Field First Aid Key Learning Points: Assessing danger The first rule of first aid also applies anywhere. Becoming a casualty due to not assessing danger is common. Use all the senses to understand a situation. Keep looking for danger all around you. Effective hostile fire, no cover or concealment, cross-infection, leaking gas or fuel, downed electrical lines, hostile bystanders, unstable buildings and secondary incendiary devices at an improvised explosive device (IED) site are just some of the dangers in a conflict zone. Top Tip: Put gloves in your ruck sack, glove compartment, office and residence. Incident Management: Remember: Be SAFE S

Safety, security, sending for help

A

Assessment, what has happened?

F

Find casualties & free anyone trapped

E

Examine and treat in order of priority

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Check for DANGER C - Deal with catastrophic bleeding first. (See below for tourniquets and bleeding) R - Check for response by tapping both shoulders and speaking to casualty, ask them to open their eyes A – Airway, open the airway by tilting the head back and lifting the chin B – Breathing, look down the chest with an ear close to the casualty’s mouth. Look for the chest to rise and fall, listen for breath sounds and try to feel breath on your cheek C – Circulation- look for any further bleeding and for signs of life

If a casualty is not breathing, then cardiac compressions should begin.  With palms flat against each other and straight, locked arms, only the heel of the hand should be flat in the centre of the chest between the nipples. Push down and hard so the chest wall goes in 5 cms.  Press 30 times at a rate of 120 per minute. Or put more simply think of the beat to the Bee Gees “Stayin’ Alive” song and you will do it well. Next, if you are willing and able, do rescue breaths. For adults, we assume that when they collapsed, they had sufficient oxygen on board. For children, we assume the opposite and give rescue breaths first. This also applies to drowning situations, give rescue breaths first.  The head should be in position from opening the airway, but if not do a head tilt, chin lift again.  If you have a face-shield, use it. Put your lips round the casualty’s mouth making a seal and blow your breath into their mouth for two seconds, then lift your mouth away. You should be able to see the chest rise and fall. Repeat the breath again.  Then go straight back to compressions. If the casualty is breathing, in order to protect their airway from vomit or their tongue blocking it, you must turn them on their side (the recovery position). Incident management Confident, calm leadership of a team is essential. Assess the casualties one by one. Communicate with the rest of the team as to who should do what. Treat the most seriously injured first, not necessarily the ones making the most noise. Remember, if they are screaming, they are breathing. Set tasks for the team and continuously review the situation for danger as well as additional assistance that may be required. Communicate with emergency personnel if available. Let them know what help you need. You may not have all the information straight away. Tell them what you do know; who you are, who the accident has happened to, numbers of casualties, where you are, what has taken place, what help you need.

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Remember when explaining what you have done to medical personnel: MIST M

Mechanism of injury

I

Injury, number and type

S

Signs and symptoms

T

Treatment

Rapid trauma survey In a critical situation, quick decisions and actions can make the difference between life and death. The rapid trauma survey starts with assessing danger, stopping catastrophic bleeding if you arrive and that has not already been done by others, response, the airway, breathing, control of bleeding, followed by the sealing of a sucking chest wound, the stabilisation of a flail chest and/or impaled objects. Any injury that penetrates the skin between the neck and the umbilicus is considered a chest injury. All such injuries must have an occlusive (plastic) dressing put over them. If a casualty has suffered blunt trauma of the chest, they may have broken ribs. These do not move with the rest of the chest wall and are very painful. Use a pad and a high arm sling to stabilise the chest and stop the broken area from moving. Anything sticking out of a casualty must be left where it is and stabilised. Pulling it out could cause further damage and bleeding. Starting from the head, moving to the neck, the chest, the abdomen, the lower extremities and the upper extremities, assess the body for the following; Deformities, contusions, abrasions, puncture, perforations, burns, tenderness, lacerations and swelling. Remember that bleeding is the most common cause of hypovolaemic shock. Massive haemorrhage takes precedent over the airway. When to use a tourniquet: If catastrophic bleeding-put the tourniquet on immediately. That means ‘any gusher or fountain’. If you could control the bleeding but it is not safe to stop and do so, put the tourniquet on remembering that you need to take action as soon as it is safe. If the situation is less obvious, after exposing the wound, putting on a dressing, a pressure bandage, putting pressure on it manually, elevating it, using pressure points plus another bandage, if the bleeding cannot be stopped and the casualty must be moved because the location poses more danger than the evacuation, then a temporary tourniquet can be used. The decision to use it must be taken fast. If you do not have a standard tourniquet, use any scarf or material that is more than 80 cm long. It should be 5cm thick. Remember that it cannot be placed over a joint and that a pad should be placed underneath it. A tourniquet should remain bandaged but not covered (by a blanket or clothes). A ‘T’ should be written on the forehead and the time the tourniquet put on, written somewhere prominent. A tourniquet can remain in place for a maximum of two hours without causing serious complications and compromising the limb. But in fact, if you cannot control the Copyright Humanitrain 2012

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bleeding, leave the tourniquet in place-the surgeon will be the one to take it off. However, if you can control the bleeding and the tourniquet has only been on for fifteen minutes you can take it off with no adverse effect on the limb. Do not keep undoing and re-doing it up. Mechanisms of injury Understanding what has taken place (blast, fall, blunt or penetrating trauma, burns or gunshot) is key to treatment and evacuation in an appropriate and timely manner is key to the correct treatment. Mechanisms of injury relate to the amount of force, length of time force was applied and the areas of the body insulted. Conflict situation By ascertaining the type of weapon used, the distance from where the weapon was fired in relation to the casualty, it is possible to use this information as an indicator of the high or low probability of injuries to other parts of the body. Fractures Check for tenderness, instability and crepitus. Pain, loss of power, unatural movement, swelling and deformity are all signs of fractures. When checking the head, look for blood and secretions in the ear, nose or mouth. Check behind the ears for Battle’s sign ( a dark bruise behind the ears) which would indicate head trauma. Assess for cyanosis (blue lips, extremities). For black skinned casualtys, check the inside of their bottom lip. Inspect and palpate chest, listen for equal breath sounds. Check for entry or exit wound. Inspect pelvis, assess for stability, priapism (indicating spinal injury). When looking at extremities, check for a pulse, motor and sensory function. Have the casualty shake your hand, push you away. Ask if they feel you stroke the affected part. Do the exact same action in close proximity and ask if that feels the same. Remember that in spinal injury there can be temporary swelling that causes tingling or loss of sensation. Spinal Injury: While only 1.4% of conflict injuries involve the spine, road traffic accidents, bomb blasts, head trauma, any deceleration trauma, falls and assault can cause spinal injury. The neck must be immobilised well and immediately. Unless there is a very good reason, such as severe bleeding, it is much better not to move anyone you suspect of spinal injury. If you MUST move them, the casualty should be log-rolled so their neck and back are in a straight line. If evacuated, it must be on a hard board, well strapped down for transfer. Remember, you can always keep the head still if the casualty is lying down, by using your knees either side of the cheeks for stability. If they are sitting, in a vehicle for example, you can hold their head tightly and explain what you are doing whilst someone else gets some material to stabilise their head and spine. If you can avoid moving anyone you suspect with a spinal injury-the better. Remember that unless their life in in danger, you should not move them.

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Evacuation It is essential that a proper assessment by qualified medical personnel is made as soon as possible. Reassurance and making the casualty as comfortable as possible is key to maintaining their status. If you are able to make radio contact with the medic, do so and describe the casualty’s condition. If you are able to position them well, this can aid pain relief. If you are permitted to give oral fluids, give oral rehydration solution (1 litre of clean water and 8 spoons of sugar and a good pinch of salt). Make sure that the casualty is accompanied, has their travel documents, insurance information and next of kin contact numbers. Ensure that everyone who needs to know the status of the casualty is informed. Quick Actions: Bleeding: Your aim is to STOP THE BLEEDING Remember: S sit or lay the casualty down E examine the wound very quickly E elevate the wound P pressure on the wound Remember: If the wound bleeds through the first dressing, keep the pressure on and apply another one tightly around the area. Do not remove the first one. Put on 3-4 dressings if necessary.

Indirect pressure points

If the bleeding does not come into the category of a ‘gusher or fountain’, but the bleeding will not stop, indirect pressure points can be pressed by the casualty or responder. For injuries to the arm, have the casualty make a fist on the uninjured side and place this under the arm pit of the injured side, pulling their arm across sufficiently to put pressure into the arm pit. For injuries to the leg, go to the groin of the affected side, use your foot, knee or fist to put pressure on the femoral artery, in the groin. For an amputation:

Stop bleeding       

Apply dressing Elevate Tourniquet if needed Rinse amputated part Wrap in saline gauze Put in plastic bag Keep cool

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Use a tourniquet if:  IF bleeding is massive (flowing blood, pumping artery ‘gusher/fountain’) not controlled with pressure  IF casualty must be moved  IF combat situation - under fire or in other danger How to put a tourniquet on: Quick decision- seconds       

5 cms width of cloth or a belt 5 cms uninjured skin NOT over a joint Pad underneath, then tie belt or strap around affected limb Square knot Wood stick and twist inside knot Extra bandage ‘T’ on forehead and write the time that you put the tourniquet on

Fractures  Stabilise  Any fracture below the elbow use a low arm sling  Any fracture above the elbow, including the collar bone, the humerous or a dislocation of the collar bone use a high arm sling  For a leg fracture, stabilise with a splint on both sides of the broken leg, or use the good leg as splint.  Keep shoes or boots on as the feet tied together is more stable.  Remember to pad between the knees and the elbows and any area where the splint comes into contact with the leg. Burns The following will impact on the severity of a burn; Size - the bigger the worse it is Cause - fat is worse than vapour for example as the tissue ‘cooks’ Age - elderly and babies cannot cope with fluid loss or infection well Location - face, hands, joints, genitals fare worse Depth (1st, 2nd, 3rd degree) that is blistering, partial thickness and full thickness To estimate the size of a burn, imagine that your hand represents 1% of the casualty’s body. Put your hand over the burnt are, not touching it to estimate the size of the burn.

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Action Cool with cool water for 10-15 minutes Remove any constricting clothes or jewellery Dress with cling film or damp cloth, cover with a plastic bag and immediate evacuation It is vital to stop the burn from getting worse to:       

Cool/irrigate burn Protect the burn Hydrate the casualty Keep casualty warm If arm or leg, put a bag over Soak with clean water if changing dressing Rest & immediate evacuation

It is vital for anyone who has breathed in hot air or fumes to be evacuated as a medical emergency as swelling of the airway does not always manifest itself straight away. Look inside their mouth, there may be soot-like particles. Even if you don’t see that, you must evacuate them straight away as they may need support to keep their airway

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