BTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 197 CHILD CPR As with adult CPR, if the child is not breathing normally summon help via 999 immediately. Try to get someone else to do this to enable you to assist the child. If no one else can summon help, carry out resuscitation for at least a minute before leaving the child to call for help. Place the child on a firm surface and open the child’s airway with the head and chin tilted, as you would do with an adult. Pinch the nose and seal your mouth around the child’s mouth. Give five initial rescue breaths – blowing in just enough to make the chest rise. Then use one hand to depress the chest, aiming for 1/3 of the depth of the chest. Give 30 compressions at a rate of 100-120 per minute. Return to the head and give two further rescue breaths. Continue then as per adult giving 30 compressions to two breaths. AED USE AND CHILDREN AEDs should not be used on infants under one year of age. For children from one to puberty, AEDs can be used, but care must be taken when placing the pads to make sure that there is at least a 3cm gap between the AED pads. If the child is too small to achieve a 3cm gap between pads, they can be placed to the front and back of the child as shown in the diagram. CONFUSED? If you are confused and cannot remember the correct technique for children and babies, simply provide adult BLS and do not worry about doing the wrong rate etc. Similarly, if you feel uncomfortable doing rescue breaths, simply carry out hands only CPR, like adults... Doing something is better than doing nothing. Resuscitation – Special circumstances Chapter 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DROWNING AND NEAR DROWNING Any casualty who is either face down in water or under the surface of the water, must be removed from the water as quickly as possible, as long as it is safe for the rescuer to do so. Once out of the water check if they are breathing normally. • If they are breathing normally, but have swallowed and / or breathed in any water then they must be taken to hospital to be checked out for further complications. Keep the casualty warm and calm whilst waiting for professional help, or are transporting them the Accident and Emergency Department. • If the casualty is unconscious but breathing normally, then place them into the recovery position and call an ambulance. Again try to keep the casualty warm, but do not attempt to ‘pump their stomach’ or ‘empty water from their lungs’ as doing so will not help, and is likely to cause the casualty to vomit and complicate matters. • If the casualty is not breathing normally, turn them onto their back and commence CPR as already described earlier in the chapter. In this situation casualties of any age should receive five initial rescue breaths followed by 30 compressions, and then continued resuscitation with two breaths and 30 compressions. To supply rescue breaths to an adult, open the airway using head-tilt / chin lift, pinch the nose and seal your mouth around the adult’s mouth. Give five initial rescue breaths – blowing in just enough to make the chest rise. If face shields or pocket masks are to hand, use them as a protective barrier between you and the casualty. If not, and you are comfortable to do so, you can supply rescue breaths without a barrier. Resuscitation – Special circumstances Chapter 11: First Aid & Medical Emergencies – No Signs of Life

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 199 Respiratory Distress – B.U.R.P.S The next step in the B.U.R.P.S assessment is respiratory distress or difficulty in breathing. Respiratory distress is typically demonstrated in two obvious ways: • Difficulty in breathing • Fast breathing In fact, a fast breathing rate (e.g. >20/min) is a reliable sign that someone is unwell. Once it reaches 30—40/min we should be very concerned, unless there is an obvious cause, such as exercise or severe pain. If we consider difficulty in breathing first, there are a number of typical causes including: • Obstructed breathing e.g. at the mouth or somewhere in the airway • Lung conditions e.g. asthma, bronchitis, emphysema • Heart conditions or failure • Trauma resulting in shock or chest injury. Respiratory distress These will be considered in turn: • Blocked airway: The airway can be obstructed for a number of key reasons. The commonest causes are: • Foreign body (choking): This is most commonly food but can be children’s toys, pen tops, sweets or other items. • Tongue: This occurs as we have seen earlier most commonly when the casualty loses consciousness and muscle tone, but it can also occur if the tongue swells. • Swelling: can affect not only the tongue but also the lips, the throat and whole airway and tracheal (windpipe) lining as may be seen in a serious. Obstructed breathing - Blocked airway Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Choking from a foreign body can cause partial obstruction of the airway where some breathing is still possible but with difficulty, or the obstruction can be complete. The casualty is likely to look terrified and very distressed. They may be trying to cough and will usually be holding their throat. RISK TO LIFE Choking IF JUST ABOUT ABLE TO BREATHE, ENCOURAGE THEM TO COUGH UNABLE TO BREATHE, SPEAK OR COUGH – Back blows – Abdominal thrusts This is clearly a life-threatening emergency. If possible encourage them to cough and this may well clear the obstruction. If they are unable to speak or cough, this is more serious and suggests that no air can get into the lungs. The obstruction needs to be cleared mechanically as the casualty will be unable to do it themselves. Adults FIVE Back blows – check mouth after each blow FIVE Abdominal thrusts – check mouth after each Hands above the umbilicus (belly button) and thrust backwards and upwards. REPEAT Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 201 CHECK THE MOUTH BACK-BLOWS X5 IN TOTAL CHECK THE MOUTH The first action is to check the mouth for any obvious foreign body. We do not encourage finger sweeps as this may push the object further back and also involves putting your fingers into their mouth which is always risky if they bite down. BACK-BLOWS Stand to the side or behind the casualty and bend them forward slightly. Feel for the space between the shoulder blades and with the heel of your hand deliver five firm blows to the back, checking each time to see if the object has dislodged or has come out of the mouth. Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ABDOMINAL THRUSTS If the back blows fail to clear the obstruction, move behind the casualty and wrap your arms around their waist. Make a fist and grip it with the other hand. Move your hands into a position in the upper abdomen, just under the ribs, in the middle. When in position, pull your hands sharply towards you - backwards and upwards. The aim is to use air in the stomach and lungs to forcibly expel the obstruction upwards and outwards. Repeat this until the object is cleared or up to FIVE times, checking for the object in the mouth between attempts. CHECK THE MOUTH ABDOMINAL THRUSTS X5 Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 203 CHILDREN >1YR - TREAT AS FOR ADULTS Children over 1 year of age are managed in exactly the same way as adults. Repeat this until the object is cleared or up to five times, checking for the object in the mouth between attempts. Small children can be led head down over a lap to allow gravity to assist the process. UNDER ONE YEAR OLD For younger children or infants less than one year of age, use back slaps as shown. If there is no success after five slaps switch to chest compressions. The reason for this is that in such young children there is a risk of damage to internal abdominal organs if the abdomen is compressed. It may be easier to position the child along the length of your arm or on your knee as shown in the photograph above. Keep rotating 5 and 5 until the obstruction is cleared or the child loses signs of life. Do not give up, keep trying to clear the obstruction rotating your methods every five attempts. Repeat until the obstruction is cleared If casualty collapses then commence Basic Life Support. Obstructed breathing - Blocked airway FOREIGN BODY; CHOKING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Tongue: Respiratory distress relating to the tongue occurs most commonly when the casualty loses consciousness and muscle tone, but it can also occur if the tongue swells. UNCONSCIOUS A famous trauma myth is that someone can ‘swallow their tongue.’ In reality, this does not happen as the tongue is actually a large lump of muscle attached to the floor of the mouth and extending down the throat, with a flap like projection that we all describe as the tongue in our mouth. Rather than being swallowed, an unconscious casualty loses all the normal muscle tone in the throat, and the muscle of the tongue, like all muscles becomes relaxed and floppy. As a result, if the casualty is lying on their back, the tongue falls backwards with gravity and closes the narrow gap at the back of the throat, restricting the flow of air as shown in the diagram on the following page. Respiratory distress - Continued Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 205 The diagram shows that air can enter the throat through both the nose and the mouth, but has to pass through the area behind the tongue on its way down to the lungs. As the tone is lost in the tongue muscle, it falls backwards into the area marked with the ‘X’. The tongue is attached in the mouth to the jaw bone. If we can move the jaw forwards (or upwards if lying on the back) we can re-open the gap at the back of the throat and even a millimeter or two will be sufficient to open the airway and to allow air through. This is the basis of the ‘jaw thrust’ manoeuvre. RECOVERY POSITION Alternatively, place the casualty in the recovery position as this will often encourage the tongue to fall forward, the opposite way, keeping the airway open. This is why this position is favoured if you need to leave an unconscious casualty to call for help. Obstructed breathing - Blocked airway TONGUE Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ALLERGIC REACTIONS The more severe allergic reactions will not only cause swelling and airway problems but also skin changes/ rashes (see later) wheezing, respiratory difficulty from both upper airway and airway narrowing in the lungs. In the most extreme cases it can also cause fainting or even cardiac arrest – ensure to check for signs of life if someone does collapse after a reaction and start resuscitation if required. BURNS – THERMAL OR CHEMICAL Another rapid cause of airway swelling is burns to the face from sudden flash-burns as you might see from accelerant poured into an open fire or barbecue. This can be identified by the typical reddening of the face and loss of facial hair. Swelling can start to occur within minutes and peak within a few hours and therefore any burn above the shoulders requires hospital review as there is a real risk to the airway. If the casualty has been exposed to fire or smoke, there is a very real risk of smoke or hot gas inhalation and injury to the lungs or the lining of the trachea (or windpipe) which can seriously affect breathing. Always suspect this in fires, especially if the casualty is coughing up sooty sputum (spit) or is wheezy. Obstructed breathing - Blocked airway SWELLING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS One of the commonest causes of swelling in the airway are allergic or anaphylactic reactions which can start at the lips, involve the mouth or the whole airway down to the lungs. Swelling like this can come on in minutes or less but can then take hours or even days to go down. Such swelling can also occur more slowly as a result of infections, such as dental abscesses.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 207 A small minority of patients may be breathing but only slowly (e.g. 6-10 breaths/minute) and clearly not sufficiently. They are likely to be unconscious or very drowsy e.g. drug overdose or head injury. However, these can be very difficult to recognise unless you see them commonly in your work. If the casualty simply needs some support with their slow breathing rate then: • Call 999 • General stimulation and verbal stimulation – raised voice and gentle shaking • Supported breathing with a pocket mask (Consider mouth to mouth ventilation, bearing in mind potential risks.) • Be prepared to commence full basic life support at 30:2 compressions to ventilations • If in doubt about breathing then commence basic life support. If not sure if breaths are normal or they are gasping in nature assume cardiac arrest, call for help and commence basic life support. Inadequate breathing RESPIRATORY DEPRESSION Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Swelling of the face, lips tongue OBVIOUS SWELLING OR GETTING WORSE NOISY BREATHING 999 EMERGENCY – AMBULANCE OPEN THE AIRWAY In summary, any swelling of the face, lips or tongue is a serious emergency especially if it is rapidly getting worse. Another useful sign is if the voice changes or becomes hoarse or if the breathing is noisy and strained. This is a time critical situation and warrants a 999 emergency call. In the meantime, sit the casualty up (unless semi-conscious) and reassure them. Obstructed breathing - Blocked airway SWELLING Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 209 LUNG DISEASE HEART PROBLEM PAIN PANIC ATTACKS. If we now consider some of the other causes of breathlessness and respiratory difficulty, medical causes are very common. This can indicate many underlying conditions, but the commonest involve some compromise or failure of the lungs or the heart. There are many lung disorders which can cause respiratory distress, including chronic obstructive pulmonary disease (COPD), asthma, bronchitis, emphysema and bronchiectasis. Breathlessness – medical causes Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FIRST AID MEASURES Mild Asthma Attack REMOVE TRIGGERS REASSURE ENCOURAGE INHALER USE REPEAT EVERY 5 MINUTES As soon as you are asked to see someone with asthma or you can hear a casualty wheezing, remove any potential causes such as dust, pollen or remove them from the trigger environment such as cold air. These casualties will usually just settle with use of their blue-grey inhaler (Ventolin) which you should encourage them to use and repeat every five minutes as required. ASTHMA – Mild attack Asthma is very common for many young and old people, but although often mild, it still remains a real killer for a small number of people every year when attacks become very severe. Asthma involves contraction and spasm of the muscles in the tubes that lead down into the lungs, which increases the resistance and work of breathing and typically causes wheezing. Most asthmatics are used to their attacks and will usually be aware if the attack is worse than normal. However, sometimes the condition can deteriorate rapidly and it is crucial that first aiders identify that situation early. • Spasm of the airways • Wheezy • Patient concerned • Mild to life threatening. Breathlessness – medical causes LUNG DISEASE Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 211 DOCTOR/HOSPITAL Moderate Asthma Attack Signs of deterioration UNABLE TO SPEAK FULL SENTENCES INCREASING RESPIRATORY RATE BECOMING MORE DISTRESSED PATIENT FEELING WORSE AMBULANCE IF NO BETTER IN 10 MINUTES If over the next 10 minutes their respiratory rate increases, they are becoming distressed and having difficulty speaking, call a 999 ambulance. ASTHMA – Moderate attack • Wheezy • Coughing • Breathless • Frightened • Still able to speak in sentences. In a more moderate attack, the wheezing is more obvious and may be in both breathing in and out. Coughing is frequent and the casualty may look afraid. A good indicator of the severity of an attack is how the casualty is speaking. If they can speak in full sentences, this is a reassuring sign, but if they are having to clip or shorten their sentences, this is of greater concern and time to be considering an ambulance or urgent transfer to hospital. Breathlessness – medical causes LUNG DISEASE Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Breathing - When to worry UNABLE TO SPEAK FULL SENTENCES BREATHING RATE >30 MINUTE DROWSY OR EXHAUSTED AIRWAY SWELLING 999 EMERGENCY AMBULANCE For any asthmatic or casualty with respiratory difficulty who: • Is unable to speak • Has a breathing rate >30/minute • Is drowsy • Has any airway swelling (suggests that this is not simple asthma and maybe a serious allergic reaction) • This is a life-threatening situation and needs immediate 999 ambulance. ASTHMA – Serious attack UNABLE TO USE INHALER? Continue to encourage the casualty to use their inhaler, but they may reach a point where they are so short of breath that they simply cannot use it. This is a very worrying sign and if not already requested, call an ambulance immediately. Asthmatics tend to deteriorate quicker than those with other respiratory conditions, but if in doubt call an ambulance for anyone with breathing difficulties or failing to respond to their inhaler. Breathlessness – medical causes LUNG DISEASE Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 213 HEART FAILURE: We tend to relate chest pain to heart problems, but if the heart is not pumping well or ‘failing’ it often presents as respiratory or breathing difficulty. This can be a longstanding problem and is often worse when lying flat and associated with swollen ankles or legs. If in an existing heart failure casualty the breathlessness gets suddenly worse this could reflect a problem with the heart and needs medical review either by the GP or if more serious (i.e. unable to breathe, high respiratory rate or exhaustion) then 999 ambulance. In otherwise fit patients, a sudden onset of breathlessness could indicate something serious, especially if associated with pain on breathing and requires urgent hospital review. Whilst waiting for the ambulance, sit the casualty upright as this will help them to breathe better than lying flat. If more severe, prepare for resuscitation and get your AED if you have one nearby, whilst awaiting the ambulance. A CHEST PAIN IS YOUR BODY SAYING CALL 999: Any significant breathlessness associated with chest pain is a heart attack until proved otherwise and warrants immediate request of a 999 ambulance. Other worrying signs include sweating, vomiting and looking grey. Breathlessness – medical causes HEART PROBLEMS Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Panic attacks may be considered trivial, but they are very distressing for patients, families and even first aiders as they can manifest in serious looking signs and symptoms, such as severe difficulty in breathing, collapse, or an inability to move hands or arms etc. The casualty will usually complain of difficulty in breathing and may have tightness in their chest or light-headedness. They also often complain of feeling like they are going to die or having either a heart attack or stroke. There will often be an obvious stress or cause of the panic, which may help to discriminate it from something more serious. However, even completely benign cases can look very dramatic, especially if the hands start to go into spasm, which typically increases the panic still further. This upward spiral in reaction to worsening symptoms is the biggest challenge in a severe panic attack and is often difficult to break. Breathlessness – medical causes PANIC ATTACKS Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 215 FIRST AID MEASURES Panic Attack REASSURE FOCUS ON SLOW STEADY BREATHING CONSIDER SHORT TRIAL OF PAPER BAG BREATHING Treatment requires early recognition, reassurance and getting the casualty to focus on their breathing rate and then taking SLOW STEADY breaths. If this proves difficult, a large paper bag can be used to allow them to ‘re-breathe’ air that they breath out. DO NOT HOLD THE BAG ON THEIR FACE. FOR SAFETY REASONS, THE CASUALTY MUST HOLD IT THEMSELVES. Encourage the casualty to breathe in and out of the bag, watching it slowly inflate and deflate slowly. At first they will probably be breathing very fast, but gradually bring it down with long exaggerated breaths – DO NOT TELL THEM TO TAKE NICE DEEP BREATHS – as big breaths can perpetuate the problem, which is a low carbon dioxide level in the blood. Using the paper bag allows the expired carbon dioxide to accumulate. Ask the casualty to hold the bag themselves as this ensures that it doesn’t go too high. PANIC ATTACK OR HEART ATTACK? ANY DOUBT THEN 999 AMBULANCE Good reassurance and a focus on slowing the breathing should relieve symptoms within a few minutes, but if not or the panic attack is spiralling out of control, an ambulance will be required. Similarly, the symptoms can easily mimic something far more serious like a heart attack. If in doubt, call for an ambulance immediately and remember that something like chest pain could actually trigger a panic attack too! Breathlessness – medical causes PANIC ATTACKS Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com TRAUMA Trauma is another significant cause of respiratory difficulty to consider. This can be as a result of an injury e.g. a stab wound to the chest or rib fractures or an injury elsewhere which causes difficulty in breathing. In trauma there may be: • Obvious injuries or wounds • Fast breathing > 20-30/min • Unequal or abnormal pattern of breathing due to some injury to the chest or an airway problem. Breathlessness – medical causes PAIN Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 217 PAIN – RELIEVE HOWEVER YOU CAN Considering the obvious injuries, any kind of major traumatic injury will cause moderate to severe pain and will increase the breathing rate significantly. In this case, controlling the pain in some way, such as splinting a fracture, will help to reduce the breathing rate and settle the casualty. RIB FRACTURES Injury to the chest will affect breathing in two ways, either indirectly as a result of the pain from bruising or rib fractures or directly from something more serious such as a collapsed lung. However, remember that there are two lungs and most people in reasonable health can manage for at least short periods on one lung with injury to the other. As with most respiratory or breathing problems, gently sitting the casualty up is likely to help their breathing. We do not strap up rib fractures any more, but can certainly encourage the casualty to hold or support their area of injury, which will help with the pain. RISK TO LIFE Trauma SITTING UP MAY HELP THEM (Caution with spinal injury) SUPPORT RIB INJURY REASSURE 999 EMERGENCY AMBULANCE Breathlessness – medical causes PAIN Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SHOCK – INTERNAL OR EXTERNAL BLEEDING If there is major blood loss related to the trauma, the casualty may be starting to show signs of shock. This will include an increased respiratory rate without any apparent problem with the chest. Remember that increased respiratory rate is a reliable sign that all is not well and may suggest that the casualty needs a proper medical evaluation in hospital. Breathlessness – medical causes PAIN Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 219 For anyone who: • Is unable to speak • Has a respiratory or breathing rate >30/minute • Is drowsy or exhausted from trying to breathe • Is blue around the lips • Call an ambulance without delay. RISK TO LIFE Breathing - When to worry UNABLE TO SPEAK BREATHING RATE >30 MINUTE DROWSY OR EXHAUSTED BLUE AROUND THE LIPS 999 EMERGENCY AMBULANCE In summary, for any casualty with breathing difficulties: • Sit them up • Work hard to reassure them • Loosen any constricting clothing • Encourage them to use inhalers if they have one (the blue-grey one called Ventolin) • If there is not improvement in 15 minutes or they are still getting worse despite your efforts then call an ambulance immediately. FIRST AID MEASURES Difficulty breathing - summary TRY SITTING THEM UP REASSURE LOOSEN CLOTHING INHALERS? NO IMPROVEMENT IN 15 MINS OR GETTING WORSE 999 EMERGENCY AMBULANCE Breathlessness – medical causes PAIN Chapter 11: First Aid & Medical Emergencies – Respiratory Distress - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Pain or Numbness – B.U.R.P.S Pain is like a big flag stuck in the casualty, indicating a problem, whereas numbness often indicates a problem somewhere else, affecting the spinal cord or nerve supply to that area. We need a reliable way to assess and define the level of pain. This allows us to monitor if it is getting better or worse, to handover to other carers and to decide about the levels of pain relief required. Many healthcare professionals use a 0-10 scale, but there is evidence that some casualties struggle defining the middle ground and as such a simpler five point scale is more usable, where zero is ‘no pain’ and ‘5’ is the worst pain imaginable. The faces below are called the Wong & Baker pain score. This overcomes the challenges of language and age as they can be used in children. Score from 0-5 • 5 worst pain imaginable • 0 no pain. How can we assess pain? 1-2 Simple ‘over the counter’ pain killers >3 usually means medical attention 4-5 Usually means hospital Consider some of the commonest types of pain or numbness that a first aider may face. THE WONG-BAKER™ PAIN SCORE Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 221 Headache is very common and can be a mild irritation through to a severely debilitating migraine. Despite what many people think, high blood pressure does not usually cause headaches, but many viral or bacterial illnesses with fever do, as can head injuries. Headache RISK TO LIFE Serious headaches SUDDEN ONSET NON-BLANCHING RASH SEVERE NECK STIFFNESS REDUCED CONSCIOUS LEVEL FIRST AID MEASURES Simple Headaches USUALLY SELF-LIMITING – IF NO OTHER FEATURES SIMPLE PAINKILLERS (SELF ADMINISTERED ONLY) FLUIDS ESPECIALLY IF DEHYDRATED DOCTOR/HOSPITAL Moderate headaches VOMITING IRRITATED BY THE LIGHT BODY RASH NECK STIFFNESS HIGH TEMPERATURE (>38 DEGREES) HEADACHE PLUS ANY OTHER - THEN DR Simple headaches are usually self-limiting and need no treatment or just simple painkillers such as paracetamol and plenty of oral fluids to keep the casualty well hydrated. These headaches are not usually associated with any other symptoms, which defines them as ‘simple’. The yellow section contains what may be described as moderate headaches. These are associated with other illnesses. Infections or sepsis affecting the whole body with fever and a general feeling of being unwell are a common cause. There may be vomiting, rash, sensitivity to light and even neck stiffness. The temperature is often 38 degrees or more and the casualty may be irritable or keen to be left alone. These cases may be just flu-like illness that require nothing more than simple painkillers and fluids, but if there is a rash or head and neck symptoms in addition to the headache, the casualty should be reviewed by a doctor. Serious headaches are associated with any of the following: • Sudden onset • Non-blanching rash (Glass test) • Severe neck stiffness • Reduced conscious level or seizures. These are all conditions that need immediate medical review or attention. Hence, they are in the red section and represent a real risk to life. Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Back pain is one of the most common things that any first aider may have to face. Up to four out of every five people will have back pain or problem at some time in their life and usually between the ages of 20 and 65 years. In most cases, it will simply settle down without any specialist treatment and although painful, it is rarely serious. FIRST AID MEASURES Back pain - simple SIMPLE PAINKILLERS e.g. paracetamol , Ibuprofen (SELF ADMINISTERED ONLY) MAINTAIN LIMITED MOBILITY SHOULD BE BETTER WITHIN 4 WEEKS The key is simple painkillers which first aiders could not directly administer but could suggest to the individual. Most importantly, the casualty should maintain as much mobility as possible. In the past, casualties would be put on strict bed rest with firm mattresses etc but this is likely to result in worsening symptoms and reduced mobility. Whilst remaining mobile, care should be taken not to unnecessarily load the back muscles. Avoid long periods of sitting when the problem is acute. All back problems should resolve within a month unless aggravated and some manual handling education may be of value to prevent further injury. If the pain has not resolved within a month, it warrants medical review by a GP. RISK TO LIFE Back pain – serious concerns Trauma causing numbness or severe pain PAIN IN CHEST / HIGH IN BACK NUMBNESS IN LEGS / BELOW KNEES LOSS OF BLADDER / BOWEL CONTROL NUMBNESS - GENITALS / BUTTOCKS Back pain is considered to be potentially more serious if it comes on suddenly in the following situations: • Traumatic injury, especially if associated with numbness or severe pain • Pain high in the back, which could be chest pain • Any numbness if the legs, especially below the knees • Any loss of bladder or bowel control or difficulty passing water • Any numbness in the genitals or buttocks • Any of these warrant immediate transfer to hospital and assessment in an Emergency Department. Back pain Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 223 Numbness and weakness can also occur in many other parts of the body, rather than just the lower limbs. There are two main groups of causes: Trauma, injury of infection e.g. injury to an individual nerve or group of nerves or injury or condition in the spinal cord. Medical Conditions: Migraine or a stroke. Other conditions can cause numbness but tend to come on more slowly and are unlikely to present to a first aider, Most warrant GP follow up for investigation e.g. Multiple Sclerosis or various nerve specific disorders. Stroke is obviously a very serious condition and needs to be identified as soon as possible. To help with this, a simple memory aid has been produced called the FAST test. FAST has been developed by the NHS to help even lay persons react when they see the signs of stroke. The test consists of four parts: FACE: Look at the face and ask the patient to smile, puff their cheeks out and then screw up their eyes or raise their eyebrows. If they are unable to do this on one side or it looks unequal, they are FAST positive. ARMS: Ask them to raise their arms out in front of them and see if one arm seems obviously weaker than the other – this would then be FAST positive. SPEECH: Is the speech slurred or abnormal? Colleagues or family can help with the answer to this question as they know what the casualty is normally like – if abnormal, they are FAST positive. TIME: If FAST is positive for any of these, immediately call for a 999 ambulance and tell the operator that you have a casualty who you believe is having a stroke as they are FAST positive. TRAUMA OR INJURY • Nerve injury • Spinal injury. RISK TO LIFE Numbness/weakness F.A.S.T SIGNS ARE A MEDICAL EMERGENCY ANY SUDDEN ONSET WEAKNESS/NUMBNESS IS A MEDICAL EMERGENCY All FAST signs are a medical emergency as is any sudden onset of weakness or numbness in any major part of the body, especially after injury. Call for an ambulance, reassure the casualty and keep them as comfortable as possible with minimal movement. Numbness or weakness MEDICAL CONDITIONS • Migraine • Stroke. Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ALWAYS CONSIDER THE HEART Another common form of altered sensation or pain is chest pain. This is obviously potentially very serious and may indicate a possible heart attack. Chest pain should always be taken very seriously and not simply dismissed as indigestion or something else. RISK TO LIFE Chest pain - signs SEVERE PAIN – ‘CRUSHING’, HEAVY, INDIGESTION CENTRAL CHEST, ARMS, JAW FEELING FAINT, PALPITATIONS OR COLLAPSE SWEATING OR CLAMMY VOMITING All chest pain should be considered as serious but the following signs should increase concern and warrant immediate 999 ambulance: • Severe ‘crushing’ pain like a very heavy weight on the chest or a tight band around the chest • Central chest pain radiating to the arms (usually left) or the jaw • Feeling faint, palpitations or collapse • Sweating or very clammy • Vomiting. RISK TO LIFE Chest pain – management SIT OR LIE DOWN REASSURE 999 AMBULANCE PREPARE FOR RESUS If a casualty has severe chest pain then: • Sit them down • Reassure them • Call a 999 ambulance. Prepare for resuscitation (get the AED, but try not to alarm the casualty). If you have any aspirin ask the Ambulance operator if you should give one to the casualty (they may say and to wait for the ambulance). Chest pain Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 225 FIRST AID MEASURES Mild (1-2/5) Mild pain 1-2/5 for example gastroenteritis, ‘tummy ache’, gripey or colicky in nature. In other words in comes and goes in waves. DOCTOR/HOSPITAL Moderate (3-4/5) Mod pain 3-4/5 for example urine infections or gastritis or ulcer pain. RISK TO LIFE Severe pain (5/5) Severe pain 5/5 e.g. appendicitis, perforated ulcer or bowel. FIRST AID MEASURES Mild - ‘Tummy ache’ GASTROENTERITIS, PERIOD PAIN D&V TEMPERATURE SIMPLE PAINKILLERS (SELF ADMINISTERED ONLY) FLUIDS DOCTOR/HOSPITAL Moderate pain GASTROENTERITIS, PERIOD PAIN, GALL BLADDER, INDIGESTION, ULCER, WATERWORKS SIMPLE PAINKILLERS (SELF ADMINISTERED ONLY) FLUIDS GP/A&E Abdominal pain has many causes and the pain varies considerably. If we stick to our colour coding then: Abdominal pain Mild abdominal pain or ‘tummy ache’ as it is often described related to gastroenteritis, diarrhoea and vomiting or even period pain, can still be very uncomfortable and quite debilitating. However, the only treatment required are simple painkillers and oral fluids. If the casualty cannot keep any fluids down at all because of vomiting and sickness, they may become dehydrated. If this persists for more than a few hours, they will need medical attention, starting with the GP or out of hours service. If the pain is more severe or moderate, this alone may trigger the need for a GP visit or out of hours/urgent care centre. Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com IN SEVERE ABDOMINAL PAIN RISK TO LIFE Abdominal pain - severe CURLED UP DIARRHOEA UNKEEN TO MOVE VOMITING VERY TENDER TO TOUCH 999 AMBULANCE The casualty may be curled up in agony. The pain may still come in waves, but can be very severe. The casualty will often be not keen to move and be very tender to touch. Their tummy maybe rigid as the muscles tense to try and reduce the pain as you touch it. This is called guarding There may also be diarrhoea and vomiting and high temperature. These casualties require emergency transfer to hospital as there are many causes and some of them are obviously quite serious. In female patients, it can be useful to ask if they are, or could be, pregnant as this could be a miscarriage, abnormal pregnancy or even early labour. Abdominal pain Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 227 TRAUMA RELATED PAIN Trauma is one of the most common causes for pain and as stated previously, the pain is like a big flag sticking out of the injury, indicating where the problem is located. Sometimes a serious injury can distract the casualty and ultimately yourself as a first aider from other injuries, so in severe trauma, always look for other injuries in your assessment. In simple terms, visually inspect the casualty from head to toe and wherever anything abnormal is found, carry out further assessment to the best of your ability. (Gently feel the area if possible). Sprains, dislocations and fractures are common in trauma and all produce: • Pain • Swelling • Deformity • Loss of Function. COMPARE WITH THE NORMAL SIDE In assessing the injury, always compare to the opposite ‘normal’ side wherever you can and look for differences in skin colour, size and mobility and feel for heat or pain on contact. DOCTOR/HOSPITAL Sprains ICE PACKS STRAPPING ELEVATION SIMPLE PAIN KILLERS (SELF ADMINISTERED ONLY) IF IN DOUBT THEN HOSPITAL OR CONSIDER GP/ HOSPITAL IF NO BETTER IN 48HRS In suspected sprains, consider a cold compress or ice pack whilst avoiding direct contact with ice on skin (thin bandage or cloth between cold compress and skin). Elevate the limb and strap it up to immobilise it as best as possible, using simple painkillers, such as paracetamol or ibuprofen for pain. If the casualty is unable to weight bear or use the limb at all, this requires medical review and probably an x-ray in hospital. Similarly, if they are no better or worse in 48hrs time, this needs medical review. Sprains, dislocations and fractures Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DISLOCATIONS Dislocations are when a joint is pushed out of its normal alignment, usually following a traumatic force. This can be small joints such as fingers or large joints such as knees or shoulders. Dislocations are painful and look unpleasant. In the larger joints they may also damage nerves and blood vessels and need urgent reduction (putting them back into alignment) but this needs to be done safely in a hospital wherever possible. First aid reductions should be avoided unless there is no alternative, as they can cause further damage in inexperienced hands. Dislocations often tear all the important ligaments which stabilise a joint but there does not have to be a fracture. DOCTOR/HOSPITAL Dislocations DISLOCATIONS AND FRACTURES ALL NEED HOSPITAL ASSESSMENT Limited exception: some recurrent dislocations All dislocations and fractures require hospital assessment for x-rays and treatment. Sprains, dislocations and fractures Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 229 FRACTURES Fractures are the medical term for broken bones. There is usually an element of trauma although in the elderly with osteoporosis, fractures can occur simply with weight bearing on occasions. Common bones to fracture include ribs, collar bone, arms, legs, pelvis and skull. The signs are the same as dislocations: • Pain • Swelling • Deformity • Loss of Function. OPEN FRACTURES If the fractured bone breaks the skin, this carries a far greater risk of infection and needs urgent hospital care with typically an operation the same day to minimise that risk, so avoid giving food or drink to anyone with such injuries. Open injuries always look very distressing to both the casualty and the first aider, so reassurance and early coverage with a clean dressing or pad, gently applied is important. DOCTOR/HOSPITAL Dislocations & fractures SUPPORT THE LIMB IMMOBILISE HOWEVER POSSIBLE SLINGS, SPLINTS, OTHER LIMB The key elements of first aid are to reduce pain and prevent further injury from abnormal movement of the damaged limb or structure. Initially support the limb by gently holding it or if possible letting the casualty support it. Immobilise the fracture however you can with simple splints, a sling or fastening to the other leg for example. This aims to reduce movement of the broken bones, which will reduce pain, bleeding and risk of further damage. Sprains, dislocations and fractures Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Dislocations & fractures MAJOR BLEEDING MULTIPLE INJURIES OPEN FRACTURES PAIN CONTROL/NUMBNESS/PARALYSIS Fractures and dislocations are more serious when they are associated with: • Major bleeding • Multiple major injuries • Open fractures • Sever pain, numbness or paralysis. In summary, pain or numbness has many causes and can act as a very useful indicator of where the problem lies in the body. However, it can distract you from other injuries that may also exist. Do a quick assessment of the location and severity of the pain with the 0-5 scoring system as you will have a better idea of how to manage it. RISK TO LIFE Fractured Pelvis or Spine USUALLY INVOLVES MAJOR TRAUMA Manage bleeding, airway etc ONLY MOVE IF LOCATION UNSAFE KEEP STILL & AWAIT ASSISTANCE DO NOT ELEVATE LEGS Anyone with a suspected fracture to the pelvis or spine, a major fall or a pedestrian road traffic collision for example, requires 999 emergency care as this is major trauma. Try and avoid moving the casualty unless they are in an unsafe position or you need to move them to do something life saving such as to open their airway or stop bleeding etc. Keep the casualty still, keep them warm and wait for help. DO NOT ELEVATE THE LEGS FOR SHOCK Sprains, dislocations and fractures Chapter 11: First Aid & Medical Emergencies – Pain or Numbness - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 231 WOUNDS TEMPERATURE INFECTION/SEPSIS RASHES BURNS REACTIONS E.G. ALLERGIC Skin – Appearance & Temperature – B.U.R.P.S Wounds are basically superficial or deep. Some will break the surface of the skin and result in bleeding, whereas others will simply cause a bruise with bleeding occurring under the unbroken skin and gradually fading away over days to weeks. Some wounds will be actively bleeding and some will be deep or involve major blood vessels and produce major life threatening bleeding. • Abrasions and grazes • Bruising • Bleeding wounds • Deep wounds and lacerations. Wounds Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GRAZES AND ABRASIONS Grazes and abrasions are the most superficial and involve friction, often with a rough surface. They can bleed, and although not major bleeding, it can be from a very large area, which can make it more significant. These wounds are often dirty or contaminated from the surface contact e.g. gravel of the road and are typically like ‘raw’ skin and painful. Some can cover very large areas, where someone has made contact with an abrasive surface at high speed without any skin cover or adequate protection e.g. a motorcyclist without leathers. Such abrasions can be deep and lead to permanent scarring or even the need for skin grafting in the most severe cases. • Involves friction & rough surfaces • May bleed significantly • Often dirty / contaminated e.g. gravel • Usually painful - ‘raw’. Wounds MINOR MAJOR Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 233 In first aid terms, these are managed like other wounds: • Control any major bleeding with pressure • If contaminated or dirty, irrigate the wound with saline eyewash or running water to clean it as much as possible • Cover with an ambulance dressing or for very large areas of skin, cover with cling-film. FIRST AID MEASURES Grazes and Abrasions APPLY PRESSURE - CONTROL BLEEDING WASH AWAY GRAVEL OR DEBRIS Irrigation: Saline eyewash or water Clean dirt or contamination APPLY AN AMBULANCE DRESSING Cover large areas with cling-film DOCTOR/HOSPITAL Grazes and Abrasions INVOLVES LARGE AREA OF BODY (more than four hands) SUGGESTION OF OTHER INJURIES E.G. FRACTURES LARGE OR MULTIPLE BLEEDING POINTS If the abrasion: • Involves a large area of skin – more than 4 hands • Is associated with other possible underlying injuries e.g. fractures • There are large bleeding points in the wound These all require medical attention and should be seen by a doctor, although they are not immediately life-threatening and rarely require an ambulance unless the other injuries are severe. Wounds Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com BRUISING / SWELLING These both suggest some injury to the tissues under the skin. Bruising is bleeding under the skin and swelling can be from bleeding or reactionary swelling of the tissues following some insult such as trauma or even an allergic reaction. If there is bruising and swelling associated with a traumatic injury and some inhibited or loss of function, assume there may be underlying injuries, such as fractures. DOCTOR/HOSPITAL Possible fracture: treatment HANDLE GENTLY IMMOBILISE THE AREA – SPLINT SIMPLE PAINKILLERS (SELF ADMINISTERED ONLY) HOSPITAL FOR X-RAYS If you suspect a fracture from the appearance, the history and the pain being experienced, handle the casualty gently, immobilise the area if possible (or support it with their hand for ribs for example). Consider if they have simple painkillers they can administer themselves and take them to hospital for x-rays. This is rarely a 999 emergency, unless involving some major trauma shortly before. Wounds Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 235 SIMPLE LOCALISED INFECTION Let us start by considering one of the most minor causes of hot skin, but one that can still be very painful and could develop into something more serious if it does not resolve quickly. A small localised infection or ‘spot’ which may be yellow as it is filled with pus. The surrounding tissues are red, swollen, painful and hot to touch. The skin is an excellent thermal indicator and anyone feeling very hot to the touch without obvious cause should be considered unwell. If there is no obvious cause, such as exercise or working in hot weather, consider that they have a fever and may have an infection, or in the worst case septicaemia. Even if the casualty has been working in a hot environment, they may have collapsed or may be unable to cool down after stopping work and becoming unwell. Heat exhaustion may be suspected. If the skin is bright red or showing a rash or weals, it may be a serious allergic reaction and the skin feels hot because of the increased blood flow through it. If the casualty feels like they are on fire and you suspect that they may have taken a recreational drug, such as Ecstasy or amphetamines, this could be a very serious drug reaction and needs to be recognised early. There are many reasons for hot and reddened skin, so when considering possible causes, take each case in context. SERIOUS LOCAL INFECTION & EARLY SEPSIS Needs to be seen by a doctor • Full of pus • Tracking in tissues • Very painful • Feel unwell • Temperature. Temperature - Hot & flushed Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GENERAL INFECTION Whenever infection becomes generalised, the casualty will feel very hot to touch, often be sweating and actually complain of feeling cold. However, if they feel hot and sweaty but look well and feel fine, get some more history as they may have just come in from running around the playground! Remember it is all about context and common sense. Comparing these two photographs, there are some obvious differences. GENERAL INFECTION - SEPSIS He is hot to touch, flushed but also listless and drowsy. On further investigation, we find that he has a sore throat, ear-ache and may also have a tummy upset or even a rash. He is clearly very unwell and different to the first little boy. Needs to be seen by a doctor If the infection does take a hold and affects the whole body it can then develop into life threatening sepsis and septic shock. • Affects the whole body • Sepsis can produce life-threatening shock. SEPTIC SHOCK – SERIOUS INFECTION In septic shock the skin feels hot and flushed as the tiny blood vessels in the skin, all over the body, are wide open. The heart will be working hard, but the circulation expands in size, but there is no more blood, so the circulation is effectively a bit ‘empty’ and the blood pressure falls. This is septic shock and in the worse cases can cause cardiovascular collapse. Sepsis or Septicaemia Not enough blood to fill the expanded circulation Skin vessels wide open Short of blood volume Heart pumping hard HOT FLUSHED DROWSY FAINT Temperature - Hot & flushed Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 237 DOCTOR/HOSPITAL Moderate Sepsis TEMPERATURE: >39 DEGREES DROWSY OR CONVULSIONS SEVERE HEADACHE / NECK STIFFNESS UNABLE TO DRINK FLUIDS RASH OVER TRUNK OR LARGE AREAS OF BODY FLUIDS, PARACETAMOL/IBUPROFEN (SELF ADMINISTERED ONLY), ELEVATE LEGS IF DROWSY OR SIGNS OF SHOCK If the symptoms of the infection get more severe, a medical review is required. The triggers for this should include: • Temperature >39 • Drowsy or convulsions • Severe headache with or without neck stiffness • Unable to tolerate any fluids • Rash over trunk or large areas of body. In managing infection and sepsis, ensure that the body gets plenty of fluids to meet the losses from high temperature, vomiting, diarrhoea or inability to eat and drink. For the fever and the symptoms such as headache, if the casualty possesses paracetamol or ibuprofen, this will tackle both. FIRST AID MEASURES Mild Sepsis FLUIDS CONSIDER PARACETAMOL OR IBUPROFEN IF SAFE (SELF ADMINISTERED ONLY) • Reduces the fever • Relieves symptoms. Sepsis or Septicaemia Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com In terms of rashes, there is one rash that everyone should be aware of and that is the non-blanching rash of meningitis. Although this is becoming less common with vaccination, it can still occur and is potentially life threatening. We detect meningitis by applying the ‘glass test’ to lesions of the rash. In most conditions the spots will blanche when you apply pressure with the glass, whereas in meningitis the lesions can still be seen through the glass and do not blanche. RISK TO LIFE Non-blanching rash RING AMBULANCE IMMEDIATELY • Especially if hot, drowsy, sore throat DO NOT SIMPLY GO TO GP SURGERY Anyone with a non-blanching rash who is unwell requires immediate review in hospital. Do not simply go to the GP as this is a medical emergency and every minute counts. Meningitis Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 239 Human beings usually have a core temperature of 37 degrees centigrade. A core temperature between 37 and 35 centigrade is classed as ‘cold’. A core temperature below 35 degrees centigrade is classed as hypothermic. It is important to recognise the difference between a cold casualty and a hypothermic one, as cold casualties can be safely treated by the first –aider whereas hypothermic casualties should be warmed up in hospital. Cold casualties can be warmed up by skin rubbing, heat sharing, head and hand coverings, being placed in warm environments, being sat in a warm shower or exercising. Warm drinks help the casualty mentally, but in fact do not increase body temperature. Hypothermic casualties should be insulated from further heat loss and emergency assistance called to transport them to hospital. 37˚ 36˚ 35˚ 34˚ 33˚ 32˚ 31˚ 30˚ 29˚ 28˚ 27˚ 26˚ 25˚ 24˚ TIME OF USEFUL CONSCIOUSNESS Sensation of cold Shivering ++ Impairment of manual dexterity Errors of commission or omission Shivering +++ Muscle Function significantly impaired Introversion Slowing of mental and physical activity Amnesia Pupils dilating Shivering being replaced by muscle spasticity Unconsciousness Ventricular fibrillation likely Slowing of respiration and heart rate Muscle Flaccidity Death (failure to rewarm) (99˚) (97˚) (95˚) (93˚) (91˚) (89˚) (87˚) (86˚) (84˚) (82˚) (81˚) (79˚) (77˚) (76˚) TIME HYPOTHERMIC COLD DEEP BODY TEMPERATURE °C (°F) HYPOTHERMIA AND COLD INJURIES Cold and hypothermia Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS COLD HYPOTHERMIC Conscious, lucid and able to give history Semi or unconscious, confused, mumbles Floppy and Flexible limbs Rigid, maybe foetal position Shivering Violent shivering leading to rigidity Warm armpit Stone cold armpit Able to be warmed up Insulate and get to hospital In the absence of a thermometer there are ways of telling the two apart:

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Individuals who have been working or exercising in extreme heat or humid environments can develop heat exhaustion and sometimes this can be hard to detect. It can ultimately lead to collapse, cardiac rhythm problems and even seizures. CAUSES • Exposure to hot environment • Intensive physical exertion • Sun-burn • Overheating • Loss of salts and water. SYMPTOMS Early symptoms of heat exhaustion include heavy sweating and dark or infrequent urine. The last two points are as a result of the body trying to retain water and not creating urine. The urine created is very dark and concentrated and this is an early and effective way to identify people who are at risk. A well hydrated individual will pass urine every few hours and it will be pale yellow. As the heat exhaustion gets worse, the casualty may get muscle cramps, nausea, feel faint or dizzy and have a racing pulse. Ultimately, they will just collapse in an unconscious state. If faced with a casualty with developing heat exhaustion: • Remove them from the hot environment/the heat source or put them in the shade • Remove any unnecessary clothing • Lay them down and elevate the legs if necessary • Actively cool the skin with cool water – a fine spray works best • Rehydrate them slowly with cool water (or an oral rehydration fluid, which is better as it contains salts). If heat exhaustion continues untreated then it can develop into life-threatening heat stroke. Heat exhaustion Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 241 CALL AN AMBULANCE If the heat stroke/exhaustion is extreme and the casualty has any of the following: • Very drowsy, unconscious • Having seizures • Unable to drink fluids • Vomiting • Not responding to simple measures after 30 minutes These require an emergency ambulance and hospital BURNS & SCALDS Burns to the skin: Extreme heat applied to the skin will cause a burn. This can occur slowly over a number of hours or very quickly with intense heat. TYPES OF BURNS Burns are classified in a simple three step way, but in reality there is considerable overlap between each. SUPERFICIAL PARTIAL THICKNESS FULL THICKNESS: Blisters Dry Red but limited swelling Moist Discoloured Painful Very painful Painless as nerves destroyed Heat exhaustion Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Sunburn is a good example of a superficial burn, but in severe cases the skin can be blistered and be close to partial thickness, which may scar. The best management of sunburn is prevention with sensible use of sunblock. Minor burns that are painful can be managed much like other burns with cool running water for 5-10 minutes. Alternatively, cooling after sun can be used and then left under a loose cotton shirt or even a loose bandage if necessary. FIRST AID MEASURES Minor burns COOL WITH COLD RUNNING WATER: 5-10 MINS CONSIDER SUN-CREAM/BURN GEL • Small burns • Sunburn LOOSE COTTON BANDAGE Sunburn Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 243 If there are blisters in the burn this reflects a more severe injury and requires more effective management. DOCTOR/HOSPITAL Burns that need hospital BURNS MORE THAN 10% OF BODY SURFACE • Palm is 1% BLISTERING OR LOSS OF PAIN SENSATION ALL ELECTRICAL BURNS: even small ones CHEMICAL BURNS (unless specialist trained) If the burns are: • More than 10% of the body surface area (palm is 1%) • Blistering or loss of pain sensation • Electrical burns • Chemical burns. These they require hospital review DOCTOR/HOSPITAL Minor to major burns REMOVE THE HEAT SOURCE & LOOSE CLOTHING COLD RUNNING WATER FOR 10 MINUTES AVOID GEL DRESSINGS (face shields ok) COVER WITH CLING-FILM (strips) Bubble – COLD RUNNING WATER FOR AT LEAST 10 mins Remove the heat source and provide active cooling with cool running water for at least 10 minutes, maximum of 20 minutes. Except for chemical burns then irrigation can be continued for up to one hour. Avoid gel dressings unless there is no water available. Face shields are a good way of providing a dressing for the face after cooling. Once cooling with water has been performed, apply loose sheets or strips of cling-film (do not wrap it around the limbs). Blisters Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE Severe burns ACTIVE COOLING – WATER 10-20 MINS IS THE AIRWAY AT RISK? Swelling & conscious level CLING FILM Burns are very painful Full thickness – not painful Remove the heat source and provide active cooling with cool running water for at least 10 minutes, maximum of 20 minutes. Except for chemical burns then irrigation can be continued for up to one hour. Avoid gel dressings unless there is no water available. Face shields are a good way of providing a dressing for the face after cooling. Once cooling with water has been performed, apply loose sheets or strips of cling-film (do not wrap it around the limbs). Burns can be hugely damaging to the skin and produce scarring, which can be very extensive and life changing. However, if burns are rapidly cooled and managed well, results can be far more effective. Good first aid is crucial to give a better chance of a successful outcome. Facial & airway burns are an emergency Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 245 MINOR - LOCALISED REACTION A bite from an insect can also cause a reaction but these tend to be localised with redness, swelling and itching. However, bee stings are notorious for causing a more severe reaction in some people. Much of the reaction is due to the release of histamine in reaction to the bite or sting. Allergic reactions MILD UP TO ANAPHYLACTIC SHOCK Allergic reactions can occur as a result of many things. Even simple household agents, drugs and foodstuffs can cause very serious allergic reactions in some people. These reactions can be mild or life threatening, but they all usually show some signs on the skin. Most minor reactions simply require: • Removal of the cause • Re-assurance • Avoid scratching • If the casualty has their own anti-histamine cream, encourage them to use it or in the case of multiple bites or more severe cases anti-histamine tablets. In asthmatics, who may start to become wheezy or feel tight, may benefit from using their Ventolin (blue-grey inhaler) or similar product. FIRST AID MEASURES First aid – allergic reactions REMOVE THE CAUSE DO NOT SCRATCH RE-ASSURANCE ANTI-HISTAMINE • Creams • Tablets (non-sedating) ASTHMATICS – CONSIDER THEIR INHALER Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com MODERATE REACTION For more extensive reactions that may produce more extensive rashes, we may also notice raised bumps or weals with more generalised symptoms such as itching, cough or wheezing and even potentially some drop in blood pressure and light headedness. In other words, allergic reactions are a spectrum, from almost nothing through to complete collapse and near arrest. Triggers: • Foods • Plants • Pollen/dust • Stings/bites • Drugs • Clothing. HISTAMINE RELEASE MAY GET WORSE! • Redness • Coughing • Weals • Wheezing • Swelling • Swelling • Itchy. • Faintness. DOCTOR/HOSPITAL More serious – allergic reaction TINGLING: MOUTH OR TONGUE WHEEZINESS/DIFFICULTLY IN BREATHING EYE IRRITATION VOMITING, TUMMY UPSET NOT IMPROVING AFTER REMOVING CAUSE Moderate reactions may also give early signs, such as: • Tingling in the tongue or mouth • Difficulty breathing • Eye irritation • Gastric upsets. If these do not improve, review by a GP or hospital is required Allergic reactions Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS