When a casualty is first encountered, communication should be established with the casualty immediately for information and reassurance and rescuers should look for clues as to what has caused the casualty's condition. This will assist the first-aider determine what injuries a casualty is likely to have and could give warning to danger. The St John Action Plan should be followed in its entirety in all situations. A secondary survey should be performed on all conscious casualties, and on unconscious casualties where time permits.
With anxiety or severe pain, a casualty may not be aware of some injuries and may lose track of time, therefore information from witnesses should always be sought.
Prior to managing any casualty's injuries, a first-aider should always explain what he is going to do and why, even if the casualty is unconscious, and a conscious casualty should be asked for the position that makes him most comfortable. This will be very reassuring to the casualty.
Where injury has occurred in a limb, circulation in the extremity must be checked before and after management.
Regular checks on the strength and rate of a casualty's breathing and pulse should be made and recorded to show up any changes in the casualty's condition. This information will be very useful to medical personnel.
Care must be taken that accurate information with as much detail as possible, including directions to the scene, is passed on when medical aid is called.
Most people who suffer injury, harm to their health or emotional upset, will go into shock. Shock is the body's attempt to provide an adequate blood supply to the vital organs, especially the brain, which is achieved by constricting the arteries feeding less vital parts of the body. If not managed, shock causes stress on the heart and progresses until even the vital organs are affected.
The management for shock is:
This plan will help stabilise and promote recovery in most casualties, regardless of what has affected their health.
An unconscious casualty must always be placed in the coma position, unless being resuscitated, regardless of any other injuries, and must never be left unattended. A neck brace should be fitted to assist in maintaining an open airway, and the casualty should be managed for shock, however managing injuries other than bleeding may be less important.
Any casualty who has suffered, or is suspected to have suffered, a fall or a blow to the back or head, should be suspected as having a spinal injury. Casualties suffering a spinal injury can be moved without further damage being caused, if the correct techniques are used.
Prolonged exertion in hot, humid conditions can lead to the body being unable to maintain its temperature at the correct level, this is known as heat exhaustion and can develop into heat stroke, which is when the body's temperature regulating system fails.
Whereas a casualty suffering from shock would have cold, clammy skin, a casualty suffering from heat exhaustion will have hot, sweaty skin and a casualty suffering from heat stroke will have hot, dry skin.
Heat exhaustion and heat stroke are managed by cooling the casualty and, if conscious, giving water to drink. Apart from these points, all other aspects of managing for shock apply when managing heat exhaustion or heat stroke.
Any casualty injured as a result of an explosion will have, apart from obvious injuries, damage to the lungs and ears.
If any part of a casualty's body is pinned under or compressed by a large weight for any length of time, the blood supply will be restricted to the part that is trapped and toxins will eventually form. If the weight is released without medical treatment, the toxins will enter the bloodstream and quickly cause damage to the organs of the body, and possibly instant heart failure.
It is vitally important to know the exact time that the casualty was crushed, from a reliable source. If the weight cannot be removed within about 45 minutes of the crush injury occurring, it must be left in place until medical aid arrives. As usual, the management for shock should be used.
The voltage that a person contacts is virtually irrelevant, it is current, or amps, passing through the body that causes injury. It is possible to be electrocuted by as little as 110V AC and 42V DC. Less than 1mA (milliamp) cannot be felt, 10mA is painful, 14mA causes paralysis and between 100mA and 200mA the heart will go into ventricular fibrillation (twitching that doesn't pump blood) and death is almost certain. Current above 200mA causes the heart to be clamped making resuscitation more likely to be successful.
Remember that a casualty will be electrified until the power is isolated. After it is safe to do so, in all cases continue with DRABC. Of less importance is the likelihood of there being a burn at the points where the current entered and left the body.
The greatest risks to a burns victim are shock and infection. The site of a burn should be cooled and kept clean, which is best achieved by flooding with saline water, but normal clean water is effective. The full management for shock should be used.
Flood the eye with a gentle stream of clean water for at least 15 minutes, then cover both eyes and transport the casualty to medical aid. Ask the casualty if he is wearing contact lenses - if so have him remove them.
Remove the affected clothing, thoroughly rinse with clean water then thoroughly wash with soap and water (in the case of hydrofluoric acid contact, apply calcium gluconate gel) and transport to medical aid.
If conscious, have the casualty rinse his mouth with water, ensuring that none is swallowed. Use the management for shock, taking care not to inhale the casualty's breath, especially if resuscitation is required (always wash the casualty's mouth first and if possible use an oxy-viva or resuscitation mask).
If conscious, have the casualty rinse his mouth with water, ensuring that none is swallowed, then drink approximately 500ml of water (use 1% sodium thiosulphate for cyanide poisoning). If certain that the chemical is not corrosive to the digestive tract and the casualty is conscious, the casualty should be made to vomit. Children can be given syrup of IPECAC to induce vomiting but with adults (or in the case of cyanide poisoning) a finger down the throat is best.
Use the management for shock, taking care not to inhale the casualty's breath, especially if resuscitation is required (always wash the casualty's mouth first and if possible use an oxy-viva or resuscitation mask).
Use the management for shock.
Hyperventilation, also known as overbreathing, is usually a result of extreme anxiety and causes the carbon dioxide level in the blood to be greatly reduced which confuses the brain's breathing regulator. Hyperventilation is best managed by giving reassurance and instructing the casualty to slow their breathing down.
When the breathing has returned to normal, the casualty should be managed for shock.
The oxy-viva has three functions:
The resuscitation unit is used for forcing oxygen into a casualty, but will also supply oxygen on demand. A full cylinder on the oxy-viva will last approximately 15 minutes when performing resuscitation, and between 20 and 40 minutes when the resuscitation unit is used on demand.
Resuscitation with the oxy-viva is far more effective than expired air resuscitation because the casualty is receiving 100% oxygen instead of less than 16%. The same rates as used in EAR and CPR apply when using the oxy-viva.
It is possible to damage to the casualty's lungs by over-inflating them with the oxy-viva during resuscitation. Start with the flow control set lower than would seem appropriate (ie set at three quarters for an adult), and make adjustments if necessary. Watch the casualty's chest, once the chest has started to rise, enough oxygen has been forced in and the trigger should be released. If the chest does not rise, it is possible that the airway has not been properly opened and oxygen could be forced into the stomach.
The therapy mask on the oxy-viva supplies oxygen at a pre-set rate. The MK II supplies 5l per minute, which gives a maximum duration of 80 minutes, and the MK III supplies 8l per minute with a maximum duration of 50 minutes.
Where a casualty's condition allows, a half sitting position will make breathing easiest. This is especially useful for a casualty suffering from chest injuries or poisoning, but only when conscious.
The suction unit uses 50l per minute which, if used continuously, would exhaust a full cylinder in 9 minutes. Suction must only be performed with a suction catheter, which is only inserted as far as the back of the throat, and only for approximately three seconds.
Always return the cylinder valve handle to its holder after each opening or closing of the cylinder valve. This avoids any chance of it being lost.
The oxy-viva (and the therapy unit of any resuscitator) is not rated as suitable for irrespirable atmospheres.
Resuscitation with the BG174
It is always preferable to resuscitate with a resuscitator, however should one not be available, it is possible to ventilate with the BG174. If the casualty was already wearing a BG174, follow the procedure for removing him from the set up to the point of checking for breathing. Roll the casualty back onto his back and place the set flat on the ground to his left with the cover uppermost. Fit the facemask and remove the cover from the set. Use the manual bypass to fill the breathing bag then press on the breathing bag to empty it. Use the manual bypass to re-fill the breathing bag, ensure that the casualty's head is tilted back and press on the breathing bag with the palm of the hand to inflate the casualty's lungs while holding your thumb over the vent hole. Follow the normal rules of resuscitation.
Resuscitation with the BG4
It is always preferable to resuscitate with a resuscitator, however should one not be available, it is possible to ventilate with the BG4. If the casualty was already wearing a BG4, follow the procedure for removing him from the set up to the point of checking for breathing. Roll the casualty back onto his back and position the set above his head. Release the inhalation tube to empty the breathing bag then pinch the tube off again. Fit the facemask and remove the cover from the set. Use the manual bypass to fill the breathing bag, ensure that the casualty's head is tilted back and press on the pressure plate to inflate the casualty's lungs. Follow the normal rules of resuscitation.
Moving a Casualty
Whenever a casualty is to be moved, and bones (including the spine) are fractured or suspected as being fractured, the casualty should be kept as straight as possible and the fractures kept under slight tension.
To load a casualty into a stretcher, there should be six rescuers to perform the lift - an unconscious casualty must always be stretchered in as close to the coma position as possible however it will be necessary to place his arms by his sides and use cushions of some description to stabilise him. Before preparing to lift a casualty, it must be decided how the manoeuvre is to be performed, the stretcher must be prepared and all obstacles removed and a neck brace and figure of eight bandage should be applied. The first-aider should hold tension on the casualty's head and call the instructions. One rescuer should hold tension on the casualty's feet and there should be two each side with a firm grip on the casualty's clothing. When everybody is ready, the first-aider will give a warning for them to prepare to lift before calling to lift.
Every movement with a casualty should come after a warning and a command, even once the casualty is in a stretcher.
An effective means for ensuring that everybody starts lifting at the same time is to give a count of three before calling 'lift'. Everybody must start lifting at the same time and lift at the same rate to keep the casualty's body straight, and correct lifting techniques should be used by the rescuers to avoid back injuries to themselves.
Once the casualty has been lifted to waist height, the first-aider will either call for the stretcher to be slid under the casualty, or give a command to walk with the casualty to the stretcher.
When a casualty is being carried in a stretcher, the first-aider should stay by the casualty's head so that he can monitor his condition. A casualty's head should be kept lower than the rest of his body if possible, and if the stretcher is being carried on level ground it is preferable for the casualty to be carried feet first in case the rescuers stumble.
Responding to the Discovery of a Casualty
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