to the lips, tongue or cheek can produce an alarming amount of blood, especially when mixed with saliva. Another common source is loss of a tooth or bleeding from the gums, especially after brushing the teeth. Any bleeding from the gums requires advice from a dentist or oral hygienist, but it is neither an emergency or a life-threatening situation. If there is no suggestion of trauma, further investigation is needed, especially if the casualty is unwell or has been vomiting or coughing. Bleeding from the mouth Chapter 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 161 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 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

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 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 163 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 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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. 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 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 165 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. (see Chapter 2, Massive External Haemorrhage) 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 Pump = Heart Water = Blood Pipes = Vessels Radiators = Tissues Causes of SHOCK Chapter 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com In shock, blood can leak out, the heart can fail or the vessels can open too wide. 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 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 Causes of SHOCK Chapter 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 167 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. Causes of SHOCK Chapter 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 11: First Aid & Medical Emergencies – Major Bleeding - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 169 Chapter 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS 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. 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.

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 171 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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. Brain Feet Feet 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 173 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 175 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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: 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. 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. 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 Chapter 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 177 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 179 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 181 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 183 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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS

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 11: First Aid & Medical Emergencies – Unconscious / Very Drowsy - BURPS 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 185 Chapter 11: First Aid & Medical Emergencies – No Signs of Life No Signs of Life In the earlier Resuscitation and Life Support Chapter we took a detailed look at resuscitation. In this chapter we will summarise, simplify and reinforce the key elements of Basic Life Support at a First Aid Level as a refresher. 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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 re-check, 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 187 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 commence 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. 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 189 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. 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 191 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 piercing 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 193 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 (e.g. 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 195 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. Return of Spontaneous Circulation (ROSC) – Recovery 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 Chapter 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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. Special circumstances – Resuscitating children Chapter 11: First Aid & Medical Emergencies – No Signs of Life