Thursday, August 20, 2020

FIRST AID MANUAL

 REVISED

10TH EDITION

FIRST AID MANUAL

WRITTEN AND AUTHORISED BY THE  UK’S LEADING FIRST AID PROVIDERS


The Authorised Manual of St John Ambulance,

St Andrew’s First Aid and the British Red Cross

St John Ambulance

Dr Margaret Austin DStJ LRCPI LRCSI LM

Chief Medical Adviser

St Andrew’s First Aid

Mr Rudy Crawford MBE BSc (Hons) MB ChB FRCS (Glasg) FRCEM

Chairman of the Board

British Red Cross

Dr Barry Klaassen BSc (Hons) MB ChB FRCS (Edin) FRCEM

Chief Medical Adviser

REVISED

10TH EDITION

LONDON, NEW YORK, MUNICH, MELBOURNE, DELHI

Consultant editor

Jemima Dunne

Senior editor

Janet Mohun

Jacket editor

Claire Gell

Producer, pre-production

Jacqueline Street

Managing editor

Angeles Gavira Guerrero

Publisher

Liz Wheeler

Publishing director

Jonathan Metcalf

Project art editor

Duncan Turner

Jacket designer

Duncan Turner

Producer

Rita Sinha

Photography

Gerard Brown,

Vanessa Davies,

Ruth Jenkinson

Jacket design development manager

Sophia MTT

Managing art editor

Michael Duffy

Art director

Karen Self

DORLING KINDERSLEY

Text revised in line with the latest guidelines from the Resuscitation Council (UK).

Note: The masculine pronoun “he” is used when referring to the first aider or casualty, unless the individual shown

in the photograph is female. This is for convenience and clarity and does not reflect a preference for either sex.

Revised 10th edition first published in Great Britain in 2016 by

Dorling Kindersley Limited, 80 Strand, London WC2R 0RL

A Penguin Random House Company

2 4 6 8 10 9 7 5 3 1

001 –289239–July/2016

Text copyright © 2016 St John Ambulance;

St Andrew’s First Aid; The British Red Cross Society

Illustration copyright © 2016 Dorling Kindersley Limited, except as listed in acknowledgments on p.288

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted

in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior

written permission of the copyright owners.

All enquiries regarding any extracts or re-use of any material in this book should be addressed

to the publishers, Dorling Kindersley Limited. A CIP catalogue record for this book is available from the British Library

ISBN: 978-0-2412-4123-3

Printed and bound in Slovakia

Discover more at

www.dk.com

St John Ambulance is a registered charity (No. 1077265/1); St Andrew’s First Aid is the trading name of St Andrew’s Ambulance

Association, incorporated by Royal Charter 1899, is a charity registered in Scotland (No. SC006750); The British Red Cross Society,

incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949), Scotland (SC037738), and the Isle of Man

(0752). Each charity receives a royalty for every copy of the book sold by Dorling Kindersley. Details of the royalties payable can be

obtained by writing to the publishers, Dorling Kindersley Limited, at 80 Strand, London WC2R 0RL. For the purposes of the Charities

Acts no further seller of this book shall be deemed to be a commercial participator with these three Societies.

THE FIRST AID SOCIETIES

Drawing on hundreds of years of combined experience, the First Aid Societies are the

acknowledged experts in training and practising first aid. Each society offers distinct charitable,

voluntary and training services, but all work together to raise standards in first aid. Our medical

advisers have based the advice in this book on the most up-to-date research, and our training

experts have presented it in a way that is both easy to learn and easy to recall.

ST JOHN AMBULANCE

As the nation’s leading first aid charity, St John

Ambulance believes that no one should die

because they needed first aid and did not get it.

This is why we teach people first aid (in schools,

workplaces and the community), equipping

them with the skills to be the difference

between life and death. Some of the people we

teach go on to become one of our 40,000

volunteers, providing first aid at events, acting

as first responders to NHS emergency calls in

the community, or supporting their local

ambulance service.

You too can be the difference between a life

lost and a life saved. To find out how, visit

sja.org.uk, or call 08700 10 49 50

ST ANDREW’S FIRST AID

St Andrew’s First Aid is Scotland’s dedicated

first aid charity and provider of first aid training,

services and supplies. Our volunteers provide

essential first aid services in communities

across Scotland, including cover for events large

and small, and teach life-saving skills to others.

We also supply a full range of first aid products

and training materials to first aid professionals,

industry and the general public.

■■ Visit www.firstaid.org.uk

■■Email info@firstaid.org.uk

■■Call 0141 332 4031

BRITISH RED CROSS

As part of the world’s largest provider of first

aid, the British Red Cross trains tens of

thousands of people in the UK every year,

building resilience within communities and

preparing them to cope with all types of

emergencies. Our courses provide training for

every need, including treatment for adult, child

and baby and first aid at work. Through our

global network of volunteers we also provide

first aid cover at public events, respond to

natural disasters conflicts and individual

emergencies.

■■The British Red Cross – refusing to ignore

people in crisis

■■For more information and to learn about first

aid, visit:

redcross.co.uk/firstaid

or call us to book a course on 0344 412 2808

CONTENTS

What is a first aider? ________________________________________ 14

How to prepare yourself ___________________________________ 15

Protection from infection ________________________________ 16

Dealing with a casualty ____________________________________ 19

Requesting help ________________________________________________ 22

The use of medication ______________________________________ 24

Remember your own needs _____________________________ 24

26

Assessing the sick or injured __________________________ 40

Mechanisms of injury _____________________________________ 42

Primary survey ________________________________________________ 44

Secondary survey ___________________________________________ 46

Head-to-toe examination _______________________________ 49

Monitoring vital signs _____________________________________ 52

38

54

Breathing and circulation ________________________________ 56

Life-saving priorities ________________________________________ 57

Unresponsive adult _________________________________________ 62

Unresponsive child __________________________________________ 72

Unresponsive infant _______________________________________ 80

How to use an AED __________________________________________ 84

88

The respiratory system ___________________________________ 90

Hypoxia ____________________________________________________________ 92

Airway obstruction __________________________________________ 93

Choking adult __________________________________________________ 94

Choking child ___________________________________________________ 95

Choking infant ________________________________________________ 96

Hanging and strangulation _____________________________ 97

Inhalation of fumes _________________________________________ 98

10

Action at an emergency ___________________________________ 28

Traffic incidents _______________________________________________30

Fires __________________________________________________________________ 32

Electrical incidents ___________________________________________ 34

Water incidents _______________________________________________ 36

Major incidents ________________________________________________ 37 RESPIRATORY

PROBLEMS

MANAGING AN

INCIDENT

BECOMING A

FIRST AIDER

ASSESSING

A CASUALTY

INTRODUCTION

THE UNRESPONSIVE

CASUALTY

12

Drowning _______________________________________________________100

Hyperventilation ___________________________________________ 101

Asthma ___________________________________________________________ 102

Croup ______________________________________________________________ 103

Penetrating chest wound ______________________________ 104

106

The heart and blood vessels __________________________ 108

Bleeding and types of wound ________________________ 110

Shock _______________________________________________________________ 112

Severe external bleeding ________________________________ 114

Internal bleeding ____________________________________________ 116

Impalement _____________________________________________________ 117

Amputation _____________________________________________________ 117

Crush injury _____________________________________________________ 118

Cuts and grazes _______________________________________________ 119

Bruising ___________________________________________________________ 119

Blisters ___________________________________________________________ 120

Infected wound ______________________________________________ 120

Foreign object in a wound ______________________________ 121

Scalp and head wounds __________________________________122

Eye wound _______________________________________________________123

Bleeding from the ear _____________________________________123

Nosebleed _______________________________________________________124

Knocked-out adult tooth _______________________________ 125

Bleeding from the mouth _______________________________ 125

Finger wound __________________________________________________126

Wound to the palm ________________________________________ 127

Wound at a joint crease _________________________________ 127

Abdominal wound ___________________________________________128

Vaginal bleeding ______________________________________________128

Bleeding varicose vein ____________________________________129

130

The skeleton __________________________________________________ 132

Bones, muscles and joints _______________________________134

Fractures ________________________________________________________ 136

Dislocated joint _____________________________________________ 139

Strains and Sprains ________________________________________ 140

The brain and nerves ______________________________________142

Head injury ______________________________________________________144

Facial injury _____________________________________________________146

Lower jaw injury ______________________________________________147

Cheekbone and nose injury ____________________________147

Collar bone injury ____________________________________________148

Shoulder injury ________________________________________________149

Upper arm injury ____________________________________________150

Elbow injury ______________________________________________________151

Forearm and wrist injuries _____________________________ 152

Hand and finger injuries _________________________________ 153

Rib injury __________________________________________________________154

Pelvic injury______________________________________________________ 155

Back pain ________________________________________________________ 156

Spinal injury ____________________________________________________ 157

Hip and thigh injuries ____________________________________ 160

Lower leg injuries __________________________________________ 162

Knee injury ______________________________________________________ 164

BONE, JOINT

WOUNDS AND MUSCLE INJURIES

AND BLEEDING

MEDICAL

CONDITIONS 208

Foreign object in the eye ________________________________196

Foreign object in the ear _________________________________197

Foreign object in the nose ______________________________197

How poisons affect the body __________________________198

Types of poison _______________________________________________199

Swallowed poisons _______________________________________ 200

Drug poisoning ______________________________________________ 201

Alcohol poisoning _________________________________________ 202

Animal and human bites ______________________________ 203

Insect sting ____________________________________________________ 204

Tick bite _________________________________________________________ 205

Other bites and stings __________________________________ 205

Snake bite ______________________________________________________ 206

Stings from sea creatures _____________________________ 207

Marine puncture wound _______________________________ 207

Angina ____________________________________________________________ 210

Heart attack ____________________________________________________ 211

Stroke _____________________________________________________________ 212

Diabetes mellitus ___________________________________________ 214

Hyperglycaemia _____________________________________________ 214

Hypoglycaemia ______________________________________________ 215

Seizures in adults ___________________________________________ 216

Seizures in children ________________________________________ 218

Fever _______________________________________________________________ 219

Meningitis _____________________________________________________ 220

The skin __________________________________________________________ 170

Assessing a burn ____________________________________________ 172

Severe burns and scalds ________________________________ 174

Minor burns and scalds _________________________________ 176

Burns to the airway _________________________________________ 177

Electrical burn _________________________________________________ 178

Chemical burn _______________________________________________ 179

Chemical burn to the eye ______________________________ 180

Flash burn to the eye ______________________________________ 181

Incapacitant spray exposure __________________________ 181

Dehydration ___________________________________________________ 182

Sunburn __________________________________________________________ 183

Heat exhaustion _____________________________________________ 184

Heatstroke ______________________________________________________ 185

Hypothermia __________________________________________________ 186

Frostbite _________________________________________________________ 189

The sensory organs _________________________________________192

Splinter ____________________________________________________________194

Embedded fish-hook ______________________________________ 195

Swallowed foreign object ______________________________ 195

Ankle injury ____________________________________________________ 165

Foot and toe injuries ______________________________________166

Cramp ____________________________________________________________ 167

168

190

EFFECTS OF

HEAT AND COLD

FOREIGN OBJECTS,

POISONING, BITES & STINGS

Fainting __________________________________________________________ 221

Allergy ____________________________________________________________ 222

Anaphylactic shock ________________________________________ 223

Headache _______________________________________________________ 224

Migraine _________________________________________________________ 224

Sore throat _____________________________________________________ 225

Earache and toothache __________________________________ 225

Abdominal pain _____________________________________________ 226

Vomiting and diarrhoea _________________________________ 227

Childbirth _______________________________________________________ 228

Emergency childbirth _____________________________________ 229

Removing clothing _________________________________________ 232

Removing headgear _______________________________________ 233

Casualty handling __________________________________________ 234

First aid materials __________________________________________ 235

Dressings ________________________________________________________ 238

Cold compresses ____________________________________________ 241

Principles of bandaging _________________________________ 242

Roller bandages ____________________________________________ 244

Tubular gauze bandages ________________________________ 248

Triangular bandages _______________________________________249

Reef knots ______________________________________________________250

Hand and foot cover bandage _______________________250

Arm sling _________________________________________________________ 251

Elevation sling ________________________________________________ 252

Improvised slings ___________________________________________ 253

Action in an emergency ________________________________ 256

CPR for an adult _____________________________________________ 258

Chest-compression-only CPR ________________________ 258

CPR for a child ______________________________________________ 260

CPR for an infant ___________________________________________ 260

Heart attack __________________________________________________ 262

Stroke _____________________________________________________________ 262

Choking adult _______________________________________________ 264

Choking child ________________________________________________ 264

Choking infant ______________________________________________ 266

Meningitis _____________________________________________________ 266

Asthma ___________________________________________________________ 268

Anaphylactic shock ________________________________________ 268

Severe external bleeding ______________________________ 270

Shock _____________________________________________________________ 270

Head injury _____________________________________________________ 272

Spinal injury ____________________________________________________ 272

Broken bones _________________________________________________ 274

Burns and scalds ____________________________________________ 274

Seizures in adults ___________________________________________ 276

Seizures in children ________________________________________ 276

Swallowed poisons _________________________________________ 278

Hypoglycaemia ______________________________________________ 278

First aid regulations _________________________________ 280

Index ________________________________________________________ 282

Acknowledgments ____________________________________288

TECHNIQUES

AND EQUIPMENT

EMERGENCY

FIRST AID

230

254

10

INTRODUCTION

HOW TO USE THIS BOOK

This publication, now in its revised 10th

edition, is the authorised manual of the First

Aid Societies – St John Ambulance, St Andrew’s

First Aid and the British Red Cross. Together,

they have endeavoured to ensure that this

manual reflects the relevant guidance from

informed authoritative sources, current at the

time of publication. While the material

contained here provides guidance on initial care

and treatment, it must not be regarded as a

substitute for medical advice.

The First Aid Societies do not accept

responsibility for any claims arising from the

use of this manual when the guidelines have

not been followed. First aiders are advised to

keep up-to-date with developments, to

recognise the limits of their competence and to

obtain first-aid training from a qualified trainer.

The first three chapters provide background

information to help you examine your role as a

first aider, manage a situation safely and learn

how to assess a sick or injured person

effectively. Treatment for injuries and conditions

is given in specific chapters that follow. Lifesaving

treatment for an unresponsive casualty

has an entire chapter. In other chapters, injuries

and conditions are grouped either by body

system, for example Respiratory Problems or by

the type of injury, such as Wounds and Bleeding

and Effects of Heat and Cold.

The chapters are grouped by body system or

cause of injury. Within the chapters there are

easy-to-understand anatomy features that

explain the risks involved with particular

injuries or conditions and how and why first

aid can help.

ANATOMY

INTRODUCTION

Colour-coded chapters

help you find relevant

sections easily

Introduction gives an

overview of the anatomy

for the section

Clear computer-generated

artworks of body systems

illustrate essential anatomy

Additional artworks

provide extra information

108 109

the heart and blood vessels

key

key

The heart and the blood vessels make up the

circulatory system. These structures supply the

body with a constant flow of blood, which

brings oxygen and nutrients to the tissues and

carries waste products away.

Blood is pumped around the body by

rhythmic contractions (beats) of the heart

muscle. The blood runs through a network

of vessels, divided into three types: arteries,

veins and capillaries. The force that is exerted

by the blood flow through the main arteries

is called blood pressure. The pressure varies

with the strength and phase of the

heartbeat, the elasticity of the arterial

walls and the volume and thickness

of the blood.

The heart pumps blood by muscular

contractions called heartbeats, which are

controlled by electrical impulses generated

in the heart. Each beat has three phases:

diastole, when the blood enters the heart; atrial

systole, when it is squeezed out of the atria

(collecting chambers); and ventricular systole,

when blood leaves the heart.

In diastole, the heart relaxes. Oxygenated

blood from the lungs flows via the pulmonary

veins into the left atrium. Blood that has given

up its oxygen to body tissues (deoxygenated

blood) flows from the venae cavae (large veins

that enter the heart) into the right atrium.

In atrial systole, the two atria contract and the

valves between the atria and the ventricles

(pumping chambers) open so that blood flows

into the ventricles.

During ventricular systole, the ventricles

contract. The thick-walled left ventricle forces

blood into the aorta (main artery), which carries

it to the rest of the body. The right ventricle

pumps blood into the pulmonary arteries, which

carry it to he lungs to collect more oxygen.

how the heart functions

wounds and bleeding the heart and blood vessels

How blood circulates

Oxygenated blood passes

from the lungs to the heart,

then travels to body tissues via the

arteries. Blood that has given up its

oxygen (deoxygenated blood) returns

to the heart through the veins.

Capillary networks

A network of fine blood vessels

(capillaries) links arteries and veins within

body tissues. Oxygen and nutrients pass

from the blood into the tissues; waste

products pass from the tissues into the

blood, through capillaries. The heart

This muscular organ pumps blood

around the body and then to the

lungs to pick up oxygen. Coronary

blood vessels supply the heart

muscle with oxygen and nutrients.

Carotid artery

Brachial vein

Jugular vein

Aorta

Heart

muscle

Superior

vena cava

Coronary

artery

Inferior

vena cava

Capillary

Small artery

(arteriole)

Small vein

(venule)

Radial vein

Femoral vein

Pulmonary arteries carry

deoxygenated blood to

lungs

Pulmonary veins carry

oxygenated blood from

lungs to heart

Heart pumps blood

around body

Vena cava carries

deoxygenated blood from

body tissues to heart

Brachial artery

Radial artery

Femoral artery

Aorta carries oxygenated

blood to body tissues

Pulmonary

artery

Blood flow through the heart

The heart’s right side pumps deoxygenated blood from

the body to the lungs. The left side pumps oxygenated

blood to the body via the aorta.

The blood cells

Red blood cells contain haemoglobin,

a red pigment that enables the cells

to carry oxygen. White blood cells

play a role in defending the body

against infection. Platelets help

blood to clot.

Right atrium

Right ventricle

Valve

Left

ventricle

White blood cell

Platelet

Left atrium

Ascending aorta carries

blood to upper body

Superior vena

cava carries

blood from

upper body

Inferior vena

cava carries

blood from

lower body

Descending aorta carries

blood to lower body

Pulmonary arteries

carry deoxygenated

blood to lungs

Red blood cell

There are about 6 litres (6 pints), or 1 litre per

13kg of body weight (1 pint per stone), of blood

in the average adult body. Roughly 55 per cent

of the blood is clear yellow fluid (plasma). In this

fluid are suspended the red and white blood

cells and the platelets, all of which make up

the remaining 45 per cent.

composition of blood

Vessels carrying oxygenated blood

Vessels carrying oxygenated blood

Vessels carrying deoxygenated blood

Vessels carrying deoxygenated blood

11

176 177

EFFECTS OF HEAT AND COLD MINOR BURNS AND SCALDS | BURNS TO THE AIRWAY

MINOR BURNS AND SCALDS BURNS TO THE AIRWAY

SEE ALSO Hypoxia p.92 | Shock pp.112–13 | The unresponsive casualty pp.54–87

■■ Reddened skin

■■ Pain in the area of the burn

Later there may be:

■■ Blistering of the affected skin

There may be:

■■ Soot around the nose or mouth

■■ Singeing of the nasal hairs

■■ Redness, swelling or actual burning

of the tongue

■■ Damage to the skin around the

mouth

■■ Hoarseness of the voice

■■ Breathing difficulties

■■ To stop the burning

■■ To relieve pain and swelling

■■ To minimise the risk of infection

■■ To maintain an open airway

■■ To arrange urgent removal

to hospital

RECOGNITION

RECOGNITION

YOUR AIMS

YOUR AIMS

Small, superficial burns and scalds are often due to domestic

incidents, such as touching a hot iron or oven shelf. Most minor

burns can be treated successfully by first aid and will heal

naturally. However, you should advise the casualty to seek

medical advice if you are at all concerned about the severity

of the injury (Assessing a burn, pp.172–73).

After a burn, blisters may form. These thin “bubbles”

are caused by tissue fluid leaking into the burnt area just

beneath the skin’s surface. You should never break a blister

caused by a burn because you risk introducing infection

into the wound. WHAT TO DO

WHAT TO DO

Call 999/112 for emergency help. Tell ambulance control that

you suspect burns to the casualty’s airway.

Flood the injured part

with cold water for at least

ten minutes or until the pain is

relieved. If there is no water

available, any cold, harmless

liquid, such as milk or canned

drinks, can be used.

Reassure the casualty. Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while waiting for

emergency help to arrive.

Seek medical advice if the

casualty is a child, or if you

are in any doubt about the

casualty’s condition.

Take any steps possible to improve the casualty’s air supply, such

as loosening clothing around his neck.

Gently remove any

jewellery, watches, belts

or constricting clothing from

the injured area before it begins

to swell.

Offer the casualty ice or small sips of cold water to reduce

swelling and pain.

When the burn is cooled,

cover it with kitchen film or

place a clean plastic bag over a

foot or hand. Apply the kitchen

film lengthways over the burn,

not around the limb because the

tissues swell. If you do not have

kitchen film or a plastic bag, use a

sterile dressing or a non-fluffy pad,

and bandage loosely in place.

4

4

2

2

1

1

3

3

Any burn to the face, mouth or throat is very serious because

the air passages rapidly become swollen. Usually, signs of

burning will be evident. Always suspect damage to the airway if

a casualty sustains burns in a confined space since he is likely to

have inhaled hot air or gases.

There is no specific first aid treatment for an extreme case of

burns to the airway; the swelling will rapidly block the airway,

and there is a serious risk of hypoxia. Immediate and specialised

medical help is required.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

■■ Do not break blisters or

otherwise interfere with the

injured area.

■■ Do not apply adhesive dressings

or adhesive tape to the skin;

removing them may tear

damaged skin.

■■ Do not apply ointments or fats;

they may damage tissues and

increase the risk of infection.

■■ The use of specialised dressings,

sprays and gels to cool burns is

not recommended.

■■ Do not put blister plasters on

blisters caused by a burn.

CAUTION CAUTION

Never burst a blister; they

usually need no treatment.

However, if a blister breaks or

is likely to burst, cover it with

a non-adhesive sterile dressing

that extends well beyond the

edges of the blister. Leave

the dressing in place until

the blister subsides.

SPECIAL CASE BLISTERS

SEE ALSO Assessing a burn pp.172–73

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INTRODUCTION | HOW TO USE THIS BOOK

The main part of the book features seven

colour-coded chapters that outline first aid for

over 110 conditions or injuries. For each entry

there is an introduction that describes the risks

and the likely cause, then first aid treatment is

shown in clear step-by-step instructions.

At the back of the manual is a quick-reference

emergency section. This provides additional

at-a-glance action plans summarising treatment

for potentially life-threatening injuries and

conditions ranging from unresponsiveness and

bleeding to asthma and heart attack.

CONDITIONS AND INJURIES

EMERGENCY ADVICE

Special Case boxes highlight

instances where alternative

action may be required

Step-by-step instructions

explain each stage of treatment

Introductory text describes

background and effects of

each condition

Lists of recognition features

help you identify a condition

Your Aims boxes summarise

purpose of first aid

See also references direct

you to related conditions

Recognition lists repeated to

provide quick identification

of a condition

Cross references guide you

back to the main article in

the book

Every step described is

illustrated for instant advice

Caution boxes advise on

possible complications

274 275

EMERGENCY FIRST AID

BROKEN BONES

BURNS AND SCALDS

Help the casualty to support the

affected part at the joints above

and below the injury, in the most

comfortable position.

Immediately flood the injury

with cold water; cool for at least

ten minutes or until pain is

relieved. Make the casualty

comfortable by helping him to

sit or lie down and protect the

injured area from contact with

the ground.

Place padding, such as towels or

cushions, around the affected

part, and support it in a

comfortable position.

Call 999/112 for emergency help

if necessary. Tell ambulance

control that the injury is a burn

and explain what caused it, and

the estimated size and depth.

For extra support or if help is

delayed, secure the injured part to

an uninjured part of the body. For

upper body injuries, use a sling;

for lower limb injuries, use broadand

narrow-fold bandages. Tie

knots on the uninjured side.

While you are cooling the burn,

carefully remove any clothing or

jewellery from the area before it

starts to swell; a helper can do this

for you. Do not remove anything

that is sticking to the burn.

A casualty with an arm injury

could be taken by car if not in

shock; a leg injury should go by

ambulance, so call 999/112 for

emergency help. Treat for shock.

Monitor and record the casualty’s

breathing, pulse and level of

response while waiting for help.

When cooled cover the burn with

kitchen film placed lengthways

over the injury, or use a plastic

bag. Alternatively, use a sterile

dressing or clean, non-fluffy pad.

Monitor and record the casualty’s

vital signs while waiting for help

to arrive.

SUPPORT

INJURED PART

START TO COOL

BURN

PROTECT INJURY

WITH PADDING

CALL FOR

EMERGENCY

HELP

SUPPORT WITH

SLINGS OR

BANDAGES

REMOVE ANY

CONSTRICTIONS

TAKE OR SEND

CASUALTY TO

HOSPITAL

COVER BURN

FIND OUT MORE pp.136–38

FIND OUT MORE pp.174–75

4

4

3

3

2

2

1

1

BROKEN BONES | BURNS AND SCALDS

■■ Do not attempt to move an injured

limb unnecessarily, or if it causes

further pain.

■■ If there is an open wound, cover

it with a sterile dressing or a

clean, non-fluffy pad and bandage

it in place.

■■ Do not give the casualty anything

to eat or drink as an anaesthetic

may be needed.

■■ Do not raise a broken leg when

treating a casualty for shock.

■■ Do not apply lotions, ointment or

fat to a burn; specialised burn

dressings are also not

recommended.

■■ Do not use adhesive dressings.

■■ Do not touch the burn or burst

any blisters.

■■ If the burn is severe, treat the

casualty for shock (pp.270–71).

■■ If the burn is on the face, do not

cover it. Keep cooling with water

until help arrives.

■■ If the burn is caused by contact

with chemicals, wear protective

gloves and cool for at least

20 minutes.

■■Watch the casualty for signs of

smoke inhalation, such as difficulty

breathing.

CAUTION

CAUTION

■■ Deformity, swelling and bruising

at the injury site

■■ Pain and difficulty in moving the

injured part

There may be:

■■ Bending, twisting or shortening of

a limb

■■ A wound, possibly with bone ends

protruding

There may be:

■■ Possible areas of superficial, partialthickness

and/or full-thickness burns

■■ Pain in the area of the burn

■■ Breathing difficulties if the airway

is affected

■■ Swelling and blistering of the skin

■■ Signs of shock

RECOGNITION

RECOGNITION

274-275_Emergency_First_Aid.indd All Pages 09/03/2016 11:24

Caution boxes alert you to

potential risks or alternative

treatments

First aid is the initial assistance or

treatment given to a person who

is injured or taken ill. The person

who provides this help is a first aider.

This chapter prepares you for being a first

aider, psychologically and emotionally, as

well as giving practical advice on what you

should and should not do in an emergency.

The information provided throughout

this book will help you to provide effective

first aid to any casualty in any situation.

However, to become a fully competent first

aider, you should complete a recognised

first aid learning programme. Completing

this will strengthen your skills and increase

your confidence. St John Ambulance,

St Andrew’s First Aid and the British Red

Cross are all able to provide first aid

education tailored to your needs.

■■ To understand your own abilities and limitations

■■ To stay safe and calm at all times

■■ To assess a situation quickly and calmly and summon

help if necessary

■■ To assist the casualty and provide the necessary

treatment, with the help of others if possible

■■ To pass on relevant information to the emergency

services, or the person who takes responsibility for

the casualty

■■ To be aware of your own needs

AIMS AND OBJECTIVES

BECOMING A

FIRST AIDER

14

BECOMING A FIRST AIDER

WHAT IS A FIRST AIDER?

First aid refers to the actions taken in response

to someone who is injured or taken ill. A first

aider is a person who takes this action while

taking care to keep everyone involved safe

(p.28) and to cause no further harm while doing

so. Using the guidelines set out in this book, you

should take actions that most benefit the

casualty. Always take into account your own

skills, knowledge and experience.

This chapter prepares you for the role of first

aider by providing guidance on responding to

a first aid situation and assessing the priorities

for the casualty. There is advice on the

psychological aspect of giving first aid and

practical guidance on how to protect yourself

and a casualty. Chapter 2, Managing an Incident

(pp.26–37), provides guidelines on dealing with

events such as traffic or water incidents or

fires. Chapter 3, Assessing a Casualty

(pp.38–53), looks at the practical steps to

take when assessing a sick or injured person.

One of the primary rules of first aid is to

ensure that an area is safe for you before you

approach a casualty (p.28). Do not attempt

heroic rescues in hazardous circumstances.

If you put yourself at risk, you are unlikely

to be able to help others and you could

become a casualty. If it is not safe, do not

approach the casualty, but call 999/112 for

emergency help.

■ Assess a situation quickly and calmly.

■ Protect yourself and any casualties from

danger – never put yourself at risk (p.28).

■ Prevent cross infection between yourself and

the casualty as far as possible (p.16).

■ Comfort and reassure casualties at all times.

■ Assess the casualty: identify, as far as you

can, the injury or nature of illness affecting a

casualty (pp.38–53).

■ Give early treatment, and treat the casualties

with the most serious (life-threatening)

conditions first.

■ Arrange for appropriate help: call 999/112

for emergency help if you suspect serious

injury or illness; in England, call 111 for a less

serious condition; take or send the casualty to

hospital; seek medical advice, or take him

home. Stay with the casualty until the right

care is available.

FIRST AID PRIORITIES

Assessing an incident

When you come across an incident stay calm and

support the casualty. Ask him what has happened.

Try not to move the casualty; if possible, treat him

in the position you find him.

15

WHAT IS A FIRST AIDER? | HOW TO PREPARE YOURSELF

HOW TO PREPARE YOURSELF

When responding to an emergency it is

important to recognise both the emotional

and physical needs of all involved, including

your own. You should look after your own

psychological health and be able to identify

stress if it develops (pp.24–25).

A calm, considerate response from you that

facilitates trust and respect from those around

you is fundamental to you being able to give

or receive information from a casualty or

witnesses effectively. This includes being aware

of, and managing, your reactions, so that you

can focus on the casualty and make an

assessment. By talking to a casualty in a kind,

considerate, gentle but firm manner, you will

inspire confidence in your actions and this will

generate trust between you and the casualty.

Without this confidence he may not be able to

tell you about an important event, injury or

symptom, and he may remain in a highly

distressed state.

The actions described in this chapter aim to

help you facilitate this trust, minimise distress

and provide support to promote the casualty’s

ability to cope and recover. The key steps to

being an effective first aider are:

■ Be calm in your approach

■ Be aware of risks (to yourself and others)

■ Build and maintain trust (from the casualty

and the bystanders)

■ Give early treatment, treating the most

serious (life-threatening) conditions first

■ Call appropriate help

■ Remember your own needs

It is important to be calm in your approach.

Consider what situations might challenge you,

and how you would deal with them. In order

to convey confidence to others and encourage

them to trust you, you need to control your

emotions and reactions.

People often fear the unknown. Becoming

more familiar with first aid priorities and the

key techniques in this book can help you feel

more comfortable. By identifying your fears in

advance, you can take steps to overcome them.

Find out as much as you can, for example, by

completing a first aid learning programme with

one of the Societies. For additional reassurance,

talk to other people about how they dealt with

similar situations or talk through your fears with

a person you trust.

STAY IN CONTROL

In an emergency situation, the body responds by

releasing hormones that may cause a “fight,

flight or freeze” response. When this happens,

your heart beats faster, your breathing quickens

and you may sweat more. You may also feel

more alert, want to run away or feel frozen

to the spot.

If you feel overwhelmed and slightly panicky,

you may feel pressured to do something before

you are clear about what is needed. Pause and

take a few slow breaths. Consider who else

might help you feel calmer, and remind yourself

of the first aid priorities (opposite). If you still

feel overwhelmed, take another breath and say

to yourself “be calmer” as a cue. When you are

calm, you will be better able to think more

clearly and plan your response.

The thoughts you have are linked to the

way you behave and the way you feel. If you

think that you cannot cope, you will have more

trouble working out what to do and will feel

more anxious: more ready to fight, flee or

freeze. If you know how to calm yourself, you

will be better able to deal with your anxiety and

so help the casualty.

BE CALM

16

BECOMING A FIRST AIDER

PROTECTION FROM INFECTION

When you give first aid, it is important to

protect yourself (and the casualty) from

infection as well as injury. Take steps to avoid

cross infection (transmitting germs or infection

to a casualty or contracting infection yourself

from a casualty). Remember, infection is a risk

even with relatively minor injuries. It is a

particular concern if you are treating a wound,

because blood-borne viruses, such as hepatitis

B or C and Human Immunodeficiency Virus

(HIV), may be transmitted by contact with

blood. In practice the risk is low and should not

deter you from carrying out first aid. The risk

does increase if an infected person’s blood

makes contact with yours for example through

a cut or graze.

Usually, taking measures such as washing

your hands and wearing disposable gloves will

provide sufficient protection for you and the

casualty. There is no known evidence of these

blood-borne viruses being transmitted during

resuscitation. If a face shield or pocket mask

is available, it should be used when you give

rescue breaths (pp.68–69 and pp.78–79).

Take care not to prick yourself with any needle

found on or near a casualty, or cut yourself on

glass. If you accidentally prick or cut your skin,

or splash your eye, wash the area thoroughly

and seek medical help immediately. If you are

providing first aid on a regular basis, it is

advisable to seek guidance on additional

personal protection, such as immunisation. If

you think you have been exposed to an infection

while giving first aid, seek medical advice as

soon as possible.

■ Do wash your hands and wear latexfree

disposable gloves. If gloves are not

available, ask the casualty to dress his

or her own wound, or enclose your hands in

clean plastic bags.

■ Do cover cuts and grazes on your hands with

waterproof dressings.

■ Do wear a plastic apron if dealing with large

quantities of body fluids and wear plastic

glasses to protect your eyes.

■ Do dispose of all waste safely (p.18).

■ Do not touch a wound with your bare hands,

and do not touch any part of a dressing that

will come into contact with a wound.

■ Do not breathe, cough or sneeze over

a wound.

WHEN TO SEEK MEDICAL ADVICE

MINIMISING THE RISK OF CROSS

INFECTION

To help protect yourself from infection you can carry

protective equipment such as:

CAUTION

■ Pocket mask or face shield

■ Latex-free disposable gloves

■ Alcohol gel to clean your hands

17

PROTECTION FROM INFECTION

HOW TO WASH YOUR HANDS

Wet your hands under

running water. Put some

soap into the palm of a cupped

hand. Rub the palms of your

hands together.

Rub the back of the fingers

of your right hand against

the palm of your left hand, then

repeat with your left hand in

your right palm.

Rub the palm of your left

hand against the back of

your right hand, then rub the

right palm on the back of your

left hand.

Rub your right thumb in

the palm of your left hand,

then your left thumb in the

right palm.

Interlock the fingers of both

hands and work the soap

between them.

Rub the fingertips of your

left hand in the palm of your

right hand and vice versa. Rinse

thoroughly, then pat dry with a

disposable paper towel.

1

4

2

5

3

6

If you can, wash your hands before you touch

a casualty, but if this is not possible, you should

wash them as soon as possible afterwards. It is

important to wash your hands thoroughly. Pay

attention to all parts of your hands – palms,

wrists, fingers, thumbs and fingernails. Use soap

and water if available, or rub your hands with

alcohol gel.

THOROUGH HAND WASHING

»

18

BECOMING A FIRST AIDER

In addition to hand washing, disposable gloves

give added protection against infection in a

first aid situation. If possible, carry protective,

disposable, latex-free gloves with you at all

times. Wear them whenever there is a likelihood

of contact with blood or other body fluids. If in

doubt, put them on anyway.

Disposable gloves should only be used to

treat one casualty. Put them on just before you

approach the person and remove them as soon

as the treatment is completed and before you

do anything else. When taking off the gloves,

hold the top edge of one glove with your other

gloved hand and peel it off so that it is inside

out. Repeat with the other hand so that you do

not touch the outside of the gloves. Dispose

of them safely – in a clinical waste bag if

possible (see below).

Ideally, wash your

hands before

putting on the gloves.

Hold one glove by the

top and pull it on. Do

not touch the main

part of the glove with

your fingers.

Pick up the second

glove with the

gloved hand. With your

fingers under the top

edge, pull it on to your

hand. Your gloved

fingers should not

touch your skin.

CAUTION

Always use latex-free gloves. Some people have a

serious allergy to latex, and this may cause

anaphylactic shock (p.223). Nitrile gloves (often blue

or purple) are recommended.

USING PROTECTIVE GLOVES

DEALING WITH WASTE

Once you have treated a casualty, all soiled

material must be disposed of carefully to

prevent the spread of infection.

Place items such as dressings or gloves in

a clinical waste bag and ask the attending

emergency service how to deal with this type of

waste. Seal the bag tightly and label it to show

that it contains clinical waste. Put sharp objects,

such as needles, in a special plastic box called a

sharps container. If there is no sharps container

available, put used needles in a jar with a screw

top and dispose of it safely.

CLINICAL WASTE BAG SHARPS CONTAINER

1 2

PUTTING ON DISPOSABLE GLOVES

«PROTECTION FROM INFECTION

19

PROTECTION FROM INFECTION | DEALING WITH A CASUALTY

DEALING WITH A CASUALTY

Casualties are often frightened because of

what is happening to them, and what may

happen next. Your role is to stay calm and take

charge of the situation – be ready to stand back

if there is someone better qualified. If there is

more than one casualty, use the primary survey

(pp.44–45) to identify the most seriously injured

casualties and treat in the order of priority.

It is important to consider the age and

appearance of your casualty when you talk to

him, since different people need different

responses. Always respect people’s wishes;

accept that someone might want to be treated

in a particular way. Communication can be

difficult if a person speaks a different language

or cannot hear you. Use simple language or

signs or write questions down. Ask if anyone

nearby speaks the same language, knows the

person and/or saw the incident and can describe

what happened.

SPECIAL CASE TREATING CHILDREN

BUILDING TRUST

DIVERSITY AND COMMUNICATION

Establish trust with your casualty by

introducing yourself. Find out what the person

likes to be called, and use his name when you

talk to him. Crouch or kneel down so you are

at the same height as the casualty. Explain

what is happening and why. You will inspire

trust if you say what you are doing before you

do it. Treat the casualty with dignity and respect

at all times. If possible, give him choices, for

example, whether he would prefer to sit or lie

down and/or who he would like to have with

him. Also, if possible, gain his consent before

you treat him by asking if he agrees with

whatever you are going to do.

You will need to use simpler, shorter

words when talking to children. If

possible, make sure a child’s parents

or carers are with him, and keep

them involved at all times. It is

important to establish the carer’s

trust as well as the child’s. Talk first

to the parent/carer and get his or

her permission to continue. Once

the parent/carer trusts you, the child

will also feel more confident.

Reassure the casualty

When treating a casualty, remain calm and do not do

anything without explaining it first. Try to answer any

questions he may have honestly and clearly.

»

20

BECOMING A FIRST AIDER

DEALING WITH A CASUALTY

Use your eyes and ears to be aware of how a

casualty responds. Listen by showing verbal and

non-verbal listening skills.

■■Make eye contact, but look away now and

then so as not to stare.

■■Use a calm, confident voice that is loud

enough to be heard but do not shout.

■■Do not speak too quickly.

■■Keep instructions simple: use short

sentences and simple words.

■■Use affirming nods and “mmms” to show you

are listening when the casualty speaks.

■■Check that the casualty understands what

you mean – ask to make sure.

■■Use simple hand gestures and movements.

■■Do not interrupt the casualty, but always

acknowledge what you are told; for example,

by summarising what a casualty has told you

to show that you understand.

WHEN A CASUALTY RESISTS HELP

TREATING THE CASUALTY

LISTEN CAREFULLY

If someone is ill or injured he may be upset,

confused, tearful, angry and/or keen to get

away. Be sensitive to a casualty’s feelings; let

him know that his reactions are understandable.

Also accept that you may not be able to help, or

might even be seen as a threat. Stay at a safe

distance until you have gained the person’s

consent to move closer, so that he does not feel

crowded. Do not argue or disagree. A casualty

may refuse help for example because he is

suffering from a head injury or hypothermia. If

you think a person needs something other than

what he asks for, explain why. For example, you

could say, “I think someone should look at

where you’re hurt before you move, in case

moving makes it worse”. If someone still refuses

your help and you think they need urgent

medical attention, call 999/112 for emergency

help. A casualty has the right to refuse help,

even if it causes further harm. Tell the

emergency services that you have offered first

aid and been refused. If you are worried that a

person’s condition is deteriorating, observe

from a distance until help arrives.

When treating a casualty, always relate to him

calmly and thoughtfully to maintain trust. Think

about how he might be feeling. Check that you

have understood what the casualty said and

consider the impact of your actions, for

example, is the casualty becoming more (or

less) upset, angry and tense? A change in

emotional state can indicate that a casualty's

condition is worsening.

Be prepared to change your manner,

depending on what a person feels comfortable

with; for example, ask fewer questions or talk

about something else. Keep a casualty updated

and give him options rather than telling him

what to do. Ask the casualty about his

next-of-kin or friends who can assist, and

help him to make contact with them. Ask if

you can help to make arrangements so that

any responsibilities the casualty may have

can be taken care of.

Stay with the casualty. Do not leave someone

who may be dying, seriously ill or badly injured

alone except to go to call for emergency help. Talk

to the casualty while touching his shoulder or

arm, or holding a hand. Never allow a casualty

to feel alone.

«

21

DEALING WITH A CASUALTY

In an emergency situation you may be faced

with several tasks at once: to maintain safety, to

call for help and to start giving first aid. Some of

the people at the scene may be able to help you

do the following:

■■Make the area safe, for example, control

traffic and keep onlookers away

■■Call 999/112 for emergency help (p.23)

■■Fetch first aid equipment, for example

an AED (automated external defibrillator)

■■Control bleeding with direct pressure,

or support an injured limb

■■Help maintain the casualty’s privacy by

holding a blanket around the scene and

encouraging onlookers to move away

■■Transport the casualty to a safe place if his

life is in immediate danger, only if it is safer

to move him than to leave him where he is,

and you have the necessary help and

equipment (p.234)

The reactions of bystanders may cause you

concern or anger. They may have had no first

aid training and feel helpless or frightened

themselves. If they have seen or been involved

in the incident, they too may be injured and

distressed. Bear this in mind if you need to

ask a bystander to help you. Talk to people in

a firm but gentle manner. By staying calm

yourself, you will gain their trust and help

them remain calm too.

ENLISTING HELP FROM OTHERS

CARE OF PERSONAL BELONGINGS

KEEPING NOTES

Make sure the casualty’s belongings are with

them at all times. If you have to search

belongings for identification or clues to a

person’s condition (medication, for example), do

so in front of a reliable witness. If possible, ask

the casualty’s consent before you do this.

Afterwards, ensure that all of the clothing,

personal belongings and medication accompany

the casualty to hospital in the ambulance or are

handed over to the police.

As you gather information about a casualty,

write it down so that you can refer to it later.

A written record of the timing of events is

particularly valuable to medical personnel.

Note, for example, the length of time a casualty

is unresponsive, the duration of a seizure, the

time of any changes in the casualty’s condition

(improvement or deterioration), and the time of

any intervention or treatment. Hand your notes

to the emergency services when they arrive, or

give them to the casualty. Useful information to

provide includes:

■■Casualty’s details, including his name, age

and contact details

■■History of the incident or illness

■■Brief description of any injuries

■■Unusual behaviour, or a change in behaviour

■■Treatment – where given, and when

■■Vital signs – breathing, pulse and level of

response (pp.52–53)

■■Medical history

■■Medication the casualty has taken, with

details of the amounts taken and when

■■Next-of-kin contact details

■■Your contact details as well as the date, time

and place of your involvement

Remember that any information you gather is

confidential. Never share it with anyone not

involved in the casualty’s care without his

agreement. Let the casualty know why you are

recording information and who you will give it

to. When you are asking for such information,

be sensitive to who is around and of the

casualty’s privacy and dignity.

22

BECOMING A FIRST AIDER

REQUESTING HELP

Further help is available from a range of

sources. If help is needed, you must decide both

on the type of help and how to access it. First,

carry out a primary survey (pp.44–45) to

ascertain the severity of the casualty’s condition.

If it is not serious, explain the options and allow

him to choose where to go. If a casualty’s

condition is serious, call 999/112 for emergency

help. Throughout the book there are guidelines

for choosing appropriate level of help.

■■Call 999/112 for emergency help if the

casualty needs urgent medical attention; for

example, when you suspect a heart attack

or stroke.

■■Take or send the casualty to hospital. Choose

this option when a casualty needs hospital

treatment, but his condition is unlikely to

worsen; for example, with a finger injury.

You can take him yourself if you can arrange

transport – either in your own car or in a taxi.

■■Seek medical advice. Depending on

what is available in his area, the casualty

should be advised to call his own doctor’s

surgery, NHS walk-in centre or NHS advice

line, such as the 111 service available in

England. He should do this, for example,

when he has symptoms such as earache

or diarrhoea.

You can telephone for help from any of the

following sources.

■■Emergency services, including police, fire and

ambulance services; mine, mountain, cave

and fell rescue; and HM Coastguard by

calling 999 or 112.

■■Utilities, including gas, electricity or water.

The phone number will be in the local

telephone directory.

■■Health services, including doctor, dentist,

nurse, midwife or NHS helpline, such as the

111 service in England – this phone number

varies in different areas. The phone numbers

will be in the local telephone directory.

Calls to the emergency services are free from

any phone, including mobiles. On motorways,

emergency phones can be found every 1.6 km

(1 mile); arrows on marker posts indicate the

direction of (and distance to) the nearest phone.

To summon help using these telephones, pick

up the receiver and your call will be answered.

Keep time away from the casualty to a

minimum. Ideally, tell someone else to make the

call while you stay with the casualty. Ask the

person to confirm that the call has been made

and that help is on the way. If you have to leave

a casualty to make a call for help, first take any

necessary vital action (primary survey pp.44–45).

TELEPHONING FOR HELP

Calling for help

Use your mobile phone to call for help. Stay calm,

be clear and concise, and give as much detail as

possible – use the hands-free facility if you need to

attend to the casualty at the same time. Stay with

the casualty once the call has been made.

23

REQUESTING HELP

When you dial 999 or 112, you will be asked

which service you require. If there are

casualties, ask for the ambulance service. Stay

on the telephone until the emergency services

clear the line; you will be asked a number of

questions and be given information about what

to do for the casualty while you wait. If someone

else makes the call, ensure he is aware of the

importance of his call and that he reports back

to you. The call should be made by someone

who is with the casualty and from a phone that

can remain with the casualty until help arrives.

Put your device on speaker phone so that you

administer first aid instructions given by the

emergency services. Identify a point of contact

to receive information from the emergency

services and to direct the ambulance personnel

to where they are needed when they arrive.

TALKING TO THE EMERGENCY

SERVICES

State your name clearly and say that you are

helping at the scene of an incident. It is

essential to provide the following information:

■■Your telephone number and/or the number

you are calling from.

■■The exact location of the incident; give

a road name or number and postcode, if

possible – some street signs include the

postcode. Your call can be traced if you

are unsure of your exact location. It can

be helpful to mention any junctions or

other landmarks in the area. If you are

on a motorway, say which direction the

vehicles are travelling in.

■■The type and gravity of the emergency. For

example, “Traffic incident, two cars, road

blocked, three people trapped”.

■■Number, gender and age of casualties. For

example, “One man, early sixties, breathing

difficulties, suspected heart attack”.

■■Details of any hazards, such as gas, toxic

substances, power-line damage, or adverse

weather conditions, such as fog or ice.

■■Follow instructions such as first aid guidance

given by the emergency services.

When the emergency services arrive, they will

take over the care of the casualty. Tell them

what has happened and any treatment given.

Hand over any notes you made while attending

the casualty. You may be asked to continue

helping, for example, by assisting relatives or

friends of the casualty while the paramedics

provide emergency care.

You may be asked to contact a relative.

Explain as simply and honestly as you can what

has happenened and where the casualty has

been taken. Do not cause unnecessary alarm.

It is better to admit ignorance than to give

someone misleading information. However, the

information you give may cause distress; if so,

remain calm and be clear about what they need

to do next.

MAKING THE CALL

WHEN THE EMERGENCY SERVICES ARRIVE

Assisting at the scene

Once the emergency services arrive, tell the team

everything that you know. While they assess and treat

the casualty, you may be asked to look after or

reassure friends.

24

BECOMING A FIRST AIDER

THE USE OF MEDICATION

REMEMBER YOUR OWN NEEDS

In first aid, administering medication is

largely confined to relieving general aches and

pains. It usually involves helping a casualty to

take his own painkillers.

A variety of medications can be bought

without a doctor’s prescription. However,

you must not buy or borrow medication to

administer to a casualty yourself.

If you advise the casualty to take any

medication other than that stipulated in this

manual, he may be put at risk, and you could

face legal action as a consequence. Whenever

a casualty takes medication, it is essential to

make sure that:

■■It is for the condition

■■It is not out of date

■■It is taken as advised

■■Any precautions are strictly followed

■■The recommended dose is not exceeded

■■You keep a record of the name and dose

of the medication as well as the time and

method of administration

Most people who learn first aid gain

significantly from doing so. As well as learning

new skills and meeting new people, by learning

first aid you can make a real difference to

peoples’ lives. Being able to help people who

are ill or injured often results in a range of

positive feelings. However, you may also feel

stressed when you are called upon to administer

first aid, and feel emotional once you have

finished treating a casualty, whatever the

outcome. Occasionally, that stress can interfere

with your physical and mental well-being after

an incident. Everyone responds to stressful

situations in different ways, and some people

are more susceptible to stress than others. It

is important to learn how to deal with any

stress in order to maintain your own health

and effectiveness as a first aider. Gaining an

understanding of your needs can help you

be better prepared for future situations.

An emergency is an emotional experience.

Many first aiders experience satisfaction, or

even elation, and most cope well. However,

after you have treated a casualty, depending

on the type of incident and the outcome, you

might experience a mixture of the following:

■■Satisfaction

■■Confusion, worry, doubt

■■Anger, sadness, fear

You may go through what has happened again

and again in your mind, so it can be helpful to talk

to someone you trust about how you feel and

what you did. Consider talking to someone else

who was there, or who you know has had a similar

experience. Never reproach yourself or hide your

feelings. This is especially important if the

outcome was not as you had hoped. Even with the

correct treatment, and however hard you try, a

casualty may not recover.

IMMEDIATELY AFTER AN INCIDENT

Aspirin should never be given to anyone under the

age of 16 years as there is risk of a rare condition

called Reye’s syndrome.

CAUTION

25

THE USE OF MEDICATION | REMEMBER YOUR OWN NEEDS

Delivering first aid can lead to positive feelings

as you notice new things about yourself, such

as, for example, your ability to deal with a crisis.

However, occasionally, the effect of an incident

on you will depend on your first aid experience

as well as on the nature of the actual incident.

The majority of the incidents you will deal

with will be of a minor nature and they will

probably involve people you know. If you have

witnessed an incident that involved a threat to

life or you have experienced a feeling of

helplessness, you may find yourself suffering

from feelings of stress after the incident. In

most cases, these feelings should disappear

over time.

If, however, you experience persistent or

distressing symptoms associated with a

stressful incident, such as nightmares and

flashbacks, seek further help from someone

you trust and feel you can confide in.

See your doctor if you feel overwhelmed by

your symptoms. Your doctor will talk through

them with you and together you can decide

what is best for you. Seeking help is nothing

to be embarrassed about, and it is important to

be able to overcome these feelings. This will not

only help you deal with your current reactions,

but it will also help you learn how to respond to

situations in the future.

LATER REACTIONS

Talking things over

Confiding in a friend or relative is often useful. Ideally,

talk to someone who also attended the incident; she

may have the same feelings about it as you. If you are

unable to deal with the effects of the event you were

part of or witnessed, seek help from your doctor.

WHEN TO SEEK HELP

The scene of any incident can present

many potential dangers, whether

someone has become ill or has been

injured, whether in the home or outside at

the scene of an incident. Before any first aid

can be provided you must make sure that

approaching the scene of the incident does

not present unacceptable danger to you,

the casualty or anyone else who is helping.

This chapter provides advice for first

aiders on how to ensure safety in an

emergency situation. There are specific

guidelines for emergencies that pose a

particular risk. These include fires, traffic

incidents and incidents involving electricity

and drowning.

The procedures used by the emergency

services for major incidents, where

particular precautions are necessary and

where first aiders may be called on to help,

are also described here.

■■ To protect yourself from danger and make the

area safe

■■ To assess the situation quickly and calmly and

summon help if necessary

■■ To assist any casualties and provide necessary

treatment with the help of bystanders

■■ To call 999/112 for emergency help if you suspect

serious injury or illness

■■ To be aware of your own needs

AIMS AND OBJECTIVES

MANAGING

AN INCIDENT

28

MANAGING AN INCIDENT

ACTION AT AN EMERGENCY

In any emergency it is important that you

follow a clear plan of action. This will enable

you to prioritise the demands that may be made

upon you, as well as help you decide on your

best response.

The principle steps are: to assess the situation,

to make the area safe (if possible) and to give

first aid. Use the primary survey (pp.44–45) to

identify the most seriously injured casualties

and treat them in the order of priority.

Evaluating the scene accurately is one of the

most important factors in the management of

an incident. You should stay calm. State that

you have first aid training and, if there are no

medical personnel in attendance, calmly take

charge of the situation.

Identify any safety risks and assess the

resources available to you. Action for key

dangers you may face, such as fire, are dealt

with in this chapter, but be aware, too, of trip

hazards, sharp objects, chemical spills and

falling masonry.

All incidents should be managed in a similar

manner. Consider the following:

■■Safety What are the dangers and do they still

exist? Are you wearing protective equipment?

Is it safe for you to approach?

■■Scene What factors are involved at the

incident? What are the mechanisms of the

injuries (pp.42–43)? How many casualties are

there? What are the potential injuries?

■■Situation What happened? How many people

are involved and what age are they? Are any

of them children or elderly?

The conditions that give rise to an incident may

still present a danger and must be eliminated if

possible. It may be that a simple measure, such

as turning off the ignition of a car to reduce the

risk of fire, is sufficient. As a last resort, move

the casualty to safety. Usually specialist help

and equipment is required for this.

When approaching a casualty make sure you

protect yourself: wear high-visibility clothing,

gloves and head protection if you have them.

Remember, too, that a casualty faces the risk of

injury from the same hazards that you face. If

extrication from the scene is delayed, try to

protect the casualty from any additional hazards

– without endangering yourself.

If you cannot make an area safe, then call

999/112 for emergency help. Stand clear of the

incident until the emergency services have

secured the scene.

ASSESSING THE SITUATION

MAKING AN AREA SAFE

Making a vehicle safe

Wear a high-visibility jacket if you have one to alert

others of your presence. Switch off the ignition (even

if the engine is no longer running); this reduces the

risk of a spark causing a fire.

29

ACTION AT AN EMERGENCY

Once an area has been made safe, use the

primary survey (pp.44–45) to quickly carry out

an initial assessment of the casualty or

casualties to establish treatment priorities. If

there is more than one casualty, attend to those

with life-threatening conditions first. If possible,

treat casualties in the position in which you find

them; move them only if they are in immediate

danger or if it is necessary for you to be able to

provide life-saving treatment.

Enlist help from others if possible. Ask

bystanders to call for the emergency services

(p.23). They can also help to protect a casualty’s

privacy, put out warning triangles in the event

of a vehicle incident (p.30) or fetch equipment

while you begin first aid.

Hand over any notes you have made to the

emergency services when they arrive (p.21).

Answer any questions they may have and follow

any instructions. As a first aider you may be

asked to help, for example, to move a casualty

using specialist equipment. If so, you should

always follow their instructions.

HELICOPTER RESCUE

Occasionally, helicopter rescue is required. If a

casualty is being rescued in this way, there are a

number of safety rules to follow. The emergency

services may already be in attendance, in which

case you should keep clear unless they give you

specific instructions.

If the emergency services are not in

attendance, it is important to keep bystanders

clear. Make sure everyone is at least 50m (55yd)

away from the landing site, and that no-one is

smoking. Kneel down as the helicopter

approaches, keeping well away from the rotor

blades. Once the helicopter has landed do not

approach it. Keep bystanders back and wait for

a member of the crew to approach you.

GIVING EMERGENCY HELP

ASSISTING THE EMERGENCY SERVICES

Begin treatment

Start life-saving

first aid as soon as

possible. Ask others to

call for help and fetch

equipment such as an

AED (automated external

defibrillator).

30

MANAGING AN INCIDENT

TRAFFIC INCIDENTS

The severity of traffic incidents can range from

a fall from a bicycle to a major vehicle crash

involving many casualties. Often, the incident

site will present serious risks to safety, largely

because of passing traffic.

It is essential to make the incident area safe

before you attend any casualties (p.28); this not

only protects you, but also the casualties and

any other road users. Once the area is safe,

quickly assess the casualty or casualties and

prioritise treatment (pp.44–45). Give first aid to

those with life-threatening injuries before

treating anyone else. Call 999/112 for

emergency help, giving as much detail as you

can about the incident, indicating the number

and age of the casualties, and types of injury.

Do not put yourself or others in further danger.

Take the following precautions.

■■Park safely, well clear of the incident site, set

your hazard lights flashing and put on a highvisibility

jacket/vest if you have one.

■■Set up warning triangles (or another vehicle

with hazard lights) at least 45m (49yd) from

the incident in each direction; bystanders can

do this while you attend to the casualty. Send

helpers who are wearing high-visibility jackets

to warn other drivers to slow down.

■■Make vehicles safe. For example, switch off

the ignition of any damaged vehicle and, if

you can, disconnect the battery. Pull the

supply cut-off on large diesel vehicles; this is

normally found on the outside of the vehicle

and will be marked.

■■Stabilise vehicles. If a vehicle is upright, apply

the handbrake, put it in gear and/or place

blocks in front of the wheels. If it is on its side,

do not attempt to right it, but try to prevent it

from rolling over further.

■■Watch out for physical dangers, such as

traffic. Make sure that no-one smokes

anywhere near the incident.

■■Alert the emergency services to damaged

power lines, spilt fuel or any vehicles with

Hazchem signs (opposite).

MAKING THE INCIDENT AREA SAFE

Warn other road users

Ask a bystander to set up

warning triangles in both

directions. Advise the

person to watch for other

vehicles while she is

doing this.

31

TRAFFIC INCIDENTS

Quickly assess any casualties by carrying out a

primary survey (pp.44–45). Deal first with those

who have life-threatening injuries. Assume that

any casualty who has been involved in a roadtraffic

incident may have a neck or spinal injury

(pp.157–59). If possible, treat casualties in the

position in which you find them, supporting

the head and neck at all times, and wait for the

emergency services.

Search the area around the incident thoroughly

to make sure you do not overlook any casualty

who may have been thrown clear, or who has

wandered away from the site. Bystanders can

help. If a person is trapped inside or under a

vehicle, she will need to be released by the fire

service. Monitor and record the casualty’s vital

signs – breathing, pulse and level of response

(pp.52–53) – while you are waiting.

ASSESSING THE CASUALTIES

Casualty in a vehicle

Assume that any injured casualty in a vehicle has a

neck injury. Support the head while you await help.

Reassure her and keep her ears uncovered so that she

can hear you.

■■ Do not cross a motorway to attend to an incident

or casualty.

■■ At night, wear or carry something light or reflective,

such as a high-visibility jacket, and use a torch.

■■ Do not move the casualty unless it is absolutely

necessary. If you do have to move her, the method

will depend on the casualty’s condition and

available help.

■■ Be aware that road surfaces may be slippery because

of fuel, oil or even ice.

■■ Be aware that undeployed air bags and unactivated

seat-belt tensioners may be a hazard.

■■ Find out as much as you can about the incident and

relay this information to the emergency services

when they arrive.

Traffic incidents may be

complicated by spillages of

toxic substances or vapours.

Keep bystanders away from

the scene and stand upwind

of the vehicle. Hazchem signs on

the back of the vehicle indicate

that it may be carrying a

potentially dangerous substance.

Give the details to the emergency

services so they can assess the

risks involved. If in doubt about

your safety or the meaning of a

symbol, keep your distance. If the

top left panel of a sign contains

the letter “E”, the substance is a

public safety hazard.

CAUTION

SPECIAL CASE HAZARDOUS SUBSTANCES

Emergency action code

for emergency services

Symbol indicates

nature of chemical,

for example, poison

Company logo

UN number, specifying

exact chemical

Phone number for

specialist advice

OXIDISING

AGENT

FLAMMABLE

GAS

RADIOACTIVE TOXIC GAS

AGENT

COMPRESSED

GAS

CORROSIVE

AGENT

32

MANAGING AN INCIDENT

FIRES

Fire spreads very quickly, so your first priority

is to warn any people at risk. If you are in a

building, activate the nearest fire alarm, call

999/112 for emergency help, then leave the

building. However, if doing this delays your

escape, make the call when you are out of the

building. As a first aider, try to keep everyone

calm. Encourage and assist people to evacuate

the area as quickly and calmly as possible.

When arriving at an incident involving fire,

stop, observe, think: do not enter the area. A

minor fire can escalate in minutes to a serious

blaze. Call 999/112 for emergency help and

wait for it to arrive.

A fire needs three components to start

and maintain it: ignition (a spark or flame); a

source of fuel (petrol, wood or fabric); and

oxygen (air). Removing one of these elements

can break this “triangle of fire”.

■■Remove combustible materials, such as

paper or cardboard, from the path of a fire,

as they can fuel the flames.

■■Cut off a fire’s oxygen supply by shutting

a door on a fire or smothering the flames

with a fire blanket. This will cause the fire

to suffocate and go out.

■■Switch off a car’s ignition, or pull the fuel

cut-off on a large diesel vehicle (this is

normally marked on the outside of the

vehicle), or switch off the gas supply.

If you see or suspect a fire in a building,

activate the first fire alarm you see. Try

to help people out of the building without

putting yourself at risk. Close doors behind you

to help prevent the fire from spreading. If you

are in a public building, use the fire exits and

look for assembly points outside.

You should already know the evacuation

procedure at your workplace. If, however, you

are visiting other premises you are not familiar

with, follow the signs for escape routes and

obey any instructions you are given by their

fire marshals.

THE ELEMENTS OF FIRE

LEAVING A BURNING BUILDING

When escaping from a fire:

■■ Do not re-enter a burning building to collect personal

possessions

■■ Do not use lifts

■■ Do not go back to a building until cleared to do

so by a fire officer

Fire precautions:

■■ Do not move anything that is on fire

■■ Do not smother flames with flammable materials

■■ Do not fight a fire if it puts your own safety at risk

■■ If your clothes catch fire and help is not available,

extinguish the flames by wrapping yourself up tightly

in suitable material and rolling along the ground

■■ Do not put water on an electrical fire: pull the plug

out or switch the power off at the mains

■■ Smother a hot fat fire with a fire blanket; never

use water

CAUTION

Evacuating other

people

Encourage people to

leave the building calmly

but quickly by the nearest

exit. If they have to use

the stairs, make sure they

do not rush and risk

falling down.

33

FIRES

If a person's clothing is on fire always follow

this procedure: Stop, Drop and Roll.

■■Stop the casualty panicking, running around

or going outside; any movement or breeze

will fan the flames.

■■Drop the casualty to the ground. If possible,

wrap him tightly in a fire blanket, or heavy

fabric such as a coat, curtain, blanket (not

a nylon or cellular type) or rug.

■■Roll the casualty along the ground until the

flames have been smothered. Treat any burns

(pp.174–80): help the casualty to lie down

with the burned side uppermost and start

cooling the burn as soon as possible.

Any fire in a confined space creates a highly

dangerous atmosphere that is low in oxygen

and may also be polluted by carbon monoxide

and other toxic fumes. Never enter a smoke- or

fume-filled building or open a door leading to a

fire. Let the emergency services do this.

■■When you are trapped in a burning building,

if possible go into a room at the front of the

building with a window and shut the door.

Block gaps under the door by placing a rug or

similar heavy fabric across the bottom of the

door to minimise smoke. Open the window

and shout for help.

■■Stay low if you have to cross a smoke-filled

room: air is clearest at floor level.

■■If escaping through a high window, climb out

backwards feet first; lower yourself to the full

length of your arms before dropping down.

CLOTHING ON FIRE

SMOKE AND FUMES

Putting out flames

Help the casualty on to the ground to stop flames

rising to his face. Wrap him in a fire blanket to starve

flames of oxygen, and roll him on the ground until

the flames are extinguished.

Avoiding smoke and fumes

Shut the door of the room you are in and put a rug or

blanket against the door to keep smoke out. Open the

window and shout for help. Keep as low as possible to

avoid fumes in the room.

34

MANAGING AN INCIDENT

ELECTRICAL INCIDENTS

When a person is electrocuted, the passage

of electrical current through the body may stun

him, causing his breathing and heartbeat to

stop (cardiac arrest, p.57). The electrical current

can also cause burns both where it enters and

where it exits the body to go to “earth”. An

electrical burn may appear very small or may

not be visible on the skin, however, the damage

the burn causes can extend deep into the

tissues (p.178).

The factors that affect the severity of the

injury are: the voltage; the type of current;

and the path of the current. A low voltage of

240 volts is found in a home or workplace, a

high voltage of 440–1,000 volts is found in

industry and voltage of more than 1,000 volts

is found in power lines. The type of current will

either be alternating (AC) or direct (DC), and

the path of the current can be hand-to-hand,

hand-to-foot or foot-to-foot.

Most low-voltage and high-tension currents

are AC, which causes muscular spasms (known

as tetany) and the “locked-on” phenomenon –

the casualty’s grasp is “locked” on to the object,

which prevents him from letting go, so he may

remain electrically charged (“live”). In contrast,

DC tends to produce a single large muscular

contraction that often throws the person away

from the source of electricty. Be aware that the

jolt may cause the casualty to be thrown or to

fall, which can results in injuries such as spinal

injuries and fractures.

Contact with a high-voltage current found

in power lines and overhead cables, is usually

immediately fatal. Anyone who survives will

have severe burns, since the temperature of the

electricity may reach up to 5,000°C (9,032°F).

Furthermore, the shock produces a muscular

spasm that propels the casualty some distance,

causing additional injuries.

High-voltage electricity may jump (“arc”) up

to 18m (20yd) from its source. The power must

be cut off and isolated before anyone

approaches the casualty. A casualty who has

suffered this type of shock is likely to be

unresponsive. Once you have been officially

informed that it is safe to approach, assess the

casualty, open the airway and check breathing

(The unresponsive casualty, pp.54–87).

HIGH VOLTAGE CURRENT

Protect bystanders

Keep everyone away from the incident. Bystanders

should stay at least 18m (20yd) from the damaged

cable and/or casualty.

■■ Do not touch the casualty if he is in contact with the

electrical current.

■■ Do not use anything metallic to break the electrical

contact.

■■ Do not approach high-voltage wires until the power

is turned off.

■■ Do not move a person with an electrical injury unless

he is in immediate danger and is no longer in contact

with the electricity.

■■ If the casualty is unresponsive, and it is safe to touch

him, open the airway and check breathing (The

unresponsive casualty, pp.54–87).

CAUTION

35

ELECTRICAL INCIDENTS

Domestic current, as used in homes and

workplaces, can cause serious injury or even

death. Incidents are usually due to faulty or

loose switches, frayed flexes or defective

appliances. Young children are at risk since

they are naturally curious, and may put fingers

or other objects into electrical wall sockets.

Water is also a very efficient conductor of

electricity, so presents additional risks to

both you and the casualty. If you handle

an otherwise safe electrical appliance with

wet hands, or when you are standing on a wet

floor, you greatly increase the risk of an

electric shock.

A natural burst of electricity discharged from

the atmosphere, lightning forms an intense trail

of light and heat. Lightning seeks contact with

the ground through the nearest tall feature in

the landscape and, sometimes, through anyone

standing nearby. However, because the duration

of a lightning strike is short it usually precludes

serious thermal injury. It may, however, set

clothing on fire, knock the casualty down or

cause the heart and breathing to stop (cardiac

arrest, p.57). Cardiopulmonary resuscitation/

CPR (adult, pp.66–71; child, pp.76–79; infant,

pp.82–83) must be started promptly.

Always clear everyone from the site of a

lightning strike since, contrary to popular belief,

it can strike again in the same place.

LOW-VOLTAGE CURRENT

LIGHTNING

BREAKING CONTACT WITH ELECTRICITY

Before beginning any treatment, look first,

do not touch. If the casualty is still in contact

with the electrical source, she will be “live” and

you risk electrocution.

Once you are sure that the contact between

the casualty and the electricity has been

broken, perform a primary survey (pp.44–45) and

treat injuries in order of priority. Call 999/112 for

emergency help.

Turn off the source of electricity, if possible, to

break the contact between the casualty and

the electrical supply. Switch off the current at the

mains or meter point if possible. Otherwise remove

the plug or wrench the cable free.

Alternatively,

move the source

away from both you and

the casualty. Stand on

some dry insulating

material, such as a

wooden box, plastic mat

or telephone directory.

Using a wooden pole or

broom, push the

casualty’s limb away

from the electrical

source or push the

source away from her.

If it is not possible to break the contact using a

wooden object, loop a length of rope around

the casualty’s ankles or under the arms, taking

great care not to touch her, and pull her away from

the source of the electrical current.

2

3

5

1

4

36

MANAGING AN INCIDENT

WATER INCIDENTS

■■ If the casualty is unresponsive, lift him clear of the

water, supporting his head and neck; try to keep him

upright. When you reach land, lay him down and

open the airway and check breathing. Begin CPR if

necessary (The unresponsive casualty, pp.54–87).

Incidents around water may involve people

of any age. However, drowning is one of the

most common causes of accidental death

among young people under the age of 16.

Young children can drown in fish ponds,

paddling pools, baths and even in the toilet

if they fall in head first, as well as in swimming

pools, in the sea and in open water. Many cases

of drowning involve people who have been

swimming in strong currents or very cold water,

or who have been swimming or boating after

drinking alcohol.

There are particular dangers connected with

incidents involving swimmers in cold water.

Open water around Great Britain and Ireland

is cold, even in summer. Sea temperatures range

from 5°C (41°F) to 15°C (59°F); inland waters may

be colder. The sudden immersion in cold water

can result in an overstimulation of nerves,

causing the heart to stop (cardiac arrest).

Submersion in cold water may cause

hypothermia (p.186) and exacerbate shock

(pp.112–13). Spasm in the throat and inhalation

of water can block the airway (Hypoxia, p.92

and Drowning, p.100). Inhaled or swallowed

water may be absorbed into the circulatory

system, causing water overload to the brain,

heart or lungs. The exertion of swimming can

also strain the heart.

CAUTION

RESCUING A PERSON FROM WATER

Your first priority is to get the casualty on

to dry land with the minimum of danger to

yourself. Stay on dry land, hold out a stick, a branch

or a rope for him to grab, then pull him from the

water. Alternatively, throw him a float.

If you are a trained life-saver and the

casualty is unresponsive, wade or swim to

the casualty and tow him ashore – try to keep

him upright. If you cannot do this safely, call

999/112 for emergency help.

Once the casualty is out of the water, shield

him from the wind, if possible. Treat him for

drowning (p.100) and the effects of severe cold

(hypothermia, pp.186–88). If possible, replace any

wet clothing with dry clothing.

Arrange to take or send the casualty to

hospital, even if he seems to have recovered

completely. If you are at all concerned, call 999/112

for emergency help.

2

1

3

4

37

WATER INCIDENTS | MAJOR INCIDENTS

MAJOR INCIDENTS

A major incident is one that presents a serious

threat to the safety of a community, or may

cause so many casualties that it requires special

arrangements from the emergency services.

Events of this kind can overwhelm the resources

of the emergency services in the area because

there may be more casualties to treat than there

are personnel available.

It is the responsibility of the emergency

services to declare a situation to be a major

incident, and certain procedures will be

activated by them if necessary. The area around

the incident will be sealed off and hospitals and

specialist medical teams will be notified. It

is not a first aider’s responsibility to organise

this, but you may be asked to help the

emergency services.

If you are the first person on the scene

of what may be a major incident, do not

approach it. Call 999/112 for emergency help

immediately (pp.22–23). The ambulance control

will need to know the type of incident that has

occurred (for example, a fire, a traffic incident

or an explosion), the location, the access,

any particular hazards and the approximate

number of casualties.

First, the area immediately around the incident

will be cordoned off – called the inner cordon.

Around this an outer cordon, the minimum safe

area for emergency personnel (fire, ambulance

and police), will be established. No one without

the correct identification and safety equipment

will be allowed inside the area. A casualty

clearing station, where treatment takes place, a

survivor reception centre, where the uninjured

assemble, and ambulance parking and loading

areas will be established inside the cordons.

TRIAGE

The emergency services initially use a system

called a triage sieve to assess casualties. All

casualties undergo a primary survey (pp.44–45)

at the scene to establish treatment priorities.

This will be followed by a secondary survey

(pp.46–48) in the casualty clearing station.

This check will be repeated and any change

monitored until a casualty recovers or is

transferred into the care of a medical team.

■■Casualties who cannot walk will undergo

further assessment. Depending on the

findings, casualties will be assigned to Red

Priority One (immediate) or Yellow Priority

Two (urgent) areas for treatment and will be

transferred to hospital by ambulance as soon

as possible.

■■Walking casualties with minor injuries will

be assigned to the Green Priority Three area

for treatment and will be transferred to

hospital if necessary.

■■Uninjured people will be taken to the

survivor reception centre.

FIRST AIDER’S ROLE

You will not be allowed to enter the

cordoned area without adequate personal

safety equipment and correct identification.

Once inside you may be asked to assist the

emergency services at an incident by, for

example, helping casualties with minor injuries,

supporting injured limbs or making a note of

casualties’ names and/or helping to contact

their relatives. You may be asked to help at the

survivor reception centre.

EMERGENCY SERVICE SCENE ORGANISATION

When a person is suddenly taken ill

or has been injured, it is important

to find out what is wrong as quickly as

possible. However, your first priority is to

make sure that you are not endangering

yourself by approaching a casualty.

Once you are sure that an incident area

is safe, you need to begin your assessment

of the casualty or casualties. This chapter

explains how to approach each casualty

and plan your assessment using a

methodical two-stage system, first

to identify and treat life-threatening

conditions according to their priority

(primary survey), then to carry out a

detailed assessment looking for injuries

that are not immediately apparent

(secondary survey). There is advice on

deciding treatment priorities, managing

more than one casualty and arranging

aftercare. A casualty’s condition may

improve or deteriorate while in your care,

so there is guidance on how to monitor

changes in his condition.

■■ To assess a situation quickly and calmly, while first

protecting yourself and the casualty from any danger

■■ To assess each casualty and treat life-threatening

injuries first

■■ To carry out a more detailed assessment of

each casualty

■■ To seek appropriate help. Call 999/112 for

emergency help if you suspect serious injury

or illness

■■ To be aware of your own needs

AIMS AND OBJECTIVES

ASSESSING A

CASUALTY

40

ASSESSING A CASUALTY

ASSESSING THE SICK OR INJURED

From the previous chapters you will now know

that to ensure the best possible outcome for

anyone who is injured or suddenly becomes ill

you need to take responsibility for making

assessments. Tell those at the scene that you

are a trained first aider and calmly take control.

However, as indicated in Chapter 2 (pp.26–37),

resist the temptation to begin dealing with any

casualty until you have assessed the overall

situation, ensured that everyone involved is safe

and, if appropriate, have taken steps to organise

the necessary help.

As you read through this chapter, look

back at Chapter 1 (pp.12–25) as well and

remember the following:

■■Be calm

■■Be aware of risks

■■Build and maintain the casualty’s trust

■■Call appropriate help

■■Remember your own needs

There are three aspects to managing a sick or

injured person. It is important to work quickly

and systematically to avoid unnecessary delay.

■■First, find out what is wrong with the casualty.

■■Second, treat conditions found in order of

severity – life-threatening conditions first.

■■Third, arrange for the next step of a casualty’s

care. You will need to decide what type of

care a casualty needs. You may need to call

for emergency help, suggest the casualty

seeks medical advice or allow him to go home,

accompanied if necessary.

Other people at the incident can help you

with this. Ask one of them to call 999/112 for

emergency help while you attend a casualty.

Alternatively, they may be able to help support

injured limbs, look after less seriously injured

casualties, or fetch first aid equipment.

MANAGING THE INJURED OR SICK

First actions

Support the casualty;

a bystander may

be able to help. Ask the

casualty what happened,

and try to identify the

most serious injury.

41

ASSESSING THE SICK OR INJURED

If there is more than one casualty, you will need to

prioritise those that must be treated first according

to the severity of their injuries. Use the primary

survey ABC principles (above) to do this. Remember

that unresponsive casualties are at greatest risk.

METHODS OF ASSESSMENT

When you assess a casualty you first need to

identify and deal with any life-threatening

conditions or injuries as quickly as possible with

a primary survey. Deal with each life-threatening

condition as you find it, working in the following

order – airway, breathing, then circulation –

before you progress to the next stage.

Depending on your findings you may not

move on to the next stage of the assessment.

If the life-threatening injuries are successfully

managed, or there are none, you continue the

assessment and perform a secondary survey.

THE PRIMARY SURVEY

This is an initial rapid assessment of a casualty

to establish and treat conditions that are an

immediate threat to life (pp.44–45).

If a casualty is suffering from minor injuries

and responding to you, for example, talking,

then this survey will be completed very quickly.

If, however, a casualty is more seriously injured

and/or not responding to you (unresponsive),

the assessment may take longer.

Follow the ABC principle: Airway, Breathing

and Circulation.

■■Airway Is the airway open and clear?

The airway is not open and clear if the

casualty is unable to speak. An obstructed

airway will prevent breathing, causing hypoxia

(p.92) and ultimately death.

The airway is open and clear if the casualty is

talking to you.

■■Breathing Is the casualty breathing normally?

If the casualty is not breathing normally, call

999/112 for emergency help, then start

chest compressions with rescue breaths

(cardiopulmonary resuscitation/CPR). If this

happens, you are unlikely to move on to the

next stage.

If the casualty is breathing, check for and

treat any breathing difficulty such as asthma,

then move on to the next stage: circulation.

■■Circulation Is the casualty bleeding severely?

If he is bleeding this must be treated

immediately since it can lead to a lifethreatening

condition known as shock

(pp.112–13). Call 999/112 for emergency help.

If there is no bleeding, continue to the

secondary survey.

THE SECONDARY SURVEY

This is a detailed examination of a casualty to

look for other injuries or conditions that may

not be immediately apparent (pp.46–48). To

do this, carry out a head-to-toe examination

(pp.49–51). Your aim is to find out:

■■History What actually happened and any

relevant medical history.

■■Symptoms Injuries or abnormalities that

the casualty tells you about.

■■Signs Injuries or abnormalities that you

can see.

By checking the recognition features of the

different injuries and conditions explained

in the chapters of this book you can identify

what may be wrong. Record your findings

and pass on any relevant information to the

medical team.

LEVEL OF RESPONSE

You will initially have noted whether or not a

casualty is responding to you. He may have

spoken to you or made eye contact or some

other gesture (see p.44). Or perhaps there has

been no response to your questions such as “Are

you all right?” or “What happened?”. Now you

need to establish the level of response using the

AVPU scale (p.52). This is important since some

illnesses and injuries cause a deterioration in a

casualty’s level of response, so it is vital to

assess the level, then monitor him for changes.

SPECIAL CASE SEVERAL CASUALTIES

42

ASSESSING A CASUALTY

MECHANISMS OF INJURY

The injury that a person sustains is directly

related to how it is caused. In addition, whether

a casualty sustains a single or multiple injury is

also determined by the mechanisms that caused

it. This is the reason why a history of the

incident, and therefore the injury mechanism

is important. In many situations, this vital

information can only be obtained by those

people who deal with the casualty at the

scene – often first aiders. Look, too, at the

circumstances in which an injury was sustained

and the forces involved.

The information is useful because it also

helps the emergency services and medical team

predict the type and severity of injury, as well

as the treatment required. This therefore helps

the diagnosis, treatment and likely outcome

for the casualty.

CIRCUMSTANCES OF INJURY

The extent and type of injuries sustained due

to impact – for example, a fall from a height or

the impact of a car crash – can be predicted if

you know exactly how the incident happened.

For example, a car occupant is more likely to

sustain serious injuries in a side-impact collision

than in a frontal collision at the same speed.

This is because the side of the car provides less

protection and cannot absorb as much energy

as the front of the vehicle. For a driver wearing a

seatbelt whose vehicle is struck either head-on

or from behind, a specific pattern of injuries can

be suspected. The driver’s body will be suddenly

propelled one way, but the driver’s head will lag

behind briefly before moving. This results in a

“whiplashing” movement of the neck (below).

The casualty may also have injuries caused by

the seatbelt restraint; for example, fracture

of the breastbone and collarbone and possibly

bruising of the heart or lungs. There may also be

injuries to the face due to contact with the

steering wheel or an inflated airbag.

Whiplash injury

The head may be whipped

backwards and then rapidly

forwards, or vice versa, due to

sudden forces on the body,

such as in a car crash. This

produces a whiplash injury, with

strained muscles and stretched

ligaments in the neck.

43

MECHANISMS OF INJURY

Most serious injury

may be hidden

A first aider should keep the

casualty still, ask someone to

support her head and call 999/112

for emergency help.

FORCES EXERTED ON THE BODY

The energy forces exerted during an impact are

another important indicator of the type or

severity of any injury. For example, if a man falls

from a height of 1m (3ft 3in) or less on to hard

ground, he will probably suffer bruising but no

serious injury. A fall from a height of more than

2m (6ft 6in), however, is likely to produce more

serious injuries, such as a pelvic fracture and

internal bleeding. An apparently less serious fall

can mask a more dangerous injury. If a person

falls down the stairs, for example, she may tell

you that she injured her ankle. If she has fallen

awkwardly on to a hard surface, however, she

may have sustained a spine and/or head injury.

A fall down more than five stairs is associated

with a greater risk of injury, than a fall down

fewer than five stairs. Be aware too that the

elderly or those suffering from bone disorders

such as osteoporosis are at greater risk of

serious injury from minor knocks or falls.

QUESTIONS TO ASK AT THE SCENE

When you are attending a casualty, ask the

casualty, or any witnesses, questions to try

to find out the mechanism of the injury.

Witnesses are especially important if the

casualty is unable to talk to you. Possible

questions include:

■■Was the casualty ejected from a vehicle?

■■Was the casualty wearing a seat-belt?

■■Did the vehicle roll over?

■■Was the casualty wearing a helmet?

■■How far did the casualty fall?

■■What type of surface did he land on?

■■Is there evidence of body contact with a

solid object, such as the floor or a vehicle’s

windscreen or dashboard?

■■How did he fall? (For example, twisting

falls can stretch or tear the ligaments or

tissues around a joint such as the knee

or ankle.)

Pass on all the information that you have

gathered to the emergency services

(pp.21 and 23).

44

ASSESSING A CASUALTY

PRIMARY SURVEY

The primary survey is a quick, systematic

assessment of a person to establish if any

conditions or injuries sustained are life

threatening. By following a methodical

sequence using established techniques,

each life-threatening condition can be

identified in a priority order and dealt with

on a “find and treat” basis. The sequence

should be applied to every casualty you attend

quickly and systematically. You should not allow

yourself to be distracted from it by other events.

The chart opposite guides you through this

sequence. Depending on your findings you

may not move on to the next stage of the

assessment. Only when life-threatening

conditions are successfully managed, or there

are none, should you perform a secondary

survey (pp.46–48).

RESPONSE

At this point you need to make a quick

assessment to find out whether a casualty is

responding to you or is unresponsive. Observe

the casualty as you approach. Introduce yourself

even if he does not appear to be responding to

you. Ask the casualty some questions, such as,

“What happened?” or “Are you all right?” or give

a command, such as “Open your eyes!” If there

is no initial response, gently shake the casualty’s

shoulders. If the casualty is a child, tap his

shoulder; if he is an infant, tap his foot. If there

is still no response, he is described as

unresponsive. If the casualty makes eye contact

or some other gesture, he is responsive.

Unresponsive casualties take priority and

require urgent treatment (pp.54–87).

AIRWAY

The first step is to check that a casualty’s airway

is open and clear. If a casualty is alert and

talking to you, it follows that the airway is open

and clear. If, however, a casualty is unresponsive,

the airway may be obstructed (p.59). You need

to open and clear the airway (adult, p.63; child,

p.73; infant, p.80) – do not move on to the next

stage until it is open and clear.

BREATHING

Is the casualty breathing normally? Look, listen

and feel for breaths. If he is alert and/or talking

to you, he will be breathing. However, it is

important to note the rate, depth and ease with

which he is breathing. For example, conditions

such as asthma (p.102) that cause breathing

difficulty require urgent treatment.

If an unresponsive casualty is not breathing,

the heart will stop. Chest compressions and

rescue breaths (cardiopulmonary resuscitation/

CPR) must be started immediately (adult,

pp.66–71; child, pp.76–79; infant, 82–83).

CIRCULATION

Conditions that affect the circulation of blood

can be life threatening. Injuries that result in

severe bleeding (pp.114–15) can cause blood

loss from the circulatory system, so must be

treated immediately to minimise the risk

of a life-threatening condition known as

shock (pp.112–13).

Only when life-threatening conditions have

been stabilised, or there are none present,

should you begin to carry out a detailed

secondary survey of the casualty (pp.46–48).

PRIMARY SURVEY

45

THE ABC CHECK

If life-threatening

conditions are managed,

or there are none present,

move on to the secondary

survey (pp.46–48) to check

for other injury or illness.

CIRCULATION

Are there any signs of

severe bleeding?

UNRESPONSIVE RESPONSIVE UNRESPONSIVE RESPONSIVE

AIRWAY

Is the casualty’s airway

open and clear (adult,

pp.62–63; child, pp.72–73;

infant, p.80)?

BREATHING

Is the casualty breathing

normally?

Look, listen and feel for

breaths.

■■ If the casualty is responsive,

treat conditions such as

choking or suffocation that

cause the airway to be blocked.

Go to the next stage,

BREATHING, when the airway

is open and clear.

■■ If the casualty is unresponsive,

tilt the head and lift the chin to

open the airway (adult, p.63;

child, p.73; infant, p.80).

Go to the next stage,

BREATHING, when the airway

is open and clear.

■■ Treat any difficulty found;

for example, asthma.

Go to the next stage,

CIRCULATION.

■■ If the casualty is unresponsive

and not breathing, call 999/112

for emergency help. Begin

chest compressions and rescue

breaths (adult, pp.66–71; child,

pp.76–79; infant, pp.82–83). If

this happens, you are unlikely

to move on to the next stage.

■■ Control the bleeding

(pp.114–15). Call 999/112 for

emergency help. Treat the

casualty to minimise the risk

of shock (pp.112–13).

NO

YES

YES

YES

NO

NO

Work through these checks quickly

and systematically to establish

treatment priorities.

46

ASSESSING A CASUALTY

SECONDARY SURVEY

Once you have completed the primary survey

and dealt with any life-threatening conditions,

start the methodical process of checking for

other injuries or illnesses by performing a headto-

toe examination. This is called the secondary

survey. Question the casualty as well as the

people around him. Make a note of your

findings if you can, and make sure you pass

all the details to the emergency services or

hospital, or whoever takes responsibility for

the casualty (p.29).

Ideally, the casualty should remain in the

position found, at least until you are satisfied

that it is safe to move him into a more

comfortable position appropriate for his

injury or illness.

This survey includes two further checks beyond

the ABC (pp.44–45).

■■Disability This is the casualty’s level of

response (p.52).

■■Examine the casualty You may need to

remove or cut away clothing to examine and/

or treat the injuries.

By conducting this survey you are aiming to

discover the following:

■■History What happened leading up to the

injury or sudden illness and any relevant

medical history

■■Symptoms Information that the casualty

gives you about his condition

■■Signs These are what you find on examination

of the casualty

HISTORY

There are two important aspects to the history:

what happened and any medical history.

EVENT HISTORY

The first consideration is to find out what

happened. Your initial questions should help

you to discover the immediate events leading

up to the incident. The casualty can usually tell

you this, but sometimes you have to rely on

information from people nearby so it is

important to verify that they are telling you

facts and not just their opinions. There may also

be clues, such as the impact on a vehicle, which

can indicate the likely nature of the casualty’s

injury. This is often referred to as the

mechanism of injury (pp.42–43).

PREVIOUS MEDICAL HISTORY

The second aspect to consider is a person’s

medical history. While this may have nothing to

do with the present condition, it could be a clue

to the cause. Clues to the existence of such a

condition may include a medical bracelet or

medication in the casualty’s possessions (p.48).

TAKING A HISTORY

■■Ask what happened; for example, establish

whether the incident is due to illness or

an accident.

■■Ask about medication the casualty is

taking currently.

■■Ask about medical history. Find out if there

are ongoing and previous conditions.

■■Find out if a person has any allergies.

■■Check when the person last had something

to eat or drink.

■■ Note the presence of a medical warning

bracelet – this may indicate an ongoing

medical condition, such as epilepsy, diabetes

or anaphylaxis.

47

SECONDARY SURVEY

Listen to the casualty

Make eye contact with the casualty as you talk to him.

Keep your questions simple, and listen carefully to the

symptoms he describes.

SYMPTOMS

These are the sensations that the casualty

feels and describes to you. When you talk to the

casualty, ask him to give you as much detail as

possible. For example, if he complains of pain,

ask where it is. Ask him to describe the pain (is

it constant or intermittent, sharp or dull). Ask

him what makes the pain better or worse,

whether it is affected by movement or breathing

and, if it did not result from an injury, where and

how it began. The casualty may describe other

symptoms, too, such as nausea, giddiness, heat,

cold or thirst. Listen very carefully to his

answers (p.20) and do not interrupt him while

he is speaking.

SIGNS

These are features such as swelling, bleeding,

discoloration, deformity and smells that you can

detect by observing and feeling the casualty.

Use all of your senses – look, listen, feel and

smell. Always compare the injured and

uninjured sides of the body. You may also notice

that the person is unable to perform normal

functions, such as moving his limbs or standing.

Make a note of any obvious superficial injuries,

going back to treat them only when you have

completed your examination.

Compare both sides of the body

Always compare the injured part of the body with

the uninjured side. Check for swelling, deformity

and/or discoloration.

QUICK REMINDER

Use the mnemonic A M P L E as a reminder

when assessing a casualty to ensure that you have

covered all aspects of the examination. When the

emergency services arrive, they may ask:

A – Allergy – does the person have any allergies?

M – Medications – is the person on any medication?

P – Previous medical history – do you know of any

pre-existing conditions?

L – Last meal – when did the person last eat?

E – Event history – what happened?

»

48

ASSESSING A CASUALTY

«SECONDARY SURVEY

LOOK FOR EXTERNAL CLUES

As part of your assessment, look for external

clues to a casualty’s condition. If you suspect

drug abuse, take care as he may be carrying

needles and syringes. You may find an

appointment card for a hospital or clinic, or a

card indicating a history of allergy, diabetes or

epilepsy. Horse-riders or cyclists may carry such

a card inside their riding hat or helmet. Food or

medication may also give valuable clues about

the casualty’s condition; for example, people

with diabetes may carry sugar lumps or glucose

gel. A person with a known disorder may also

have medical warning information on a special

locket, bracelet, medallion or key ring (such as a

“MedicAlert” or “SOS Talisman”). Keep any such

item with the casualty or give it to the

emergency services.

If you need to search a casualty’s belongings,

always try to ask the casualty first and then

carry out the search in front of a reliable

witness (p.21).

MEDICAL CLUES

MEDICATION

A casualty may be carrying medication such as

anti-inflammatories for back pain or glyceryl

trinitrate for angina.

“PUFFER” INHALER

The presence of an inhaler usually indicates that the

casualty has asthma; reliever inhalers are generally blue

and preventive inhalers are usually brown or white.

MEDICAL WARNING BRACELET

This may be inscribed with information about a casualty’s

medical history (for example, epilepsy, diabetes or

anaphylaxis), or there may be a number to call.

AUTO-INJECTOR

This contains adrenaline for use by people at risk of

anaphylactic shock. The pens are colour-coded for

adult and child doses.

INSULIN PEN

This may indicate that a person has diabetes. The casualty

may also have a glucose testing kit.

49

SECONDARY SURVEY | HEAD-TO-TOE EXAMINATION

»

Once you have taken the casualty’s history

(p.46) and asked about any symptoms she

has (p.47), you should carry out a detailed

examination. Use all your senses when you

examine a casualty: look, listen, feel and smell.

Always start at the casualty’s head and work

down; this “head-to-toe” routine is both easily

remembered and thorough. You may have to

sensitively loosen, open, cut away or remove

clothing where necessary to examine the

casualty (p.232). Always be sensitive to a

casualty’s privacy and dignity, and ask her

permission before doing this.

Protect yourself and the casualty by putting

on your disposable gloves. Make sure that you

do not move the casualty more than is strictly

necessary. If possible, examine a casualty who is

responding to you in the position in which you

find her, or one that best suits her condition,

unless her life is in immediate danger. If an

unresponsive breathing casualty has been

placed in the recovery position, leave her in

this position while you carry out the head-totoe

examination.

Check the casualty’s breathing and pulse

rates (pp.52–53), then work from her head

downwards (see overleaf). Initially, note any

minor injuries found but continue your

examination to make sure that you do not miss

any concealed potentially serious conditions;

only return to the minor injuries when you have

completed your examination.

HEAD-TO-TOE EXAMINATION

■ Pain ■ Anxiety ■ Heat ■ Cold ■ Loss of sensation ■ Abnormal

sensation ■ Thirst ■ Nausea ■ Tingling ■ Pain on touch

or pressure ■ Faintness ■ Stiffness ■ Weakness ■ Memory loss

■ Dizziness ■ Sensation of broken bone ■ Sense of

impending doom

The casualty may tell you of these

symptoms

METHOD OF IDENTIFICATION

POSSIBLE FINDINGS ON CARRYING OUT AN EXAMINATION

SYMPTOMS OR SIGNS

You may see these signs

You may feel these signs

You may hear these signs

You may smell these signs

■ Temporary unresponsiveness ■ Anxiety and painful expression ■ Unusual chest

movement ■ Burns ■ Sweating ■ Wounds ■ Bleeding from orifices ■ Response

to touch ■ Response to speech ■ Bruising ■ Abnormal skin colour ■ Muscle

spasm ■ Swelling ■ Deformity ■ Foreign bodies ■ Needle marks ■ Vomit

■ Incontinence ■ Loss of normal movement ■ Containers and other

circumstantial evidence

■ Dampness ■ Abnormal body temperature ■ Swelling ■ Deformity

■ Irregularity ■ Grating bone ends

■ Noisy or distressed breathing ■ Groaning ■ Sucking sounds from a

penetrating chest injury ■ Response to touch ■ Response to speech

■ Grating bone (crepitus)

■ Acetone ■ Alcohol ■ Burning ■ Gas or fumes ■ Solvents or glue

■ Urine ■ Faeces ■ Cannabis

50

ASSESSING A CASUALTY

Look at the skin. Note the colour and

temperature: is it pale, flushed or grey-blue

(cyanosis); is it hot or cold, dry or damp? Pale, cold,

sweaty (clammy) skin suggests shock; a flushed,

hot face suggests fever or heatstroke. A blue tinge

indicates lack of oxygen; look for this in the lips,

ears and face.

Look in the mouth for anything that might

obstruct the airway. If the casualty has

dentures that are intact and fit firmly, leave them.

Look for mouth wounds or burns and check for

irregularity in the line of the teeth.

Check the nose for discharges as you did

for the ears. Look for bleeding, clear fluid

or watery blood coming from either nostril.

Any of these discharges might indicate serious

head injury.

6

7

5

HEAD-TO-TOE EXAMINATION

Loosen clothing around the neck, and

look for signs such as a medical warning

medallion (p.48) or a hole (stoma) in the windpipe.

Run your fingers gently along the spine from the

base of the skull down as far as possible without

moving the casualty; check for irregularity,

swelling, tenderness or deformity.

Assess breathing (p.52). Check the rate (fast or

slow), depth (shallow or deep) and nature (is it

easy or difficult, noisy or quiet). Check the pulse

(p.53). Assess the rate (fast or slow), rhythm

(regular or irregular) and strength (strong or weak).

Start the physical examination at the

casualty’s head. Run your hands carefully over

the scalp to feel for bleeding, swelling, tenderness

or depression of the bone, which may indicate a

fracture. Be careful not to move the casualty if you

suspect that she may have injured her neck.

Speak clearly to the casualty in both ears

to find out if she responds or if she can hear.

Look for bleeding, clear fluid or watery blood

coming from either ear. These discharges may be

signs of a serious head injury (pp.144–45).

Examine both eyes. Note whether they are

open. Check the size of the pupils (the black

area). If the pupils are not the same size it may

indicate head injury. Look for any foreign object,

blood or bruising in the whites of the eyes.

WHAT TO DO

1

2

3

4

8

«

51

HEAD-TO-TOE EXAMINATION

Gently feel the casualty’s abdomen to

detect any evidence of bleeding, and

to identify any rigidity or tenderness of the

abdomen’s muscular wall, which could be a sign

of internal bleeding. Compare one side of the

abdomen with the other.

Check that the casualty has no abnormal

sensations in the arms or fingers. If the

fingertips are pale or grey-blue there may be

a problem with blood circulation. Look out for

needle marks on the forearms, or a medical

warning bracelet (p.48).

If there is any impairment in movement or

loss of sensation in the limbs, do not move

the casualty to examine the spine, since these

signs suggest spinal injury. Otherwise, gently

pass your hand under the hollow of the back

and check for swelling and tenderness.

13

11

12

Check the legs. Look and feel for bleeding,

swelling, deformity or tenderness. Ask the

casualty to raise each leg in turn, and to move

her ankles and knees.

Feel both sides of the hips, and examine the

pelvis for signs of fracture. Check clothing

for any evidence of incontinence, which suggests

spinal or bladder injury, or bleeding from orifices,

which suggests pelvic fracture.

15

14

Check the movement and feeling in the

toes. Check that the casualty has no

abnormal sensations in her feet or toes.

Compare both feet. Look at the skin colour:

grey-blue skin may indicate a circulatory

disorder or an injury due to cold.

16

Look at the chest. Ask the casualty to breathe

deeply, and note whether the chest expands

evenly, easily and equally on both sides. Feel the

ribcage to check for deformity, irregularity or

tenderness. Ask the casualty if she is aware of

grating sensations when breathing, and listen for

unusual sounds. Note whether breathing causes

any pain. Look for any external injuries, such as

bleeding or stab wounds.

Feel along the collar bones, shoulders,

upper arms, elbows, hands and fingers for

any swelling, tenderness or deformity. Check

the movements of the elbows, wrists and fingers

by asking the casualty to bend and straighten

each joint.

10

9

52

ASSESSING A CASUALTY

MONITORING VITAL SIGNS

When treating a casualty, you may need to

assess and monitor his breathing, pulse and

level of response. This information can help you

to identify problems and indicate changes in a

casualty’s condition. Monitoring should be

repeated regularly, and your findings recorded

and handed over to the medical assistance

taking over (p.21).

In addition, if a casualty has a condition that

affects his body temperature, such as fever, heat

stroke or hypothermia, you will also need to

monitor his temperature.

You need to assess and monitor a casualty’s

level of response and make a note of any change

in her condition (deterioration or improvement)

while she is in your care. Any injury or illness

that affects the brain may alter a person's ability

to respond, and any deterioration is potentially

serious. Assess the level of response using the

AVPU scale (right) and repeat the assesment at

regular intervals.

■■A – Is the casualty Alert? Are her eyes open

and does she respond to questions?

■■V – Does the casualty respond to Voice? Can

she open her eyes, answer simple questions

and obey commands?

■■P – Does the casualty respond to Pain?

Does she open her eyes or move if you pinch

her ear lobe?

■■U – Is the casualty Unresponsive to any

stimulus (unconscious)?

LEVEL OF RESPONSE

When assessing a casualty’s breathing,

check the rate of breathing and listen for

any breathing difficulties or unusual noises.

An adult’s normal breathing rate is 12–16

breaths per minute; in babies and young

children, it is 20–30 breaths per minute. When

checking breathing, listen for breaths and watch

the casualty’s chest movements. For a baby or

young child, it might be easier to place your

hand on the chest and feel for movement of

breathing. Record the following information:

■■Rate – count the number of breaths per

minute

■■Depth – are the breaths deep or shallow

■■Ease – are the breaths easy, difficult

or painful

■■Noise – is the breathing quiet or noisy, and

if noisy, what are the types of noise

BREATHING

Checking a casualty’s breathing rate

Observe the chest movements and count the number

of breaths per minute. Use a watch to time breaths.

For a baby or young child, place your hand on the

chest and feel for movement.

53

MONITORING VITAL SIGNS

Brachial pulse

Place the pads of two fingers

on the inner side of an infant’s

upper arm.

Digital thermometer

Used to measure temperature

under the tongue or armpit. Leave

it in place until it makes a beeping

sound (about 30 seconds), then

read the display.

Radial pulse

Place the pads of three fingers just

below the wrist creases at the base

of the thumb.

Forehead thermometer

A heat-sensitive strip for use on a

young child. Hold it against the

child’s forehead for about 30

seconds. The colour on the strip

indicates temperature.

Carotid pulse

Place the pads of two fingers in the

hollow between the large neck

muscle and the windpipe.

Ear sensor

Place the probe inside the ear.

Press the measurement key and

wait for a beeping sound, then read

the display. This thermometer can

be used while a person is asleep.

PULSE

BODY TEMPERATURE

Each heartbeat creates a wave of pressure

as blood is pumped along the arteries

(pp.108–109). Where arteries lie close to the

skin surface, such as on the inside of the wrist

and at the neck, this pressure wave can be felt

as a pulse. The normal pulse rate for an adult is

60–80 beats per minute. The pulse rate is faster

in children and may be slower in very fit adults.

An abnormally fast or slow pulse rate may be a

sign of illness or injury.

The pulse may be felt at the wrist (radial pulse),

or if this is not possible, the neck (carotid pulse).

In babies, the pulse in the upper arm (brachial

pulse) is easier to find.

When checking a pulse, use your fingers (not

your thumb) and press lightly against the skin.

Record the following points.

■■Rate (number of beats per minute).

■■Strength (strong or weak).

■■Rhythm (regular or irregular).

Although not a vital sign, you may need to

record temperature to assess body temperature.

You can feel exposed skin on the forehead for

example, but use a thermometer to obtain an

accurate reading. Normal body temperature is

37°C (98.6°F). A temperature above this (fever)

is usually caused by infection, but can also be

the result of heat exhaustion or heatstroke

(pp.184–85). A lower body temperature may

result from exposure to cold and/or wet

conditions – hypothermia (pp.186–88) – or it

may be a sign of life-threatening infection or

shock (pp.112–13). There are different several

types of thermometer, see below.

To stay alive we need an adequate supply

of oxygen to enter the lungs and be

transferred to all cells in the body by the

circulating blood. If a person is deprived

of oxygen for any length of time, the brain

will begin to fail. As a result, the casualty

will eventually become unresponsive,

breathing will cease, the heart will stop

and death results.

The casualty’s airway must be kept

open so that breathing can occur, allowing

oxygen to enter the lungs and be circulated

in the body.

Therefore, the priority of a first aider

when treating any collapsed casualty is

to establish an open airway and maintain

breathing and circulation. An AED

(automated external defibrillator) may

be used to “shock” a fibrillating heart back

into a normal rhythm. This chapter outlines

the priorities to remember when dealing

with an unresponsive adult, child or infant.

There are important differences in

the treatment for unresponsive infants,

children and adults; this chapter gives

separate step-by-step instructions for

dealing with each of these groups.

■■ To maintain an open airway, to check breathing and

resuscitate if required

■■ To call 999/112 for emergency help

AIMS AND OBJECTIVES

THE UNRESPONSIVE

CASUALTY

56

THE UNRESPONSIVE CASUALTY

BREATHING AND CIRCULATION

Oxygen is essential to support life. Without it,

cells in the body die – those in the brain survive

only a few minutes without oxygen. Oxygen is

taken in when we breathe in (pp.90–91), and it

is then circulated to all the body tissues via the

circulatory system (p.108). It is vital to maintain

breathing and circulation in order to sustain life.

The process of breathing enables air, which

contains oxygen, to be taken into the air sacs

(alveoli) in the lungs. Here, the oxygen is

transferred across blood vessel walls into the

blood, where it combines with blood cells. At

the same time, the waste product of breathing,

carbon dioxide, is released and exhaled in the

breath. When oxygen has been transferred to

the blood cells it is carried from the lungs to the

heart through the pulmonary veins. The heart

then pumps the oxygenated blood to the rest

of the body via blood vessels called arteries.

After oxygen is given up to the body tissues,

deoxygenated blood is brought back to the

heart by blood vessels called veins (p.108).

The heart pumps this blood to the lungs via the

pulmonary arteries, where the carbon dioxide is

released and the blood is reoxygenated before

circulating around the body again.

SEE ALSO How breathing works p.91 | The heart and blood vessels pp.108–109 | The respiratory system p.90

How the heart and lungs

work together

Air containing oxygen is taken into the

lungs via the mouth and nose. Blood

is pumped from the heart to the lungs,

where it absorbs oxygen. Oxygenated

blood is returned to the heart before

being pumped around the body.

Exchange of gases in the air sacs

Carbon dioxide passes out of blood

cells into air sacs (alveoli). Oxygen

crosses the walls of alveoli into

blood cells.

Red blood cell

Air sac

(alveolus)

Lungs

Heart pumps

oxygenated blood

around the body

Direction of

carbon dioxide

flow

Direction of

oxygen flow

Oxygenated blood

returns from the lungs

to the heart

Fresh oxygen is drawn into the lungs via the

nose and mouth by the windpipe (trachea)

Oxygenated blood

leaves the heart to

be circulated around

the body via the aorta

Deoxygenated

blood returns

from body

tissue to

the heart

Deoxygenated

blood is pumped

to the lungs by the

heart through

the pulmonary

arteries

57

BREATHING AND CIRCULATION | LIFE-SAVING PRIORITIES

LIFE-SAVING PRIORITIES

The procedures set out in this chapter can

maintain a casualty’s circulation and breathing.

With an unresponsive casualty your priorities

are to maintain an open airway, to maintain

blood circulation (to get oxygenated blood to

the tissues), and to breathe for the casualty (to

get oxygen into the body). In an adult during

the first minutes after the heart stops (cardiac

arrest), the blood oxygen level remains

constant, so chest compressions are more

important than rescue breaths in the initial

phase of resuscitation. After about two to four

minutes, the blood oxygen level falls and rescue

breathing becomes more important. The

combination of chest compressions and rescue

breaths is known as cardiopulmonary

resuscitation, or CPR.

In addition to CPR, a machine called an AED

(automated external defibrillator) can be used

to deliver an electric shock that may restore a

normal heartbeat (pp.84–87). In children and

infants, a problem with breathing is the most

likely reason for the heart to stop. Because

of this they should therefore be given FIVE

initial rescue breaths before the chest

compressions are started.

CHEST-COMPRESSION-ONLY CPR

If you have not had any training in CPR, or you

are unwilling or unable to give rescue breaths, you

can give chest compressions only. The emergency

services will give instructions for chestcompression-

only CPR (pp.70–71).

KEY ELEMENTS FOR SURVIVAL

If all of the following elements are complete,

the casualty’s chances of survival are as good

as they can possibly be:

■■Emergency help is called quickly

■■CPR is used to provide circulation and oxygen

to the body tissues

■■AED is used promptly

■■Specialised treatment and advanced care

arrive quickly

Call 999/112 for

emergency help so

that an AED and

expert help can be

brought to the

casualty.

Chest compressions

and rescue breaths

are used to “buy

time” until expert

help arrives.

A controlled electric

shock from an AED

is given. This can

“shock” the heart into

a normal rhythm.

Specialised treatment

by paramedics and in

hospital stabilises the

casualty’s condition.

CHAIN OF SURVIVAL

EARLY ADVANCED

CARE

EARLY

DEFIBRILLATION

EARLY HELP EARLY CPR

»

58

THE UNRESPONSIVE CASUALTY

If the heart stops beating, blood does not

circulate through the body. As a result, vital

organs – most importantly the brain – become

starved of oxygen. Brain cells are unable to

survive for more than three to four minutes

without a supply of oxygen.

Some circulation can be maintained

artificially with chest compressions (pp.66–67).

These act as a mechanical aid to the heart in

order to get blood flowing around the body.

Pushing vertically down on the centre of the

chest increases the pressure in the chest cavity,

expelling blood from the heart and forcing it

into the tissues. As pressure on the chest is

released, the chest recoils, or comes back up,

and more blood is “sucked” into the heart; this

blood is then forced out of the heart by the next

compression. It is possible to find the hand

position for chest compressions without

removing clothing.

To ensure that the blood is supplied with

enough oxygen, chest compressions should be

combined with rescue breathing (opposite).

A machine called an AED (automated external

defibrillator) will be used to attempt to restart

the heart when it has stopped (pp.84–87). The

earlier the AED is used, the greater the chance

of the casualty surviving. With each minute’s

delay, the chances of survival fall – however, do

not leave a casualty to search for an AED; ask

a bystander to fetch one (p.60). AEDs can be

used safely and effectively without any prior

training in their use.

AEDs are found in many public places, such

as railway stations, shopping centres, airports,

coach stations and ferry ports. They are

generally housed in cabinets, often marked with

a recognised symbol (p.85), and placed where

they can be easily accessed – on station

platforms for example. The cabinets are not

locked, but most are fitted with an alarm that is

activated when the door is opened.

RESTORING HEART RHYTHM

IMPORTANCE OF MAINTAINING CIRCULATION

USING AN AED

GIVING CHEST COMPRESSIONS

«LIFE-SAVING PRIORITIES

59

LIFE-SAVING PRIORITIES

An unresponsive casualty’s airway can become

narrowed or blocked. This can be the result of

muscular control being lost, which allows the

tongue to fall back and block the airway. When

this happens, the casualty’s breathing becomes

difficult and noisy and may stop altogether.

Lifting the casualty's chin and tilting the

head back lifts the tongue away from the

entrance of the air passage, which allows

the casualty to breathe.

Exhaled air contains about 16 per cent oxygen

(only 5 per cent less than inhaled air) and a

small amount of carbon dioxide. Your exhaled

breath therefore contains enough oxygen to

supply another person with oxygen – and

potentially keep him alive – when it is forced

into his lungs during rescue breathing.

By giving a casualty rescue breaths (p.67),

you force air into his air passages. This reaches

the air sacs (alveoli) in the lungs, and oxygen

is then transferred to the blood vessels in

the lungs.

When you take your mouth away from the

casualty’s, his chest falls, and air containing

waste products is pushed out, or exhaled, from

his lungs. This process, performed together with

chest compressions (pp.66–67), can supply the

tissues with oxygen until help arrives.

AN OPEN AIRWAY

BREATHING FOR A CASUALTY

Blocked airway

In an unresponsive

casualty, the

muscle control in

the tongue is lost

so it falls back,

blocking the

throat and airway.

Open airway

In the head-tilt,

chin-lift position,

the tongue is

lifted from the

back of the

throat and the

trachea is open,

so the airway will

be clear.

Tongue

blocking

airway

Tongue free

of airway

Air cannot

enter airway

Air entering

airway

CAUTION

AGONAL BREATHING

This type of breathing usually takes the form

of short, irregular gasps for breath. It is common

in the first few minutes after a cardiac arrest. It

should not be mistaken for normal breathing and,

if it is present, chest compressions and rescue

breaths (cardiopulmonary resuscitation/CPR)

should be started without hesitation.

GIVING RESCUE BREATHS

»

60

THE UNRESPONSIVE CASUALTY

This action plan is a summary of the techniques

to use when attending a collapsed adult. There

are more detailed instructions given on the

following pages. Carry out the following

steps in rapid succession to minimise

interruption to CPR.

ADULT RESUSCITATION

Leave the casualty in the position

found. Use the primary survey

(pp.44–45) to identify the most

serious injury and treat in order

of priority.

■■ Try to get a response by asking

questions and gently shaking his

shoulders (p.62).

Is there a response?

If possible, leave the casualty in

the position found. Use the

primary survey (pp.44–45) to

identify the most serious injury

and treat in order of priority. Place

the casualty in the recovery

position (pp.64–65). Call 999/112

for emergency help.

■■ Tilt the head back and lift the chin

to open the airway (p.63).

■■ Check for breathing (p.63).

Is he breathing normally?

■■ Give 30 chest compressions

(pp.66–67).

■■ Give TWO rescue breaths (p.67).

■■ Alternate 30 chest compressions

with TWO rescue breaths (30:2)

until help arrives; the casualty

shows signs of becoming

responsive, for example, coughing,

opening his eyes, speaking, or

moving purposefully, and starts

to breathe normally; or you are

too exhausted to continue.

■■ If you are on your own, start CPR

straight away; do not leave the

casualty in search of an AED.

■■ If you have not had training in

CPR, or you are unwilling or unable

to give rescue breaths, you can

give chest compressions only

(pp.70–71). The emergency

services will give instructions for

chest-compression-only CPR.

■■ If the casualty starts breathing

normally, but remains

unresponsive, place him in the

recovery position (pp.64–65).

Ask a helper to call 999/112 for emergency help and fetch an AED

■■ If you are on your own, make the call yourself.

OPEN THE AIRWAY; CHECK FOR BREATHING

CHECK CASUALTY’S RESPONSE

BEGIN CPR

NO

NO

YES

YES

«LIFE-SAVING PRIORITIES

61

LIFE-SAVING PRIORITIES

This action plan shows the order for the

techniques to use when attending a child

between the ages of one and puberty or an

infant under one year.

CHILD/INFANT RESUSCITATION

Leave the child in the position

found. Use the primary survey

(pp.44–45) to identify the most

serious injury and treat in order

of priority.

If possible, leave the casualty in

the position found. Use the

primary survey (pp.44–45) to

identify the most serious injury

and treat in order of priority. Place

the child in the recovery position

(pp.74–75), or hold an infant (p.81).

Call 999/112 for emergency help.

■■ It is better to give a combination

of rescue breaths and chest

compressions with infants and

children. However, if you have not

had training in CPR, or you are

unwilling or unable to give rescue

breaths, you may give chest

compressions only (pp.70–71).

The emergency services will

give instructions for chestcompression-

only CPR.

■■ If you are alone, carry out CPR

for one minute before calling for

emergency help. Take the infant

or child with you to the phone

if necessary – never leave a child

to search for an AED.

■■ If the child starts breathing

normally, but remains

unresponsive, place her in the

recovery position (child, pp.74–75;

infant, p.81).

■■ Try to get a response by asking

questions and gently tapping

the child’s shoulder or an

infant’s foot.

Is there a response?

■■ Tilt the head back and lift the chin

to open the airway (child, p.73;

infant, p.80).

■■ Check for breathing (child, p.73;

infant, p.81).

Is she breathing normally?

Ask a helper to call 999/112 for emergency help and, for a child,

fetch an AED, ideally with paediatric pads.

■■ Do not use an AED on an infant.

■■ Carefully remove any visible

obstruction from the mouth.

■■ Give FIVE initial rescue breaths

(child, p.76; infant, p.80).

■■ Give 30 chest compressions

(child, p.77; infant, p.83).

■■ Follow with TWO rescue breaths.

■■ Alternate 30 chest compressions

with TWO rescue breaths (30:2)

until emergency help arrives; the

child shows signs of becoming

responsive, such as coughing,

opening her eyes, speaking, or

moving purposefully, and starts to

breathe normally; or you are too

exhausted to continue.

GIVE INITIAL RESCUE BREATHS

OPEN THE AIRWAY; CHECK FOR BREATHING

CHECK CHILD’S RESPONSE

BEGIN CPR

NO

NO

YES

YES

62

THE UNRESPONSIVE CASUALTY

The following pages describe techniques for

the management of an unresponsive adult who

may require resuscitation.

Always approach and treat the casualty from

the side, kneeling down next to his head or

chest. You will then be in the correct position to

perform all the stages of resuscitation: opening

the airway; checking breathing; and giving chest

compressions and rescue breaths (together

called cardiopulmonary resuscitation, or CPR).

At each stage you will have decisions to make –

for example, is the casualty breathing? The

steps given here tell you what to do next;

work through them in rapid succession with

minimal interruption.

The first priority is to open the casualty’s

airway so that he can breathe or you can give

rescue breaths. If normal breathing returns at

any stage, you should place the casualty in the

recovery position. If the casualty is not breathing,

the early use of an AED (automated external

defibrillator) may increase his chance of survival.

On discovering a collapsed casualty, you should first make sure

the scene is safe and then establish whether he is responsive or

unresponsive. Do this by gently shaking the casualty’s shoulders.

Ask “What has happened?” or give a command such as, “Open

your eyes”. Always speak loudly and clearly to the casualty.

HOW TO CHECK THE RESPONSE

If there is no further danger, leave the casualty

in the position in which he was found. Use the

primary survey (pp.44–45) to identify the most

serious injury and treat conditions in order of

priority. Summon help if needed.

Shout for help. Leave the casualty in the

position in which he was found and open

the airway.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – until

help arrives or the casualty recovers.

If you are unable to open the airway in

the position in which he was found, roll

him on to his back and open the airway. Go to

How to open the airway (opposite).

1

1

2

2

IF THERE IS NO RESPONSE

IF THERE IS A RESPONSE

■■ Always assume that there is a

neck injury and shake the

shoulders very gently.

CAUTION

UNRESPONSIVE ADULT

63

UNRESPONSIVE ADULT

Keeping the airway open, look, listen and feel

for normal breathing: look for chest movement;

listen for sounds of breathing; and feel for

breaths on your cheek. Do this for no more than

10 seconds before deciding whether or not the

casualty is breathing normally. Breathing may

be agonal (p.59). If there is any doubt, act as if

it is not normal.

HOW TO CHECK BREATHING

HOW TO OPEN THE AIRWAY

Place one hand on his forehead. Gently tilt his

head back. As you do this, the mouth will fall

open slightly.

Place the fingertips of your other hand on the

point of the casualty’s chin and lift the chin.

Check the casualty’s breathing. Go to How to check

breathing, below.

1 2

Use the primary survey (pp.44–45) to identify

the most serious injury and treat conditions in

order of priority.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while

waiting for help to arrive. Go to How to place

casualty in recovery position (pp.64–65).

Place the casualty in the recovery

position (pp.64–65) and call 999/112 for

emergency help.

Begin CPR with chest compressions – do not

leave a casualty in search of an AED. Go to

How to give CPR (pp.66–67).

1

3

1

2

2

IF THE CASUALTY IS BREATHING

IF THE CASUALTY IS NOT BREATHING

»

Ask a helper to call 999/112 for emergency

help. Ask the person to bring an AED if one

is available. If you are alone, make the call

yourself, ideally use your mobile device set to

speaker phone to make the call.

64

THE UNRESPONSIVE CASUALTY

If the casualty is found lying on his side or

front, rather than his back, not all the following

steps will be necessary to place him in the

recovery position. If the mechanism of injury

suggests a spinal injury, treat as described

opposite and on pp.157–59.

WHAT TO DO

Kneel beside the casualty. Remove his

spectacles and any bulky objects, such as

mobile phones or large bunches of keys, from his

pockets. Do not search his pockets for small items.

Make sure that both of the casualty’s legs are

straight. Place the arm that is nearest to you at

right angles to the casualty’s body, with the elbow

bent and the palm facing upwards.

Bring the arm that is farthest from you

across the casualty’s chest, and hold the

back of his hand against the cheek nearest to

you. With your other hand, grasp the far leg just

above the knee and pull it up, keeping the foot

2 flat on the ground.

1 3

4

HOW TO PLACE CASUALTY IN RECOVERY POSITION

Keeping the casualty’s hand pressed against

his cheek, pull on the far leg and roll the

casualty towards you and on to his side.

«UNRESPONSIVE ADULT

65

UNRESPONSIVE ADULT

If necessary, adjust the hand under the cheek

to keep the airway open.

Tilt the casualty’s head back and tilt his chin so

that the airway remains open (p.63).

If it has not already been done, call 999/112

for emergency help. Monitor and record vital

signs – breathing, pulse and level of response

(pp.52–53) – while waiting for help to arrive.

If the casualty is likely to remain in the

recovery position for a while, after 30 minutes

roll him on to his back, and then roll him on to the

opposite side – unless other injuries prevent you

from doing this.

Adjust the upper leg so that both the hip and

the knee are bent at right angles. 5 7

6

8

9

If you suspect a spinal injury (pp.157–59) and

need to place the casualty in the recovery

position because you cannot maintain an

open airway, try to keep the spine straight

using the following guidelines:

■■ If you are alone, use the technique shown

opposite and above.

■■ If you have one helper, one of you should

steady the head while the other turns the

casualty (right).

■■With three people, one person should steady

the head while another turns the casualty. The

third person should keep the casualty’s back

straight during the manoeuvre.

■■ If there are four or more people in total, use the

log-roll technique (p.159).

SPECIAL CASE RECOVERY POSITION FOR SUSPECTED SPINAL INJURY

»

66

THE UNRESPONSIVE CASUALTY

Place your hand on the casualty’s breastbone as

indicated here. Make sure that you do not press

on the casualty’s ribs, the lower tip of the breastbone

or the upper abdomen.

WHAT TO DO

Kneel beside the casualty level with his chest.

Place the heel of one hand on the centre of the

casualty’s chest. You can identify the correct hand

position for chest compressions through a

casualty’s clothing.

Place the heel of your other hand on top of the

first hand, and interlock your fingers, making

sure the fingers are kept off the ribs.

Leaning over the casualty, with your arms

straight, press down vertically on the

breastbone and depress the chest by 5–6cm

(2–2½in). Release the pressure without removing

your hands from his chest. Allow the chest to

come back up fully (recoil) before giving the

next compression.

2

1

3

HAND POSITION

Hand position

Ribs

Breastbone

Upper

abdomen

Lower tip of

breastbone

HOW TO GIVE CPR

«UNRESPONSIVE ADULT

67

UNRESPONSIVE ADULT

If there is more than one rescuer,

change over every 1–2 minutes,

with minimal interruption to

chest compressions.

Move to the casualty’s

head and make sure that

the airway is still open. Put one

hand on his forehead and two

fingers of the other hand under

the tip of his chin. Move the

hand that was on the forehead

down to pinch the soft part of

the nose with the finger and

thumb. Allow the casualty’s

mouth to fall open

Maintaining head tilt

and chin lift, take your

mouth off the casualty’s mouth

and look to see the chest fall.

If the chest rises visibly as

you blow and falls fully when

you lift your mouth away, you

have given a rescue breath –

one rescue breath should take

one second. Give a second

rescue breath.

Take a breath and place

your lips around the

casualty’s mouth, making

sure you have a good seal. Blow

into the casualty’s mouth until

the chest rises. A complete

rescue breath should take one

second. If the chest does not

rise, you may need to adjust

the head position (How to open

the airway, p.63).

Continue the cycle of 30

chest compressions followed

by TWO rescue breaths (30:2)

until: emergency help arrives

and takes over; the casualty

shows signs of becoming

responsive – such as coughing,

opening his eyes, speaking, or

moving purposefully – and starts

to breathe normally; or you are

too exhausted to continue.

Compress the chest 30

times at a rate of 100–120

compressions per minute.

The time taken for compression

and release should be about

the same.

4 5

6 7 8

CAUTION

»

68

THE UNRESPONSIVE CASUALTY

There are circumstances when it may be more

difficult to deliver CPR:

■■If you have not been trained in CPR or are

unwilling or unable to give rescue breaths you

can give chest compressions only (pp.70–71).

An ambulance dispatcher will give

instructions for chest-compression-only CPR.

■■If there is more than one rescuer, change over

every 1–2 minutes, with minimal interruption

to chest compressions.

■■If the casualty vomits during CPR, roll him

away from you onto his side, ensuring that his

head is turned towards the floor to allow

vomit to drain away. Clear any residual debris

from his mouth, then immediately roll him

onto his back again and recommence CPR.

■■If a woman in the late stage of pregnancy

requires CPR, raise her right hip off the

ground by tilting it upwards before you begin

compressions, see below.

■■Modified rescue breathing may be necessary

in some cases: for example, if a casualty has

a chemical around the mouth, you can give

rescue breaths through the nose (opposite).

A casualty may breathe through a hole in the

front of the neck – a stoma – opposite). You

can also use a pocket mask or face shield

when giving rescue breaths.

If a casualty's chest does not rise when giving

rescue breaths:

■■Re-check the head tilt and chin lift.

■■Re-check the casualty's mouth and remove

any obvious obstructions, but do not do a

finger sweep of the mouth.

Make no more than two attempts to achieve

rescue breaths before repeating compressions.

If a heavily pregnant woman is lying on her

back, the pregnant uterus will press against the

large blood vessels in the abdomen. This

restricts blood from the lower part of the body

returning to the heart, which reduces

the amount of blood circulation that can be

achieved with chest compressions. To prevent

this from happening, tilt her right hip upwards.

CPR IN LATE STAGES OF PREGNANCY

SPECIAL CONSIDERATIONS FOR CPR

Positioning the woman

Keep the woman's upper body

as flat on the floor as possible in

order to give good-quality

compressions. Raise her right hip

and ask a helper to kneel beside

the woman so that his knees are

underneath the raised hip. If you

are on your own, place tightly

rolled up clothing or towels under

the woman’s hip to lift it.

PROBLEMS WITH RESCUE BREATHING

«UNRESPONSIVE ADULT

69

UNRESPONSIVE ADULT

FACE SHIELDS AND POCKET MASKS

Face shields are plastic barriers with a filter that

is placed over the casualty’s mouth. A pocket

mask has a mouthpiece through which breaths

are given. If you have one of these barrier

devices, avoid unnecessary interruptions to

CPR when you use it.

There are some situations where mouth-tomouth

rescue breaths are not appropriate and

you need to use a mouth-to-nose or mouth-tostoma

technique.

The ambulance service may initially send a

sole responder in a fast-response vehicle or

a community first responder ahead of the

ambulance. If an AED is not already attached

to the casualty, the ambulance personnel will

do that. They will also use additional drugs and

equipment to provide advanced care (p.57). If

you are asked to help you should listen carefully

and follow the instructions given (p.23).

The ambulance personnel will make a decision

whether to transfer the casualty to hospital

immediately or to continue treatment at the

scene. Any decision to stop resuscitation can only

be made by a health care professional.

VARIATIONS FOR RESCUE BREATHING

WHEN THE AMBULANCE ARRIVES

Mouth-to-nose rescue breathing

If a casualty has injuries to the mouth that make it

impossible to achieve a good seal, you can use the

mouth-to-nose method for giving rescue breaths.

With the casualty’s mouth closed, form a tight seal

with your lips around the nose and blow steadily

into the casualty’s nose. Then allow the mouth

to fall open to let the air escape.

Mouth-to-stoma rescue breathing

A casualty who has had his voice-box surgically

removed breathes through an opening in the front

of the neck (a stoma), rather than through the mouth

and nose. Always check for a stoma before giving

rescue breaths. If you find a stoma, close off the

mouth and nose with one hand and then breathe

into the stoma.

Using a pocket mask

Kneel behind the casualty’s head. Open the airway

and place the mask, narrow end towards you, over

the casualty’s mouth and nose. Deliver rescue breaths

through the mouthpiece.

Using a face shield

Tilt the casualty’s head back to open the airway. Place

the shield over the casualty’s face so that the filter is

over the mouth and pinch the nostrils shut. Deliver

rescue breaths through the filter.

»

70

THE UNRESPONSIVE CASUALTY

Healthcare professionals and trained first aiders will deliver

CPR using chest compressions combined with rescue breaths

(pp.66–67). However, if you have not had training in CPR or you

are unwilling or unable to give rescue breaths, chestcompression-

only CPR has been shown to be of great benefit

certainly in the first minutes after the heart has stopped. The

emergency services will give instructions for chest-compressiononly

resuscitation for an unresponsive casualty when advising an

untrained person by telephone. Put your device on speakerphone

mode so that you can deliver first aid and talk to the

dispatcher. Start chest compressions as soon as possible and

continue them until: emergency help arrives and takes over; the

casualty shows signs of becoming responsive – such as coughing,

opening his eyes, speaking or moving purposefully – and starts

breathing normally; or you are too exhausted to continue.

WHAT TO DO

Check for a response.

Gently shake the casualty’s

shoulders, and talk to him or give

a command (p.62).

IF THERE IS A RESPONSE

Use the primary survey (pp.44–45)

to identify the most serious injury

and treat conditions in order

of priority.

IF THERE IS NO RESPONSE

Shout for help and open the

airway, step 2.

Open the casualty’s airway.

Place one hand on the

forehead and gently tilt the head

– the mouth should fall open.

Place the fingertips of your other

hand on the chin and lift it.

2

1

■■ If there is more than one rescuer

swap every 1–2 minutes to

prevent fatigue. Make sure there

is minimal interruption when

you change over to maintain the

quality of the compressions.

■■ For unresponsive children and

infants who are not breathing,

it is best to give CPR using

rescue breaths with chest

compressions (pp.76–77 and

pp.82–83).

■■ If a casualty has been rescued

from water and is not breathing,

it is best to give CPR using

rescue breaths and chest

compressions (Drowning, p.100).

CAUTION CHEST-COMPRESSION-ONLY CPR

«UNRESPONSIVE ADULT

71

UNRESPONSIVE ADULT

Check breathing: look,

listen and feel for signs

of breathing for no more

than 10 seconds.

IF HE IS BREATHING

Use the primary survey (pp.44–45)

to identify the most serious injury

and treat conditions in order of

priority. Place in the recovery

position (pp.66–65).

IF HE IS NOT BREATHING

Call 999/112 for emergency help

then begin chest compressions,

step 4.

Kneel beside the casualty,

level with his chest. Place

one hand on the centre of the

chest (p.66) – you can identify the

position through clothing. Put the

heel of your other hand on top of

the first and interlock your fingers.

Make sure your fingers are not in

contact with the ribs.

Begin chest compressions:

lean over the casualty, with

your arms straight and press down

vertically on his breastbone,

depressing the chest by about

5–6cm (2–2½in). Release the

pressure – but do not take your

hands off the chest – and let the

chest come back up. The time

taken for compression and release

should be about the same.

Continue with chest

compressions at a rate of

100–120 per minute until:

emergency help arrives; the

casualty shows signs of becoming

responsive – such as coughing,

opening his eyes, speaking or

moving purposefully – and starts

breathing normally; or you are

too exhausted to continue.

3

4

5

6

72

The following pages describe the techniques

that may be needed for the resuscitation of

an unresponsive child aged between one year

and puberty.

When treating a child, always approach and

treat her from the same side, kneeling down

next to the head or chest. You will then be in

the correct position to carry out all the different

stages of resuscitation: opening the airway,

checking breathing and giving rescue breaths

and chest compressions (together known as

cardiopulmonary resuscitation, or CPR). At each

stage you will have decisions to make; for

example, is the child breathing? The steps given

here tell you what to do next; work through all

of them in rapid succession with minimal

interruption. Your first priority is to open the

child’s airway, so that she can breathe, or so

that you can give rescue breaths. If normal

breathing resumes, place the child in the

recovery position (pp.74–75).

If a child with a known heart condition

collapses, call 999/112 for emergency help

immediately and ask for an AED to be brought

(pp.84–87). Early access to advanced care can

be life-saving.

On discovering a collapsed child, you should

first establish whether she is responsive or

unresponsive. Do this by speaking loudly and

clearly to the child. Ask “What has happened?”

or give a command such as, “Open your eyes”.

Place one hand on her shoulder, and gently tap

her to see if there is a response.

HOW TO CHECK RESPONSE

THE UNRESPONSIVE CASUALTY

If there is no further danger, leave the

child in the position in which she was found.

Use the primary survey (pp.44–45) to identify the

most serious injury and treat conditions in order

of priority.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – until

emergency help arrives or the child recovers.

Shout for help. Leave the child in the position

in which she was found, and open the airway.

If you are unable to open the airway in

the position in which she was found, roll the

child on to her back and open the airway. Go to

How to open the airway (opposite).

2

1

1

2

IF THERE IS A RESPONSE

IF THERE IS NO RESPONSE

UNRESPONSIVE CHILD ONE YEAR TO PUBERTY

73

Keep the airway open and look, listen and

feel for normal breathing – look for chest

movement, listen for sounds of normal

breathing and feel for breaths on your cheek.

Do this for no more than 10 seconds.

HOW TO CHECK BREATHING

HOW TO OPEN THE AIRWAY

UNRESPONSIVE CHILD

IF THE CASUALTY IS BREATHING

IF THE CASUALTY IS NOT BREATHING

Place one hand on the child’s forehead. Gently

tilt her head back. As you do this, the mouth

will fall open slightly.

Use the primary survey (pp.44–45) to identify

the most serious injury and treat conditions in

order of priority.

Ask a helper to call 999/112 for emergency

help. If you are on your own, perform CPR

for one minute and then make the emergency

call yourself. Use your mobile device set to speaker

phone to make the call or take the child with you to

the telephone if necessary.

Place the child in the recovery position and

call 999/112 for emergency help.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while

waiting for help to arrive. Go to How to place child

in recovery position (pp.74–75).

Begin CPR with FIVE initial rescue breaths.

Go to How to give CPR (pp.76–77).

Place the fingertips of your other hand on the

point of the chin and lift. Do not push on the

soft tissues under the chin since this may block the

airway. Now check to see if the child is breathing.

Go to How to check breathing (below).

2

1

1

2

3

2

1

»

74

THE UNRESPONSIVE CASUALTY

UNRESPONSIVE CHILD ONE YEAR TO PUBERTY

If the child is found lying on her side or front,

rather than her back, not all of these steps will

be necessary to place her in the recovery

position. If the mechanisms of injury suggest a

spinal injury, treat as described on pp.157–59.

HOW TO PLACE CHILD IN RECOVERY POSITION

Make sure that both of the child’s legs are

straight. Place the arm nearest to you at right

angles to the child’s body, with the elbow bent and

the palm facing upwards.

Bring the arm that is farthest from you across

the child’s chest, and hold the back of her hand

against the cheek nearest to you. With your other

hand, grasp the far leg just above the knee and pull

it up, keeping the foot flat on the ground.

Kneel beside the child. Remove her spectacles

and any bulky objects from her pockets, but do

not search them for small items.

1

2

3

WHAT TO DO

Keeping the child’s hand pressed against her

cheek, pull on the far leg and roll the child

towards you and on to her side.

4

«

75

UNRESPONSIVE CHILD

Adjust the upper leg so that both the hip and

the knee are bent at right angles. Tilt the child’s

head back and lift the chin so that the airway

remains open.

If necessary, adjust the hand under the cheek

to make sure that the head remains tilted and

the airway stays open. If it has not already been

done, call 999/112 for emergency help. Monitor

and record vital signs – breathing, pulse and level

of response (pp.52–53) – until help arrives.

If the child is likely to remain in the recovery

position for a while, after 30 minutes you

should roll her on to her back, then turn her on to

the opposite side – unless other injuries prevent

you from doing this.

6

7

If you suspect a spinal injury (pp.157–59) and need

to place the child in the recovery position because

you cannot maintain an open airway, try to keep

the spine straight using the following guidelines:

■■ If you are on your own, use the technique shown

opposite and left.

■■ If there are two of you, one person should steady the

head while the other turns the child, see below.

■■ If there are three of you, one person should steady the

head while one person turns the child. The third

person should keep the child’s back straight during the

manoeuvre.

■■ If there are four or more people in total, use the logroll

technique (p.159).

»

SPECIAL CASE RECOVERY POSITION

FOR SUSPECTED SPINAL INJURY

5

76

THE UNRESPONSIVE CASUALTY

WHAT TO DO

Ensure the airway is still open by keeping one

hand on the child’s forehead and two fingers of

the other hand on the point of her chin.

Pinch the soft part of the

child’s nose with the finger

and thumb of the hand that was

on the forehead. Make sure that

her nostrils are closed to prevent

air from escaping. Allow her

mouth to fall open.

Take a deep breath in

before placing your lips

around the child’s mouth,

making sure that you form an

airtight seal. Blow steadily into

the child’s mouth; the chest

should rise.

Maintaining head tilt and

chin lift, take your mouth

off the child’s mouth and look to

see the chest fall. If the chest

rises visibly as you blow and falls

fully when you lift your mouth,

you have given a rescue breath.

Each complete rescue breath

should take one second. If the

chest does not rise you may

need to adjust the head (p.73).

Give a child FIVE initial

rescue breaths.

Pick out any visible obstructions from the

mouth. Do not sweep the mouth with your

finger to look for obstructions.

1 2

3 4 5

«UNRESPONSIVE CHILD ONE YEAR TO PUBERTY

HOW TO GIVE CPR

77

UNRESPONSIVE CHILD

HAND POSITION

With more than one rescuer, change every 1–2

minutes with minimal interruption to compressions.

Return to the child’s head, open the airway

and give TWO further rescue breaths.

If you are on your own, alternate 30 chest

compressions with TWO rescue breaths (30:2)

for one minute, then stop to call 999/112 for

emergency help. Continue CPR until: emergency

help arrives and takes over; the child shows signs

of becoming responsive – such as coughing,

opening her eyes, speaking, or moving purposefully

– and starts to breathe normally; or you become

too exhausted to continue.

Kneel level with the child’s chest. Place one

hand on the centre of her chest. This is the

point at which you will apply pressure.

Lean over the child, with your arm straight,

and then press down vertically on the

breastbone with the heel of your hand. Depress

the chest by at least one-third of its depth. Release

the pressure without removing your hand from

the chest. Allow the chest to come back up

completely (recoil) before you give the next

compression. Compress the chest 30 times, at

a rate of 100–120 compressions per minute. The

time taken for compression and release should

be about the same.

8

9

6

7

CAUTION

Place one hand on the child’s breastbone as

indicated here. Make sure that you do not apply

pressure over the child’s ribs, the lower tip of the

breastbone or the upper abdomen.

Hand position

Ribs

Breastbone

Lower tip of

breastbone

Upper

abdomen

»

78

There are circumstances when it may be more

difficult to deliver CPR. While it is better to give

a combination of rescue breaths and chest

compressions, you may not have been formally

trained in CPR or you may be unwilling or

unable to give rescue breaths. In this situation

you can give chest compressions only. The

emergency services will give instructions for

chest-compression-only CPR when you call.

■■If there is more than one rescuer, change over

every 1–2 minutes, with minimal interruption

to compressions.

■■If the child vomits during CPR, roll her away

from you onto her side, ensuring that her head

is turned towards the floor to allow vomit to

drain away. Clear the mouth, then immediately

roll her onto her back again and recommence

CPR.

■■If the child is large, or the rescuer is small, you

can give chest compressions using both hands,

as for an adult casualty (pp.66–67). Place one

hand on the chest, cover it with your other

hand and interlock your fingers, keeping them

clear of the chest.

If a child’s chest does not rise when giving

rescue breaths:

■■Recheck the head tilt and chin lift;

■■Recheck the mouth. Remove any obvious

obstructions, but do not do a finger sweep of

the mouth.

Make no more than two attempts to achieve

rescue breaths before repeating the chest

compressions.

PROBLEMS WITH RESCUE BREATHING

SPECIAL CONSIDERATIONS FOR CPR

THE UNRESPONSIVE CASUALTY

GIVING CHEST-COMPRESSION-ONLY CPR

Kneel beside the child, level with her chest.

Place the heel of one hand on the centre of

her chest.

Lean over the child with your arm straight and

depress the chest by at least one third of the

depth, and release the pressure (but do not remove

your hand).

Repeat compressions at a rate of 100–120

per minute until: emergency help arrives and

takes over; the child shows signs of becoming

responsive – such as coughing, opening her eyes,

speaking, or moving purposefully – and starts to

breathe normally; or you become too exhausted

to continue.

2

3

1

«UNRESPONSIVE CHILD ONE YEAR TO PUBERTY

79

There are some cases where mouth-to-mouth

rescue breaths are not appropriate and you will

need to use a mouth-to-nose technique.

FACE SHIELDS AND POCKET MASKS

A face shield is a plastic barrier with a filter that

is placed over the casualty’s mouth. A pocket

mask is more substantial and has a valve

through which breaths are given. If you have

one of these barrier devices, avoid unnecessary

interruptions when giving CPR to the child.

The ambulance service may initially send

a sole responder in a fast response vehicle or

a community first responder ahead of the

ambulance. If an AED is not already attached

to the child the ambulance personnel will do

that. They will also use additional drugs and

equipment to provide advanced care (p.57). If

you are asked to help you should listen carefully

and follow the instructions given (p.23).

The ambulance personnel will make a

decision whether to transfer the child to

hospital immediately or to continue treatment

at the scene. Any decision to stop resuscitation

can only be made by a health care professional.

VARIATIONS FOR RESCUE BREATHING

WHEN THE AMBULANCE ARRIVES

Mouth-to-nose rescue breathing

If a child has been rescued from water, or injuries to

the mouth make it impossible to achieve a good seal,

you can use the mouth-to-nose method for giving

rescue breaths. With the child’s mouth closed, form a

tight seal with your lips around the nose and blow

steadily into the casualty’s nose. Then allow the

mouth to fall open to let the air escape.

Using a pocket mask

Kneel behind the child’s head. Open the airway and

place the mask, broad end towards you, over the

child’s mouth and nose. Deliver breaths through

the mouthpiece.

Using a face shield

Tilt the child’s head back to open the airway and lift

the chin. Place the plastic shield over the child’s face

so that the filter is over her mouth. Pinch the nose

and deliver breaths through the filter.

UNRESPONSIVE CHILD

80

UNRESPONSIVE INFANT UNDER ONE YEAR

The following pages describe techniques that

may be used for the resuscitation of an

unresponsive infant under one year. For a child

over the age of one year, use the child

resuscitation procedure (pp.72–79).

Always treat the infant from the side, the

correct position for doing all the stages of

resuscitation: opening the airway, checking

breathing and giving rescue breaths and

chest compressions (cardiopulmonary

resuscitation, or CPR). Work through all of them

in rapid succession with minimal interruption.

Your first priority is to ensure that the airway

is open and clear. If normal breathing resumes

at any stage, hold the infant in the recovery

position (opposite). Call 999/112 for

emergency help immediately if an infant with a

known heart condition becomes unresponsive.

Gently tap or flick the sole of the infant’s foot

and call his name to see if he responds. Never

shake an infant.

HOW TO CHECK THE RESPONSE

HOW TO OPEN THE AIRWAY

IF THERE IS NO RESPONSE

Shout for help, then lay her on her back on a firm

surface and open the airway. Go to How to open

the airway (below).

IF THERE IS A RESPONSE

THE UNRESPONSIVE CASUALTY

Place one fingertip of your

other hand on the point

of the infant's chin. Gently lift the

point of the chin. Do not push on

the soft tissues under the chin

since this may block the airway.

Place one hand on the

infant’s forehead and very

gently tilt the head back.

Now check to see if the

infant is breathing. Go

to How to check breathing

(opposite).

2

1 3

Use the primary survey (pp.44–45) to identify

the most serious injury and treat conditions in

order of priority.

Summon help if needed – take the infant with

you to make the call. Monitor and record vital

signs – breathing, pulse and level of response

(pp.52–53) – until help arrives.

2

1

81

Keep the airway open and look, listen and

feel for normal breathing – look for chest

movement, listen for sounds of breathing

and feel for breaths on your cheek. Do this for

no more than ten seconds.

HOW TO CHECK BREATHING

HOW TO HOLD IN AN INFANT IN THE RECOVERY POSITION

IF THE INFANT IS BREATHING

IF THE INFANT IS NOT BREATHING

UNRESPONSIVE INFANT

Use the primary survey (pp.44–45) to identify

the most serious injury and treat conditions in

order of priority.

Hold the infant in the recovery position.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – regularly

until help arrives. Go to How to hold an infant in

the recovery position (below).

Ask a helper to call 999/112 for emergency

help. If you are on your own, perform CPR for

one minute before making the call yourself. Use

your mobile device set to speaker phone to make

the call or take the infant with you to the telephone

if necessary.

Begin CPR with FIVE initial rescue breaths. Go

to How to give CPR (pp.82–83).

2

1

1

2

Cradle the infant in your arms with his head

tilted downwards. This position prevents him

from choking on his tongue or from inhaling vomit.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – until

help arrives.

2

1

»

82

If you cannot achieve rescue breaths:

■■ Recheck the head tilt and chin lift

■■ Recheck the infant’s mouth and nose and remove

obvious obstructions. Do not do a finger sweep

■■ Check that you have a firm seal around the mouth

and nose

■■Make up to five attempts to achieve rescue breaths,

then begin chest compressions

If the infant vomits during CPR, roll him away from

you onto his side to allow the vomit to drain. Resume

CPR as soon as possible.

WHAT TO DO

Place the infant on his back on a firm surface,

at about waist height in front of you, or on the

floor. Make sure that the airway is still open by

keeping one hand on the infant’s forehead and one

fingertip of the other hand under the tip of his chin.

Take a breath. Place your lips around the

infant’s mouth and nose to form an airtight

seal. If this is not possible, close the infant’s mouth

and make a seal around the nose only. Blow gently

and steadily into the infant’s nose for one second;

the chest should rise.

Pick out any visible obstructions from mouth

and nose. Do not sweep the mouth with your

finger looking for obstructions.

Maintaining head tilt and chin lift, take your

mouth off the infant’s mouth and see if his

chest falls. If the chest rises visibly as you blow and

falls fully when you lift your mouth, you have given

a breath. Each complete rescue breath should take

one second. Give FIVE rescue breaths.

3

2 4

1

CAUTION

THE UNRESPONSIVE CASUALTY

«UNRESPONSIVE INFANT UNDER ONE YEAR

HOW TO GIVE CPR

83

Place two fingertips of your lower hand on the

centre of the infant’s chest. Press down

vertically on the infant’s breastbone and depress

his chest by at least one-third of its depth. Release

the pressure without moving your fingers from the

breastbone. Allow the chest to come back up fully

(recoil) before giving the next compression. The

time taken for compression and release should be

about the same. Repeat to give 30 compressions at

a rate of 100–120 times per minute.

Return to the infant’s head, open the airway

and give TWO further rescue breaths.

If you are on your own, alternate 30 chest

compressions with TWO rescue breaths (30:2)

for one minute then stop to call 999/112 for

emergency help. Continue CPR until: emergency

help arrives and takes over; the infant shows signs

of becoming responsive – such as coughing,

opening his eyes, speaking or moving – and starts

to breathe normally; or you become too exhausted

to continue.

6

5

7

UNRESPONSIVE INFANT

Place your fingers on the breastbone as indicated

here. Make sure that you do not apply pressure

over the ribs, the lower tip of the infant’s

breastbone or the upper abdomen.

HAND POSITION

Finger position Breastbone

Lower tip of

Upper breastbone

abdomen

Ribs

While it is better to give a combination of rescue

breaths and chest compressions, if you have not had

formal training in CPR, or if you are unwilling or

unable to give rescue breaths, you can give chest

compressions only. The emergency services will give

instructions for chest-compression-only CPR; put

your mobile device on speaker phone so you can

deliver first aid and talk to the ambulance dispatcher.

CHEST-COMPRESSION-ONLY CPR

With more than one rescuer, change every 1–2

minutes with minimal interruption to compressions.

CAUTION

84

HOW TO USE AN AED

When the heart stops, a cardiac arrest has occurred. The most

common cause is an abnormal rhythm of the heart, known as

ventricular fibrillation. This abnormal rhythm can occur when

the heart muscle is damaged as a result of a heart attack or when

insufficient oxygen reaches the heart. A machine called an AED

(automated external defibrillator) can be used on adults and

children over the age of one year to correct the heart rhythm

by giving an electric shock. AEDs can be used safely and

effectively without prior training. They are available in many

public places, including shopping centres, railway stations and

airports – the logo opposite will be visible on the outside of the

case. The machine analyses the casualty’s heart rhythm and

visual prompts or voice prompts describe the action to take at

each stage. In most situations when an AED is called for, you will

have already started CPR. When the AED is brought, continue

with CPR while the pads are being attached to the casualty.

THE UNRESPONSIVE CASUALTY

■■Make sure that no-one is

touching the casualty because

this will interfere with the AED

readings and there is a risk of

electric shock.

■■ Do not turn off the AED or

remove the pads at any point,

even if the casualty appears to

have recovered.

■■ It does not matter if the AED

pads are reversed. If you put

them on the wrong way round,

do not try to move them; it

wastes time and the pads may

not stick to the chest properly

when they are reattached.

CAUTION

The AED will start analysing

the heart rhythm. Ensure

that no-one is touching the

casualty. Follow the voice and/or

visual prompts given by the

machine (opposite).

4

WHAT TO DO

1 Switch on the AED and take the pads out 2

of the sealed pack. Remove or cut through

clothing and wipe away sweat from the chest

if necessary.

Remove the backing paper and attach the

pads to the casualty’s chest in the positions

indicated. Place the first pad on the casualty’s

upper right side, just below his collarbone.

Place the second pad on the

casualty’s left side, just

below his armpit (inset above).

Make sure the pad has its long

axis along the head-to-toe axis of

the casualty’s body.

3

85

The AED will start to give you a series of visual

and verbal prompts as soon as it is switched on.

There are several different AED models

available, each of which has different voice

prompts. Do not stop chest compressions while

the pads are applied. You should follow the

prompts given by the machine that you have

until advanced care arrives.

SEQUENCE OF AED INSTRUCTIONS

HOW TO USE AN AED

■■ Switch on the AED.

■■ Attach pads to casualty’s chest.

The AED re-analyses heart rhythm.

The AED re-analyses heart rhythm.

■■ If the casualty shows signs of becoming

responsive, such as coughing, opening his

eyes, speaking or moving purposefully and

starts to breathe normally, place him in the

recovery position (pp.64–65). Leave the AED

attached to the casualty.

AED advises that a shock is needed; the

machine charges up.

AED instructs you to deliver the shock.

■■ Make sure everyone is clear of the casualty.

■■ Depending on the type of AED, it will either

deliver the shock automatically or instruct you

to push the shock button. The casualty may

appear to “jump” with each shock; this is

quite normal.

AED instructs you to continue CPR for two

minutes before it re-analyses.

AED instructs you to continue CPR for two

minutes before it re-analyses heart rhythm.

AED advises that no shock is needed.

AED gets ready to analyse the casualty’s heart rhythm. It may state

“Stand clear, analysing now” or “Analysing”. Make sure that no-one is

touching the casualty while it is analysing.

Is a shock advised?

»

YES NO

European AED symbol

All AED cabinets feature

a form of this symbol on

the front. The European

standard one is green,

as here, but some

companies use other

colours.

86

The use of an AED is occasionally complicated by underlying

medical conditions, external factors, clothing or the cause of

the cardiac arrest. Safety of all concerned should always be

your first consideration.

CLOTHING AND JEWELLERY

Any clothing or jewellery that could interfere

with pads should be removed or cut away.

Normal amounts of chest hair are not a

problem, but if hair prevents good contact

between the skin and the pads, it should be

shaved off. Ensure any metal is removed from

the area where the pads will be attached.

Remove clothing containing metal, such as an

underwired bra.

EXTERNAL FACTORS

Water or excessive sweat on the chest can

reduce the effectiveness of the shock so the

chest should be dry. If a casualty is rescued

from water (p.36), dry the chest before applying

the AED pads.

If the casualty is unresponsive following an

electric shock, start CPR immediately the

contact with electricity is broken. The electric

current may cause muscle paralysis, which can

make rescue breaths and chest compressions

more difficult to perform, however, it will not

affect the use of the AED.

MEDICAL CONDITIONS

Some casualties with heart conditions have a

pacemaker or an implantable cardioverter

defibrillator (ICD). This should not stop you

using an AED. However, if you can see or feel a

device under the chest skin, do not place the

pad directly over it. If a casualty has a patch

such as a glyceryl trinitrate (GTN) patch on the

chest, remove it before you apply the AED.

PREGNANT CASUALTIES

There are no contra-indications to using an

AED during pregnancy; however, the increased

breast size may present some problems.

Therefore, to place the AED pads correctly, you

may need to move one or both breasts. This

must be carried out with respect and dignity.

CONSIDERATIONS WHEN USING AN AED

THE UNRESPONSIVE CASUALTY

Never use an AED on an infant

under one year.

CAUTION

«HOW TO USE AN AED

87

Standard adult AEDs can be used on children over the age of

eight years. For children between the ages of one and eight, use a

paediatric AED or a standard machine and paediatric pads. If

neither is available, then a standard AED and pads can be used.

When the emergency services arrive continue

to resuscitate the child until they take over from

you. They need to know:

■■Casualty’s present status; for example,

unresponsive and not breathing

■■Number of shocks you have delivered

■■When the casualty collapsed and the length

of time he has been unresponsive

■■Any relevant history, if known

If the casualty recovers at any point, leave the

AED pads attached to his chest. Ensure that

any used materials from the AED cabinet are

disposed of as clinical waste (p.238). Inform

the relevant person what has been taken out

of the cabinet as it will need to be replaced.

POSITIONING AED PADS ON CHILDREN

HANDING OVER TO THE EMERGENCY SERVICES

Positioning paediatric AED pads

Place one pad in the centre of the child’s back. Then

place the second pad over the centre of the child’s

chest. Make sure both pads are vertical. Connect the

pads to the AED and proceed as described on p.85.

Using AED pads on a larger child

Place the pads on the child’s chest as for an adult –

one on the child’s upper right side, just below his

collarbone, and the second pad on the child’s left side,

just below the armpit. Make sure the pad has its long

axis along the head-to-toe axis of the child’s body.

HOW TO USE AED

Never use an AED on an infant

under one year.

CAUTION

Oxygen is essential to life. Every time

we breathe in, air containing oxygen

enters the lungs. This oxygen is then

transferred to the blood, to be transported

around the body. Breathing and the

exchange of oxygen and carbon dioxide

(a waste product from body tissues) are

described as respiration. The structures

within the body that enable us to breathe –

the air passages and the lungs – together

make up the respiratory system, and work

with the heart and circulatory system.

Respiration can be impaired in several

different ways. The airways may be blocked

causing choking or suffocation, the

exchange of oxygen and carbon dioxide in

the lungs may be affected by the inhalation

of smoke or fumes, lung function may be

impaired by chest injury, or the breathing

mechanism may be affected by conditions

such as asthma. Anxiety can also cause

breathing difficulties. Problems with

respiration can be life-threatening and

need urgent first aid.

■■ To assess the casualty’s condition

■■ To identify and remove the cause of the problem and

provide fresh air

■■ To comfort and reassure the casualty

■■ To maintain an open airway, check breathing and be

prepared to resuscitate if necessary

■■ To obtain medical help if necessary. Call 999/112

for emergency help if you suspect a serious illness

or injury

AIMS AND OBJECTIVES

RESPIRATORY

PROBLEMS

90

RESPIRATORY PROBLEMS

THE RESPIRATORY SYSTEM

This system comprises the mouth, nose,

windpipe (trachea), lungs and pulmonary

blood vessels (the blood vessels of the lungs).

Respiration involves the process of breathing

and the exchange of gases (oxygen and carbon

dioxide) both in the lungs and in cells

throughout the body.

We breathe in air to take oxygen into the

lungs, and we breathe out to expel the waste

gas, carbon dioxide, a by-product of respiration.

When we breathe, air is drawn through the nose

and mouth into the airway and the lungs. In the

lungs, oxygen is taken from air sacs (alveoli) into

the pulmonary capillaries. At the same time,

carbon dioxide is released from the capillaries

into the alveoli. The carbon dioxide is then

expelled as we breathe out. An average man’s

lungs can hold approximately 6 litres (10 pints)

of air; a woman’s lungs can hold about 4 litres

(7 pints) of air.

Structure of the

respiratory system

The lungs form the central

part of the respiratory system.

Together with the circulatory

system, they perform the vital

function of gas exchange in order to

distribute oxygen around the body

and remove carbon dioxide.

Gas exchange in air sacs

A network of tiny blood vessels

(capillaries) surrounds each air sac

(alveolus). The thin walls of both

structures allow oxygen to diffuse into

the blood and carbon dioxide to leave it.

Epiglottis

Pulmonary

capillary

Alveolus

Larynx

Ribs surround

and protect the

chest cavity

Windpipe (trachea)

extends from the larynx to

two main bronchi

Intercostal muscles

span spaces

between ribs

Lungs are two

spongy organs that

occupy a large part

of the chest cavity

Pleural membrane, which

has two layers separated

by a lubricating fluid,

surrounds and protects

each of the lungs

Diaphragm is a sheet of muscle

that separates chest and

abdominal cavities

Bronchioles are small

air passages that

branch from bronchi

and eventually open

into air sacs (alveoli)

within the lungs

Windpipe divides into

two main bronchi (sing.

bronchus), one to each

lung, further subdivide

into smaller bronchi,

then bronchioles

Bronchiole

91

THE RESPIRATORY SYSTEM

The breathing process consists of the actions

of breathing in (inspiration) and breathing out

(expiration), followed by a pause. Pressure

differences between the lungs and the air

outside the body determine whether air is

drawn in or expelled. When the air pressure

in the lungs is lower than outside, air is drawn

in; when pressure is higher, air is expelled. The

pressure within the lungs is altered by the

movements of the two main sets of muscles

involved in breathing: the intercostal muscles

and the diaphragm.

Breathing is regulated by a group of nerve cells

in the brain called the respiratory centre. This

centre responds to changes in the level of

carbon dioxide in the blood. When the carbon

dioxide level in the body rises, the respiratory

centre reacts by stimulating the intercostal

muscles and the diaphragm to contract, and a

breath occurs. Our breathing rate can be altered

consciously under normal conditions or in

response to abnormal levels of carbon dioxide,

low levels of oxygen, or with stress, exercise,

injury or illness.

HOW BREATHING WORKS

HOW BREATHING IS CONTROLLED

Breathing in

The intercostal muscles (the muscles between the ribs)

and the diaphragm contract, causing the ribs to move

up and out, the chest cavity to expand, and the lungs to

expand to fill the space. As a result, the pressure inside

the lungs is reduced, and air is drawn into the lungs.

Breathing out

The intercostal muscles relax, and the ribcage returns to

its resting position, while the diaphragm relaxes and

resumes its domed shape. As a result, the chest cavity

becomes smaller, and pressure inside the lungs

increases. Air flows out of the lungs to be exhaled.

Lung

inflates

Lung

deflates

Intercostal muscles

between ribs contract

Ribs rise and

swing outwards

Diaphragm returns to

domed position

Intercostal muscles

between ribs relax

Ribs move down

and inwards

Diaphragm contracts and

moves down

92

RESPIRATORY PROBLEMS

HYPOXIA

SEE ALSO Anaphylactic shock p.223 | Asthma p.102 | Burns to the airway p.177 | Croup p.103 | Drowning p.100 |

Hanging and strangulation p.97 | Inhalation of fumes pp.98–99 | Penetrating chest wound pp.104–05 | Stroke pp.212–13

In moderate and severe hypoxia,

there will be:

■■ Rapid breathing

■■ Breathing that is distressed or

gasping

■■ Difficulty speaking

■■ Grey-blue skin (cyanosis). At first,

this is more obvious in the

extremities, such as lips, nailbeds

and earlobes, but as the hypoxia

worsens cyanosis affects the rest

of the body

■■ Anxiety

■■ Restlessness

■■ Headache

■■ Nausea and possibly vomiting

■■ Cessation of breathing if the hypoxia

is not quickly reversed

RECOGNITION This condition arises when there is insufficient oxygen in the

body tissues. There are a number of causes of hypoxia, ranging

from suffocation, choking or poisoning to impaired lung or brain

function. The condition is accompanied by a variety of

symptoms, depending on the degree of hypoxia. If not treated

quickly, hypoxia is potentially fatal because a sufficient level of

oxygen is vital for the normal function of all the body organs and

tissues, especially the brain.

In a healthy person, the amount of oxygen in the air is more

than adequate for the body tissues to function normally.

However, in an injured or ill person, a reduction in oxygen

reaching the tissues results in deterioration of body function.

Mild hypoxia reduces a casualty’s ability to think clearly, but

the body normally responds to this by increasing the rate and

depth of breathing (p.91). However, if the oxygen supply to the

brain cells is cut off for as little as three to four minutes, the

brain cells will begin to die. All the conditions covered in this

chapter can result in hypoxia.

■■Suffocation by smoke or gas ■ Changes in atmospheric pressure, for

example, at high altitude or in a depressurised aircraft

Insufficient oxygen in inspired air

INJURY OR CONDITION

INJURIES OR CONDITIONS CAUSING LOW BLOOD OXYGEN (HYPOXIA)

CAUSES

Airway obstruction

Conditions affecting the chest wall

Impaired lung function

Damage to the brain or nerves

that control respiration

Impaired oxygen uptake by

the tissues

■ Blocking or swelling of the airway ■ Hanging or strangulation

■ Something covering the mouth or nose ■ Asthma ■ Choking

■ Anaphylaxis

■ Crushing, for example, by a fall of earth or sand or pressure from a crowd

■ Chest wall injury with multiple rib fractures or constricting burns

■ Lung injury ■ Collapsed lung ■ Lung infections, such as pneumonia

■ A head injury or stroke that damages the breathing centre in the brain

■ Some forms of poisioning ■ Paralysis of nerves controlling the

muscles of breathing, as in spinal cord injury

■■Carbon monoxide or cyanide poisioning ■ Shock

93

HYPOXIA | AIRWAY OBSTRCTION

AIRWAY OBSTRUCTION

SEE ALSO Asthma p.102 | Burns to the airway p.177 | Choking adult p.94 | Choking child p.95 |

Choking infant p.96 | Drowning p.100 | Hanging and strangulation p.97 | Inhalation of fumes pp.98–99

The airway may be obstructed externally or internally, for

example, by an object that is stuck at the back of the throat

(pp.94–96). The main causes of obstruction are:

■■Inhalation of an object, such as food

■■ Blockage by the tongue, blood or vomit while a casualty is

unresponsive (p.59)

■■Internal swelling of the throat occurring with burns, scalds,

stings or anaphylaxis

■■Injuries to the face or jaw

■■An asthma attack in which the small airways in the lungs

constrict (p.102)

■■External pressure on the neck, as in hanging or strangulation.

■■Peanuts, which can swell up when in contact with body fluids.

These pose a particular danger in young children because they

can completely block the airway

Airway obstruction requires prompt action; be prepared to give

chest compressions and rescue breaths if the casualty stops

breathing (The unresponsive casualty, pp.54–87).

The information on this page is appropriate for all causes of

airway obstruction, but if you need detailed instructions for

specific situations, refer to the relevant pages given below.

■■ Features of hypoxia (opposite), such

as grey-blue tinge to the lips,

earlobes and nailbeds (cyanosis)

■■ Difficulty speaking and breathing

■■ Noisy breathing

■■ Red, puffy face

■■ Signs of distress from the casualty,

who may point to the throat or grasp

the neck

■■ Flaring of the nostrils

■■ A persistent cough

■■ To remove the obstruction

■■ To restore normal breathing

■■ To arrange removal to hospital

■■ If the casualty is unresponsive,

open the airway and check

breathing (The unresponsive

casualty, pp.54–87).

CAUTION

WHAT TO DO

Remove the obstruction

if it is external or visible in

the mouth.

Even if the casualty appears

to have made a complete

recovery, call 999/112 for

emergency help. Monitor and

record his vital signs – breathing,

pulse and level of response

(pp.52–53) – until help arrives.

If the casualty is responsive

and breathing normally,

reassure him, but keep him

under observation.

3

2

1

RECOGNITION

YOUR AIMS

94

RESPIRATORY PROBLEMS

CHOKING ADULT

SEE ALSO Unresponsive adult pp.62–71

WHAT TO DO

If the casualty is breathing,

encourage her to continue

coughing. Remove any obvious

obstruction from the mouth.

Check her mouth. If

the obstruction has not

cleared, call 999/112 for

emergency help.

Repeat steps 2 and 3 –

rechecking the mouth

after each step – until help

arrives or the casualty

becomes unresponsive (see

CAUTION, above, left).

If back blows fail to clear the

obstruction, try abdominal

thrusts. Stand behind the

casualty and put both arms

around the upper part of her

abdomen. Make sure that she is

still bending well forwards.

Clench your fist and place it

between the navel and the

bottom of her breastbone. Grasp

your fist firmly with your other

hand. Pull sharply inwards and

upwards up to five times.

If the casualty cannot speak

or stops coughing or

breathing, carry out back blows.

Support her upper body with one

hand, and help her to lean well

forward. Give up to five sharp

blows between her shoulder

blades with the heel of your

hand. Stop if the obstruction

clears. Check her mouth.

3

4

5

2

1

A foreign object that is stuck in the throat may block it and

cause muscular spasm. If blockage of the airway is mild, the

casualty should be able to clear it; if it is severe, she will be

unable to speak, cough or breathe, and will eventually become

unresponsive. If she is unresponsive the throat muscles may

relax and the airway may open enough to do rescue breathing. Be

prepared to begin rescue breaths and chest compressions.

Ask the casualty: “Are you

choking?”

Mild obstruction:

■■ Casualty able to speak, cough and

breathe

Severe obstruction:

■■ Casualty unable to speak, cough or

breathe, and eventually becomes

unresponsive

■■ To remove the obstruction

■■ To arrange urgent removal to

hospital if necessary

RECOGNITION

YOUR AIMS

■■ If at any stage the casualty

becomes unresponsive, open

the airway and check breathing

(p.63). If she is not breathing,

begin CPR (pp.66–69) to try to

relieve the obstruction.

CAUTION

95

CHOKING ADULT | CHOKING CHILD

CHOKING CHILD ONE YEAR TO PUBERTY

■■ To remove the obstruction

■■ To arrange urgent removal

to hospital if necessary

Ask the child: “Are you choking?”

Mild obstruction:

■■ Child able to speak, cough and

breathe

Severe obstruction:

■■ Child unable to speak, cough or

breathe, and eventually becomes

unresponsive

■■ If at any stage the child

becomes unresponsive, open

the airway and check breathing

(p.73). If she is not breathing,

begin CPR to try to relieve the

obstruction (pp.76–79).

Young children especially are prone to choking. A child may

choke on food, or may put small objects into her mouth and

cause a blockage of the airway.

If a child is choking, you need to act quickly. If she becomes

unresponsive, the throat muscles may relax and the airway

may open enough to do rescue breathing. Be prepared to

begin rescue breaths and chest compressions.

CAUTION

WHAT TO DO

If the child is breathing,

encourage her to cough;

this may clear the obstruction.

Remove any obvious obstruction

from her mouth.

If the back blows fail, try

abdominal thrusts. Put your

arms around the child’s upper

abdomen. Make sure that she is

bending well forwards. Place

your fist between the navel and

the bottom of her breastbone,

and grasp it with your other

hand. Pull sharply inwards and

upwards up to five times. Stop

if the obstruction clears.

If the child cannot speak, or

stops coughing or breathing,

carry out back blows. Bend her

well forward and give up to five

blows between her shoulder

blades using the heel of your

hand. Check her mouth, but do

not sweep the mouth with

your finger.

Check the mouth. If

the obstruction has not

cleared, call 999/112 for

emergency help.

Repeat steps 2 and 3 –

rechecking the mouth after

each step – until help arrives or

the child becomes unresponsive

(see CAUTION, above, right).

3

2

1

4

5

YOUR AIMS

RECOGNITION

SEE ALSO Unresponsive child pp.72–79

96

RESPIRATORY PROBLEMS

CHOKING INFANT UNDER ONE YEAR

SEE ALSO Unresponsive infant pp.80–83

■■ To remove the obstruction

■■ To arrange urgent removal

to hospital if necessary

Mild obstruction:

■■ Infant able to cough, but has

difficulty crying or making any

other noise

Severe obstruction:

■■ Unable to make any noise or

breathe, and eventually becomes

unresponsive

■■ If at any stage the infant

becomes unresponsive, open

the airway and check breathing

(pp.80–81). If the infant is not

breathing, begin CPR (pp.82–83)

to try to relieve the obstruction.

An infant is more likely to choke on food or small objects than

an adult. The infant will rapidly become distressed, and you need

to act quickly to clear any obstruction. If the infant becomes

unresponsive, the throat muscles may relax and the airway may

open enough to do rescue breathing. Be prepared to begin

rescue breaths and chest compressions.

CAUTION

WHAT TO DO

If the infant is unable to cry,

cough or breathe, lay her

face down along your forearm

and thigh and support her head.

Give up to five back blows

between the shoulder blades,

with the heel of your hand.

If back blows fail to clear

the obstruction, try chest

thrusts. These are similar to

chest compressions, but sharper

in nature and delivered at a

slower rate. Lay the infant face

up on your leg, place two fingers

on the lower part of the

breastbone one finger’s breadth

below the nipple line and push

downwards. Give up to five

chest thrusts.

Check the mouth. If the

obstruction still has not

cleared, call 999/112 for

emergency help; take the infant

with you if necessary.

Repeat steps 1 to 3 –

rechecking the mouth after

each step – until help arrives or

the infant becomes unresponsive

(see CAUTION, above left).

3

2

1

4

5

YOUR AIMS

RECOGNITION

Turn the infant over so

that she is face up along

your other leg and check her

mouth. Remove any obvious

obstructions with your

fingertips. Do not sweep the

mouth with your finger as this

may push the object further

down the throat.

97

CHOKING INFANT | HANGING AND STRANGULATION

HANGING AND STRANGULATION

SEE ALSO Spinal injury pp.157–59 | The unresponsive casualty pp.54–87

If pressure is exerted on the outside of the neck, the airway is

squeezed and the flow of air to the lungs is cut off. The main

causes of such pressure are:

■■Hanging – suspension of the body by a noose around

the neck.

■■Strangulation – constriction or squeezing around the neck

or throat.

Sometimes, hanging or strangulation may occur accidentally –

for example, by ties or clothing becoming caught in machinery.

Hanging may cause a broken neck; for this reason, a casualty in

this situation must be handled extremely carefully.

■■ A constricting article around

the neck

■■Marks around the casualty’s neck

■■ Rapid, difficult breathing; impaired

consciousness; grey-blue skin

(cyanosis)

■■ Congestion of the face, with

prominent veins and, possibly, tiny

red spots on the face or on the

whites of the eyes

■■ To restore adequate breathing

■■ To arrange urgent removal

to hospital

■■ Do not move the casualty

unnecessarily, in case of spinal

injury.

■■ Do not destroy or interfere with

any material that has been

constricting the neck, such as

knotted rope as the police may

need it for evidence.

■■ If the casualty is unresponsive,

open the airway and check

breathing (The unresponsive

casualty, pp.54–87).

CAUTION

WHAT TO DO

If the casualty is hanging,

support the body while

you relieve the constriction. Be

aware that the body will be very

heavy if he is unresponsive.

Quickly remove any

constriction from around

the casualty’s neck.

Call 999/112 for emergency

help, even if he appears to

recover fully. Monitor and record

his vital signs – breathing, pulse

and level of response (pp.52–53)

– until help arrives.

If the casualty is responsive,

help him to lie down while

supporting his head and neck.

4

3

2

1

RECOGNITION

YOUR AIMS

98

RESPIRATORY PROBLEMS

INHALATION OF FUMES

The inhalation of smoke, gases (such as carbon

monoxide) or toxic vapours can be lethal. A

casualty who has inhaled fumes is likely to have

low levels of oxygen in his body tissues

(Hypoxia, p.92) and therefore needs urgent

medical attention.

Do not attempt to carry out a rescue if it is

likely to put your own life at risk; fumes that

have built up in a confined space will quickly

overcome anyone who is not wearing

protective equipment.

SMOKE INHALATION

Any person who has been enclosed in a

confined space during a fire should be assumed

to have inhaled smoke. Smoke from burning

plastics, foam padding and synthetic wall

coverings is likely to contain poisonous fumes.

Casualties who have suffered from fume

inhalation should also be examined for other

injuries due to the fire, such as external burns.

INHALATION OF CARBON

MONOXIDE

Carbon monoxide is a poisonous gas, but it is

hard to detect as it has no taste or smell. The

gas acts directly on red blood cells, preventing

them from carrying oxygen to the body tissues.

If carbon monoxide is inhaled in large

quantities – for example, from smoke or

vehicle exhaust fumes in a confined space –

it can very quickly prove fatal. However,

lengthy exposure to even a small amount of

carbon monoxide – for example, due to a

leakage of fumes from a defective heater or

flue – may also prove fatal.

■ Exhaust fumes of motor vehicles ■ Smoke

from most fires ■ Back-draughts from blocked

chimney flues ■ Emissions from defective gas

or paraffin heaters and poorly maintained

boilers ■ Disposable or portable barbeques

used in a confined space

Prolonged exposure to low levels:

■ Headache ■ Confusion ■ Aggression ■ Nausea

and vomiting ■ Diarrhoea

Brief exposure to high levels:

■ Grey-blue skin coloration ■ Rapid, difficult breathing

■ Impaired level of response, leading to

unresponsiveness

Carbon

monoxide

FUMES

EFFECTS OF FUME INHALATION

POSSIBLE SOURCE EFFECTS

Smoke

Carbon

dioxide

Solvents

and fuels

■ Tends to accumulate and become dangerously

concentrated in deep enclosed spaces, such as

coal pits, wells and underground tanks

■ Fires: smoke is a bigger killer than fire itself.

Smoke is low in oxygen (which is used up by the

burning of the fire) and may contain toxic fumes

from burning materials.

■ Breathlessnes ■ Headache ■ Confusion

■ Unresponsiveness

■ Rapid, noisy and difficult breathing ■ Coughing and

wheezing ■ Burning in the nose or mouth ■ Soot

around the mouth and nose ■ Unresponsiveness

■ Glues ■ Cleaning fluids ■ Lighter fuels

■ Camping gas and propane-fuelled stoves

(Solvent abusers may use a plastic bag to

concentrate the vapour, especially with glues)

■ Headache and vomiting ■ Impaired level of

response ■ Airway obstruction from using a plastic

bag or from choking on vomit may result in death ■

Solvent abuse is a potential cause of cardiac arrest

99

INHALATION OF FUMES

WHAT TO DO

Call 999/112 for emergency

help. Tell ambulance control

that you suspect fume

inhalation.

Stay with the casualty until

help arrives. Monitor and

record the casualty’s vital

signs – breathing, pulse and level

of response (pp.52–53) – until

help arrives.

If it is necessary to escape

from the source of the

fumes, help the casualty away

from the fumes into fresh air.

Do not enter the fume-filled

area yourself.

Support the casualty and

encourage him to breathe

normally. If the casualty’s

clothing is still burning, try to

extinguish the flames (p.33).

Treat any obvious burns

(pp.174–77) or other injuries.

2 4

1 3 ■■ If the casualty is in a garage

filled with vehicle exhaust

fumes, open the doors wide

and let the gas escape before

you enter.

■■ If the casualty is found

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

CAUTION

■■ To restore adequate breathing

■■ To call 999/112 for emergency help

and obtain urgent medical attention

YOUR AIMS

SEE ALSO Burns to the airway p.177 | Fires pp.32–33 | Hypoxia p.92 | The unresponsive casualty pp.54–87

100

RESPIRATORY PROBLEMS

DROWNING

SEE ALSO The unresponsive casualty pp.54–87 | Hypothermia pp.186–88 | Water incidents p.36

Drowning causes breathing impairment as a result of

submersion or immersion in a liquid. Drowning begins when a

casualty is unable to breathe because the nose, mouth and air

passages are submerged below the surface of a liquid. Any

incident involving immersion when there is no problem with

breathing is not defined as drowning but as a rescue (p.36).

A casualty rescued from a drowning incident must be assessed

using the primary survey (pp.44–45) to establish whether or not

CPR is required. If he is unresponsive and not breathing, give five

initial rescue breaths before you start chest compressions, then

continue with CPR at a rate of 30 chest compressions to two

rescue breaths. Always call 999/112 for the emergency services.

■■ To restore breathing

■■ To arrange urgent removal to hospital

■■ Take care to avoid putting yourself

in danger when rescuing a person

from water (p.36).

■■ If the liquid is a chemical or a

waste liquid such as in a slurry

tank be aware that there may be

toxic fumes in the atmosphere.

■■Many casualties who drown may

regurgitate stomach contents so

be prepared to roll him onto his

side to clear his airway (p.68).

■■ If you are a trained rescuer and it

is safe to do so, start rescue

breaths while removing the

casualty from the liquid.

■■ Call 999/112 for emergency help

even if a casualty appears to

recover immediately after rescue.

CAUTION

YOUR AIMS

WHAT TO DO

When the casualty is rescued from liquid

(p.36), start the primary survey. Check his level

of response, open his airway and check breathing.

Continue CPR at a rate of 30:2 until help

arrives; the casualty shows signs of becoming

responsive – coughing, opening his eyes, speaking,

or moving purposefully – and starts breathing

normally; or you are too exhausted to continue.

If he is unresponsive and not breathing

normally, shout for help and call 999/112 for

emergency help or ask someone to make the call

and request an AED.

2

1 4

If an AED is available attach while continuing

CPR (pp.84–86). 5

If the casualty starts to breathe normally,

treat him for hypothermia (pp.186–87) by

covering him with warm clothes and blankets.

If possible replace wet clothes with dry

ones. Monitor and record the casualty’s vital

signs – breathing, pulse and level of response

(pp.52–53) until help arrives.

Check that the airway is open and give FIVE 6

initial rescue breaths. Follow this with 30 chest

compressions, then TWO rescue breaths.

3

DROWNING CHAIN

OF SURVIVAL

Prevent drowning

Always be safe in

and around water.

Recognize distress

Ask someone to call

for help.

Provide flotation

This can prevent

submersion.

Remove from water

Do this only if it is

safe to do so.

Provide care as needed

Seek medical attention

and treat as necessary.

101

DROWNING | HYPERVENTILATION

HYPERVENTILATION

WHAT TO DO

When speaking to the casualty be kind and reassuring. If

possible, lead the casualty away to a quiet place where she may

be able to regain control of her breathing more easily and quickly. If

this is not possible, ask any bystanders to leave.

Encourage the casualty to seek medical advice on preventing and

controlling panic attacks in the future. 2

1

This is commonly a manifestation of acute anxiety and may

accompany a panic attack. It may occur in individuals who have

recently experienced an emotional upset or those with a history

of panic attacks.

The unnaturally fast or deep breathing of hyperventilation

causes an increased loss of carbon dioxide from the blood, which

leads to chemical changes within the blood. These changes result

in symptoms such as dizziness and trembling, as well as tingling

in the hands. As breathing returns to normal, these symptoms

will gradually subside.

■■ Unnaturally fast or deep breathing

■■ Fast pulse rate

■■ Apprehension

There may also be:

■■ Dizziness or faintness

■■ Trembling, sweating and dry mouth,

or marked tingling in the hands

■■ Tingling and cramps in the hands and

feet and around the mouth

■■ To remove the casualty from the

cause of distress

■■ To reassure the casualty and calm

her down

■■ Do not advise the casualty to

rebreathe her own air from a

paper bag as it may aggravate

a more serious illness.

■■ Hyperventilation due to acute

anxiety is rare in children. Look

for other causes.

■■ Be aware that serious illness

may also cause rapid breathing

and anxiety.

CAUTION

RECOGNITION

YOUR AIMS

102

RESPIRATORY PROBLEMS

ASTHMA

In an asthma attack, the muscles of the air passages in

the lungs go into spasm. As a result, the airways become

narrowed, which makes breathing difficult.

Sometimes, there is a recognised trigger for an attack, such

as an allergy, a cold, a particular drug or cigarette smoke. At

other times, there is no obvious trigger. Many sufferers have

sudden attacks.

People with asthma usually deal with their own attacks by

using a “reliever” inhaler at the first sign of an attack. Most

reliever inhalers have blue caps. Preventer inhalers have brown

or white caps and are used to help prevent attacks. They should

not be used during an asthma attack.

WHAT TO DO

Keep calm and reassure

the casualty. Get her to

take her usual dose of her reliever

inhaler; use a spacer if she has

one. Ask her to breathe slowly

and deeply.

Sit her down in the position

she finds most comfortable.

A mild attack should ease

within a few minutes. If it

does not, the casualty may take

one to two puffs from her

inhaler every two minutes until

she has had ten puffs.

Call 999/112 for emergency

help if the attack is severe

and one of the following occurs:

the inhaler has no effect; the

casualty is getting worse;

breathlessness makes talking

difficult; she is becoming

exhausted.

Help the casualty to

continue to use her inhaler

as required. Monitor her vital

signs – breathing, pulse and level

of response (pp.52–53) – until

help arrives.

2

1

3

4

5

■■ Difficulty breathing

■■Wheezing

■■ Difficulty speaking, leading to short

sentences and whispering

■■ Coughing

■■ Distress and anxiety

■■ Features of hypoxia (p.92), such as a

grey-blue tinge to the lips, earlobes

and nailbeds (cyanosis)

■■ Exhaustion in a severe attack. If the

attack worsens the casualty may

stop breathing and become

unresponsive

■■ To ease breathing

■■ To obtain medical help

if necessary

■■ If this is a first attack and the

casualty has no medication call

999/112 for emergency help

immediately.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty

pp.54–87).

CAUTION

RECOGNITION

YOUR AIMS

A spacer device can be fitted

to an asthma inhaler to help

a casualty breathe in the

medication more effectively.

They are especially useful

when giving medication to

young children.

SPECIAL CASE USING A SPACER DEVICE

103

ASTHMA | CROUP

CROUP

WHAT TO DO

Sit your child on your knee, supporting her back. Calmly reassure

the child. Try not to panic; this will only alarm her, which is likely

to make the attack worse.

Call medical help or, if

the croup is severe, call

999/112 for emergency help.

Keep monitoring her vital signs –

breathing, pulse and level of

response (pp.52–53) – until

help arrives.

1

2

An attack of breathing difficulty in young children is known

as croup. It is caused by inflammation in the windpipe and larynx.

Croup can be alarming but usually passes without lasting harm.

Attacks of croup usually occur at night and can be made worse

if the child is crying and distressed.

If an attack of croup persists, or is severe, and accompanied by

fever, call for emergency help. There is a small risk that the child

is suffering from a rare, croup-like condition called epiglottitis,

in which the epiglottis (p.90), a small, flap-like structure in the

throat, becomes infected and swollen and may block the airway

completely. The child then needs urgent medical attention.

■■ Distressed breathing in a young child

There may also be:

■■ A short, barking cough

■■ A rasping noise, especially on

breathing in (stridor)

■■ Croaky voice

■■ Blue-grey skin (cyanosis)

■■ In severe cases, the child uses

muscles around the nose, neck and

upper arms in trying to breathe

Suspect epiglottitis if:

■■ A child is in respiratory distress and

not improving

■■ The child has a high temperature

■■ To comfort and support the child

■■ To obtain medical help if necessary

■■ Do not put your fingers down

the child’s throat. This can cause

the throat muscles to go into

spasm and block the airway.

CAUTION

RECOGNITION

YOUR AIMS

104

RESPIRATORY PROBLEMS

PENETRATING CHEST WOUND

SEE ALSO Hypoxia p.92 | Shock pp.112–13 | The unresponsive casualty pp.54–87

The heart and lungs, and the major blood vessels around them,

lie in the chest, protected by the breastbone and the 12 pairs of

ribs that make up the ribcage. The ribcage extends far enough

downwards to protect organs such as the liver and spleen in the

upper part of the abdomen.

If a sharp object penetrates the chest wall, there may

be severe damage to the organs in the chest and the upper

abdomen and this will lead to shock. The lungs are particularly

susceptible to injury, either by being damaged themselves or

from wounds that perforate the two-layered membrane (pleura)

that surrounds and protects each lung. Air can then enter

between the membranes and exert pressure on the lung, and

the lung may collapse – a condition called pneumothorax.

Pressure around the affected lung may build up to such

an extent that it affects the uninjured lung. As a result, the

casualty becomes increasingly breathless. This build-up of

pressure may prevent the heart from refilling with blood

properly, impairing the circulation and causing shock – a

condition known as a tension pneumothorax. If the wound is

not actively bleeding, it is important to leave it exposed,

without a dressing.

■■ To seal the wound and maintain

breathing

■■ To minimise shock

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ Difficult and painful breathing,

possibly rapid, shallow and uneven

■■ Casualty feels an acute sense of

alarm

■■ Features of hypoxia (p.92), including

grey-blue skin coloration (cyanosis)

There may also be:

■■ Coughed-up frothy, red blood

■■ A crackling feeling of the skin around

the site of the wound, caused by air

collecting in the tissues

■■ Blood bubbling out of the wound

■■ Sound of air being sucked into the

chest as the casualty breathes in

■■ Veins in the neck becoming

prominent

RECOGNITION

Pleural

membranes

Pressure

balance

Lung

pulled

out

Pressure

balance

maintained

Chest wall

pulled out

Pooled blood in

pleural cavity

Normal breathing

The lungs inflate by being pulled out as they “suck”

onto the chest wall. Pressure is maintained within

the fluid-filled pleural space.

Collapsed (right) lung

Air from the right lung enters the surrounding pleural

space and changes the pressure balance. The lung

shrinks away from the chest wall.

Pleural space

Entry

of air

Rupture

site

Rib

Air enters

lung

Bronchus Lung collapses

inwards

105

PENETRATING CHEST WOUND

Help the casualty to sit down. Encourage him to lean towards the

injured side. Leave the wound exposed, without a dressing. 1

SPECIAL CASE IF THE CASUALTY IS UNRESPONSIVE

If the casualty is unresponsive,

open the airway and check breathing

(The unresponsive casualty,

pp.54–87). If you need to place a

breathing casualty in the recovery

position, roll him on to his injured

side to help the healthy lung to

work effectively (p.64).

If the wound is obviously bleeding, control with direct pressure

and, if necessary, apply a dressing. 2

Call 999/112 for emergency

help. While waiting for help,

continue to support the casualty

in the same position as long as

he continues to be responsive.

3 Monitor and record the

casualty’s vital signs –

breathing, pulse and level of

response (pp.52–53) – until

help arrives.

4

WHAT TO DO

The heart and blood vessels are

collectively known as the circulatory

(cardiovascular) system. This system keeps

the body supplied with blood, which carries

oxygen and nutrients to all body tissues.

The circulatory system may be disrupted by

severe internal or external bleeding or fluid

loss, for example from burns (pp.174–79).

The techniques described in this section

show how you can help to maintain an

adequate blood supply to the heart and

brain following injury that affects the

circulatory system.

A break in the skin or the internal body

surfaces is known as a wound. Wounds can

be daunting, particularly if there is a lot of

bleeding, but prompt action reduces the

amount of blood loss and minimises shock.

Treatments for all types of wound are

covered in this chapter.

■■ To assess the casualty’s condition quickly and calmly

■■ To control blood loss by applying pressure and

elevating the injured part

■■ To minimise the risk of shock

■■ To comfort and reassure the casualty

■■ To call 999/112 for emergency help if you suspect

a serious injury or illness

■■ To be aware of your own needs, including the need to

protect yourself against blood-borne infections

AIMS AND OBJECTIVES

WOUNDS AND

BLEEDING

108

THE HEART AND BLOOD VESSELS

KEY

The heart and the blood vessels make up the

circulatory system. These structures supply

the body with a constant flow of blood, which

brings oxygen and nutrients to the tissues and

carries waste products away.

Blood is pumped around the body by

rhythmic contractions (beats) of the heart

muscle. The blood runs through a network

of vessels, divided into three types: arteries,

veins and capillaries. The force that is exerted

by the blood flow through the main arteries

is called blood pressure. The pressure varies

with the strength and phase of the

heartbeat, the elasticity of the arterial

walls and the volume and thickness

of the blood.

WOUNDS AND BLEEDING

How blood circulates

Oxygenated blood passes

from the lungs to the heart,

then travels to body tissues via the

arteries. Blood that has given up its

oxygen (deoxygenated blood) returns

to the heart through the veins.

Capillary networks

A network of fine blood vessels

(capillaries) links arteries and veins within

body tissues. Oxygen and nutrients pass

from the blood into the tissues; waste

products pass from the tissues into the

blood, through capillaries. The heart

This muscular organ pumps blood

around the body and then to the

lungs to pick up oxygen. Coronary

blood vessels supply the heart

muscle with oxygen and nutrients.

Carotid artery

Brachial vein

Jugular vein

Aorta

Heart

muscle

Superior

vena cava

Coronary

artery

Inferior

vena cava

Capillary

Small artery

(arteriole)

Small vein

(venule)

Radial vein

Femoral vein

Pulmonary arteries carry

deoxygenated blood to

lungs

Pulmonary veins carry

oxygenated blood from

lungs to heart

Heart pumps blood

around body

Vena cava carries

deoxygenated blood from

body tissues to heart

Brachial artery

Radial artery

Femoral artery

Aorta carries oxygenated

blood to body tissues

Pulmonary

artery

Vessels carrying oxygenated blood

Vessels carrying deoxygenated blood

109

KEY

The heart pumps blood by muscular

contractions called heartbeats, which are

controlled by electrical impulses generated

in the heart. Each beat has three phases:

diastole, when the blood enters the heart; atrial

systole, when it is squeezed out of the atria

(collecting chambers); and ventricular systole,

when blood leaves the heart.

In diastole, the heart relaxes. Oxygenated

blood from the lungs flows via the pulmonary

veins into the left atrium. Blood that has given

up its oxygen to body tissues (deoxygenated

blood) flows from the venae cavae (large veins

that enter the heart) into the right atrium.

In atrial systole, the two atria contract and the

valves between the atria and the ventricles

(pumping chambers) open so that blood flows

into the ventricles.

During ventricular systole, the ventricles

contract. The thick-walled left ventricle forces

blood into the aorta (main artery), which carries

it to the rest of the body. The right ventricle

pumps blood into the pulmonary arteries, which

carry it to the lungs to collect more oxygen.

HOW THE HEART FUNCTIONS

THE HEART AND BLOOD VESSELS

Blood flow through the heart

The heart’s right side pumps deoxygenated blood from

the body to the lungs. The left side pumps oxygenated

blood to the body via the aorta.

The blood cells

Red blood cells contain haemoglobin,

a red pigment that enables the cells

to carry oxygen. White blood cells

play a role in defending the body

against infection. Platelets help the

blood to clot.

Right atrium

Right ventricle

Valve

Left

ventricle

White blood cell

Platelet

Left atrium

Ascending aorta carries

blood to upper body

Superior vena

cava carries

blood from

upper body

Inferior vena

cava carries

blood from

lower body

Descending aorta carries

blood to lower body

Pulmonary arteries

carry deoxygenated

blood to lungs

Red blood cell

There are about 6 litres (10 pints), or 1 litre per

13kg of body weight (1 pint per stone), of blood

in the average adult body. Roughly 55 per cent

of the blood is clear yellow fluid (plasma). In

this fluid are suspended the red and white

blood cells and the platelets, all of which

make up the remaining 45 per cent.

COMPOSITION OF BLOOD

Vessels carrying oxygenated blood

Vessels carrying deoxygenated blood

110

BLEEDING AND TYPES OF WOUND

When a blood vessel is damaged, the vessel

constricts, and a series of chemical reactions

occur to form a blood clot – a “plug” over the

damaged area (below). If large blood vessels are

torn or severed, uncontrolled blood loss may

occur before clotting can take place, and shock

(pp.112–13) may develop.

TYPES OF BLEEDING

Bleeding (haemorrhage) is classified by the type

of blood vessel that is damaged. Arteries carry

oxygenated blood under pressure from the

heart. If an artery is damaged, bleeding will

be profuse. Blood will spurt out with each

heartbeat. If a main artery is severed, the

volume of circulating blood will fall rapidly.

Blood from veins, having given up its oxygen

into the tissues, is darker red. It is under less

pressure than arterial blood, but vein walls can

widen greatly and the blood can “pool” inside

them (varicose vein). If a large or varicose vein

is damaged, blood will flow from the wound

profusely and blood volume can fall rapidly.

Bleeding from capillaries occurs with any

wound. At first, bleeding may be brisk, but

blood loss is usually slight. A blow may rupture

capillaries under the skin, causing bleeding into

the tissues (bruising).

When a blood vessel is severed or damaged,

it constricts (narrows) in order to prevent

excessive amounts of blood from escaping.

Injured tissue cells at the site of the wound,

together with specialised blood cells called

platelets, then trigger a series of chemical

reactions that result in the formation of a

substance that creates a mesh. This mesh traps

blood cells to make a blood clot. The clot

releases a fluid known as serum, which

contains antibodies and specialised cells.

This serum begins the process of repairing

the damaged area.

At first, the blood clot is a jelly-like mass.

Fibroblast cells form a plug within the clot.

Later, this dries into a crust (scab) that seals and

protects the site of the wound until the healing

process is complete.

HOW WOUNDS HEAL

WOUNDS AND BLEEDING

Injury

At the site of injury, platelets in the

blood arrive to begin formation of a

clot. Other cells are attracted to the

site to help with repair.

Clotting

A clot is formed by platelets in the

blood and blood-clotting protein.

Tissue-forming cells migrate to the

damaged area to start repair.

Plugging and scabbing

A plug of fibrous tissue forms within

the clot. The plug hardens and forms

a scab that eventually drops off

when the skin beneath it is healed.

Blood clot

New tissue

Site of injury

Epidermis Dermis

Plug of

fibrous tissue

Severed

blood vessel

Fibroblast

111

Wounds can be classified into a number of

different types, depending on the object that

produces the wound – such as a knife or a

bullet – and the manner in which the wound

has been inflicted.

Each of these types of wound carries

specific risks associated with surrounding

tissue damage and infection.

TYPES OF WOUND

Incised wound

This is caused by a clean

surface cut from a sharpedged

object such as a

razor. Blood vessels are cut

straight across, so bleeding

may be profuse. Structures

such as tendons or nerves

may be damaged.

Laceration

Blunt or ripping forces result in

tears or lacerations. These wounds

may bleed less profusely than

incised wounds, but there is likely to

be more tissue damage. Lacerations

are often contaminated with germs,

so the risk of infection is high.

Puncture wound

An injury such as standing on a nail

or being pricked by a needle will

result in a puncture wound. It has

a small entry site but a deep track

of internal damage. Since germs

and dirt can be carried far into

the body, the infection risk with

this kind of wound is high.

Abrasion (graze)

This is a superficial wound in which

the topmost layers of skin are

scraped off, leaving a raw, tender

area. Abrasions are often caused by

a sliding fall or a friction burn. They

can contain embedded foreign

particles that may cause infection.

Stab wound

This is a deep incision caused by

a sharp or bladed instrument,

usually a knife, penetrating the

body. Stab wounds to the trunk

must always be treated seriously

because of the danger of injury

to vital organs and life-threatening

internal bleeding.

Contusion (bruise)

A blunt blow can rupture capillaries

beneath the skin, causing blood to

leak into the tissues. This process

results in bruising. Extensive

contusion and swelling may

indicate deeper damage, such as

a fracture or an internal injury.

Gunshot wound

This type of wound is caused by

a bullet or missile being driven into

or through the body, resulting in

serious internal injury and sucking

in clothing and contaminants from

the air. The entry wound may be

small and neat; any exit wound

may be large and ragged.

BLEEDING AND TYPES OF WOUND

Entry wound

Exit wound

112

SHOCK

This is a life-threatening condition that occurs when the

circulatory system (which distributes oxygen to the body tissues

and removes waste products) fails and, as a result, vital organs

such as the heart and brain are deprived of oxygen. It requires

immediate emergency treatment. Shock can be made worse

by fear and pain. Minimise the risk of shock developing by

reassuring the casualty and making him comfortable.

The most common cause of shock is severe blood loss.

If blood loss exceeds 1.2 litres (2 pints), which is about one-fifth

of the normal blood volume, shock will develop. This degree of

blood loss may result from external bleeding. It may also be

caused by: hidden bleeding from internal organs (p.116), blood

escaping into a body cavity (p.116) or bleeding from damaged

blood vessels due to a closed fracture (p.136 and p.138). Loss of

other body fluids can also result in shock. Other conditions that

can cause severe fluid loss include diarrhoea, vomiting, bowel

obstruction and serious burns.

In addition, shock may occur when there is sufficient blood

volume but the heart is unable to pump the blood around the

body. This problem can be due to severe heart disease, heart

attack or acute heart failure (cardiogenic shock). Other causes

of shock include overwhelming infection (septic shock), severe

allergic reaction (anaphylactic shock) and spinal cord injury

(neurogenic shock).

SEE ALSO Anaphylactic shock p.223 | Internal bleeding p.116 | Severe burns and scalds pp.174–75 |

Severe external bleeding pp.114–15 | Spinal injury pp.157–59 | The unresponsive casualty pp.54–87

■■ Do not allow the casualty

to eat or drink because an

anaesthetic may be needed. If

he complains of thirst, moisten

his lips with a little water.

■■ Do not leave the casualty

unattended, unless you have to

call emergency help.

■■ Do not warm the casualty with

a hot-water bottle or any other

direct source of heat.

■■ If the casualty is in the later

stages of pregnancy, help her

to lie down leaning towards her

left side to prevent the pregnant

uterus restricting blood flow

back to the heart.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

■■Little or no effect; this is the quantity of blood normally taken in a

blood donor session

■■Hormones such as adrenaline are released, quickening the pulse and inducing

sweating ■■Small blood vessels in non-vital areas, such as the skin, shut down to

divert blood and oxygen to the vital organs ■ Shock becomes evident

0.5 litre (about 1 pint)

APPROXIMATE VOLUME

EFFECTS OF BLOOD OR FLUID LOSS

EFFECTS ON THE BODY

Up to 2 litres (3½ pints)

2 litres (3½ pints) or more

(over a third of the normal

volume in the average adult)

■ As blood or fluid loss approaches this level, the pulse at the wrist may become

undetectable ■■Casualty will gradually become unresponsive ■ Breathing will

cease and finally the heart will stop

WOUNDS AND BLEEDING

CAUTION

113

WHAT TO DO

Treat any possible cause of shock that you can detect, such

as severe bleeding (pp.114–15) or serious burns (pp.174–75).

Reassure the casualty.

Loosen tight clothing to

reduce constriction at

the neck, chest and waist.

Call 999/112 for emergency

help. Tell the ambulance

control that you suspect shock.

Keep the casualty warm by covering

his body and legs with coats or blankets.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while

waiting for help to arrive.

4

3

5 6

1

Help the casualty to lie down – on a rug or blanket if there is

one, as this will protect him from the cold. Raise and support

his legs above the level of his heart to improve blood supply to

the vital organs.

2

■■ To recognise shock

■■ To treat any obvious cause of shock

■■ To improve the blood supply to the

brain, heart and lungs

■■ To arrange urgent removal to

hospital

Initially there may be:

■■ A rapid pulse

■■ Pale, cold, clammy skin

■■ Sweating

As shock develops:

■■ Rapid, shallow breathing

■■ A weak, “thready” pulse. When the

pulse at the wrist disappears, about

half of the blood volume will have

been lost

■■ Grey-blue skin (cyanosis),

especially inside the lips. A

fingernail or earlobe, if pressed, will

not regain its colour immediately

■■Weakness and dizziness

■■ Nausea, and possibly vomiting

■■ Thirst

As the brain’s oxygen supply

weakens:

■■ Restlessness and aggressive

behaviour

■■ Yawning and gasping for air

■■ Casualty becomes unresponsive

■■ Finally, the heart will stop

SHOCK

YOUR AIMS

RECOGNITION

114 SEE ALSO Foreign object in a wound p.121 | Shock pp.112–13

When bleeding is severe, it can be dramatic and distressing. If

bleeding is not controlled shock will develop and the casualty

may no longer be responsive.

Bleeding from the mouth or nose may affect breathing. When

treating severe bleeding, check first whether there is an object

embedded in the wound; take care not to press directly on the

object. Do not let the casualty have anything to eat or drink as he

may need an anaesthetic later.

SEVERE EXTERNAL BLEEDING

WOUNDS AND BLEEDING

■■ To control bleeding

■■ To prevent and minimise the effects

of shock

■■ To minimise infection

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Remove or cut away clothing to

expose a wound if necessary

(p.232).

■■ If the casualty is unresponsive,

open the airway and check

breathing (The unresponsive

casualty, pp.54–87).

WHAT TO DO

2

1

CAUTION

Apply direct pressure over the wound with your fingers

using a sterile dressing or clean, non-fluffy pad. If you do not

have a dressing, ask the casualty to apply direct pressure himself. If

there is an object in the wound, apply pressure on either side of the

object (opposite).

Ask a helper to call 999/112 for emergency help. Tell him or her

to give ambulance control details of the site of the bleeding and

the extent of the bleeding.

115

Control bleeding by pressing firmly on either

side of the embedded object to push the

edges of the wound together. Do not press directly

on the object, or try to remove it.

To protect the wound, drape a piece of gauze

over the object. Build up padding on either

side, then carefully bandage over the object and

pads without pressing on the object (p.121). Check

the circulation beyond the bandage every ten

minutes (p.243). If the circulation is impaired,

loosen the bandage and reapply.

Call 999/112 for emergency help. Monitor

and record vital signs – breathing, pulse

and level of response (pp.52–53) – while waiting

for help to arrive. Treat for shock if necessary

(pp.112–13).

2

3

1

SEVERE EXTERNAL BLEEDING

If bleeding shows through

the dressing, apply a second

one on top of the first. If blood

seeps through the second

dressing, remove both and

apply a fresh one, ensuring that

pressure is applied accurately at

the point of bleeding.

Support the injured part in

with a sling and/or bandage.

Check the circulation beyond

the bandage every ten minutes

(p.243). If the circulation is

impaired, loosen the bandage

and reapply.

Monitor and record the

casualty’s vital signs –

breathing, pulse and level of

response (pp.52–53) – while

waiting for help to arrive.

Secure the dressing with a bandage that is firm

enough to maintain pressure, but not so tight

that it impairs circulation (p.243). Call 999/112 for

emergency help if this has not been done already.

As shock is likely to develop (pp.112–13), help

the casualty to lie down – on a rug or blanket if

there is one, as this will protect him from the cold.

Raise and support his legs so that they are above

the level of his heart.

6 7

3

4

5

SPECIAL CASE IF THERE IS AN OBJECT IN THE WOUND

116 SEE ALSO Crush injury p.118 | Head injury pp.144–45 | Shock pp.112–13

■■ Initially, pale, cold, clammy skin. If

bleeding continues, the skin may

turn blue-grey (cyanosis)

■■ Rapid, weak pulse

■■ Thirst

■■ Rapid, shallow breathing

■■ Confusion, restlessness and

irritability

■■ Possible collapse and casualty may

become unresponsive

■■ Bleeding from body openings

(orifices)

■■ In cases of violent injury, “pattern

bruising” – an area of discoloured

skin with a shape that matches the

pattern of clothes or crushing or

restraining objects

■■ Pain

■■ Information from casualty that

indicates recent injury, illness, or

operation

RECOGNITION Bleeding inside body cavities may follow an injury, such as a

fracture or a blow from a blunt object, but it can also occur

spontaneously – for example, bleeding from a stomach ulcer. The

main risk from internal bleeding is shock (pp.112–13). In addition,

blood can build up around organs such as the lungs or brain and

exert damaging pressure on them.

Suspect internal bleeding if a casualty develops signs of shock

without obvious blood loss. Check for any bleeding from body

openings (orifices) such as the ear, mouth and nose. There may

also be bleeding from the urethra or anus (below).

The signs of bleeding vary depending on the site of the blood

loss (below), but the most obvious is a discharge of blood from a

body opening. Blood loss from any orifice is significant and can

lead to shock. In addition, bleeding from some orifices can

indicate a serious underlying injury or illness. Follow treatment

for shock (pp.112–13).

INTERNAL BLEEDING

WOUNDS AND BLEEDING

■ Bright red, frothy, coughed-up blood ■■Bleeding in the lungs

■ Vomited blood, red or dark reddishbrown,

resembling coffee grounds

■ Bleeding within the digestive system

Mouth

SITE

POSSIBLE SIGNS OF INTERNAL BLEEDING

APPEARANCE OF BLOOD CAUSES OF BLOOD LOSS

Ear

Nose

Anus

Urethra

Vagina

■ Fresh, bright red blood ■ Injury to the inner or outer ear or perforated eardrum

■ Thin, watery blood ■ Leakage of fluid from around the brain due to head injury

■ Thin, watery blood ■ Leakage of fluid from around the brain due to head injury

■ Fresh, bright red blood ■ Ruptured blood vessel in the nostril

■ Fresh, bright red blood ■ Piles or injury to the anus or lower intestine

■ Black, tarry, offensive-smelling stool (melaena) ■ Disease or injury to the intestine

■ Red or smoky appearance to urine,

occasionally containing clots

■ Bleeding from the bladder, kidneys or urethra

■ Either fresh or dark blood ■ Menstruation ■ Miscarriage ■ Pregnancy

■■Recent childbirth ■ Assault

117

IMPALEMENT

INTERNAL BLEEDING | IMPALEMENT | AMPUTATION

SEE ALSO Severe external bleeding pp.114–15 | Shock pp.112–13

If someone has been impaled, for example by falling on to

railings, never attempt to lift the casualty off the object involved

since this may worsen internal injuries. Call 999/112 for

emergency help immediately, giving clear details about the

incident. They will bring special cutting equipment with them to

free the casualty.

A limb that has been partially or completely severed can,

in many cases, be reattached by microsurgery. The operation

will require a general anaesthetic, so do not allow the casualty

to eat or drink. It is vital to get the casualty and the amputated

part to hospital as soon as possible. Shock is likely, and needs

to be treated.

WHAT TO DO

WHAT TO DO

Control blood loss by applying direct pressure and raising

the injured part above the casualty’s heart (pp.114–15).

Call 999/112 for emergency

help. Send a helper to make

the call if possible. Explain the

situation clearly to ambulance

control, so that the right

equipment can be brought.

Support the casualty’s body

weight until the emergency

services arrive and take over.

Reassure the casualty while you

wait for emergency help.

Place a sterile dressing or a non-fluffy, clean pad on the

wound, and secure it with a bandage. Treat the casualty for

shock (pp.112–13).

Call 999/112 for emergency help. Tell ambulance control

that amputation is involved. Monitor and record vital signs –

breathing, pulse and level of response (pp.52–53) – while waiting

for help to arrive.

Wrap the severed part in kitchen film or a plastic bag. Wrap the

package in gauze or soft fabric and place it in a container full of

crushed ice. Mark the container with the time of injury and the

casualty’s name. Give it to the emergency service personnel.

1

1 2

2

3

4

AMPUTATION

■■ To prevent further injury

■■ To control bleeding

■■ To minimise the effects of shock

■■ To arrange urgent removal to

hospital

■■ To prevent deterioration of the

injured part

YOUR AIM

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Do not wash the severed part.

■■ Do not let the severed part

touch the crushed ice when

packing it.

■■ Do not allow the casualty

to eat or drink because an

anaesthetic may be needed.

CAUTION

CAUTION

118 SEE ALSO Fractures pp.136–38 | Severe external bleeding pp.114–15 | Shock pp.112–13

WHAT TO DO

If you know the casualty has been crushed for

less than 15 minutes and you can release him,

do this as quickly as possible. Control bleeding,

steady and support any suspected fracture

(pp.136–38) and treat him for shock (pp.112–13).

If the casualty has been crushed for more than

15 minutes, or you cannot move the cause of

injury, leave him in the position found and comfort

and reassure him.

Call 999/112 for emergency help, giving clear

details of the incident to ambulance control.

Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while

waiting for help to arrive.

2

3

1

4

Traffic and building site incidents are the most common causes

of crush injuries. Other possible causes include explosions,

earthquakes and train crashes.

A crush injury may include a fracture, swelling and internal

bleeding. The crushing force may also cause impaired circulation,

which results in numbness at or below the site of injury.

DANGERS OF PROLONGED CRUSHING

If the casualty is trapped for any length of time, two serious

complications may result. First, prolonged crushing may cause

extensive damage to body tissue, especially to muscles. Once the

pressure is removed, shock may develop rapidly as tissue fluid

leaks into the injured area.

Secondly, and more dangerously, toxic substances will build

up in damaged muscle tissue around a crush injury. If released

suddenly into the circulation, these toxins may cause kidney

failure. This process, called “crush syndrome”, is extremely

serious and can be fatal.

CRUSH INJURY

WOUNDS AND BLEEDING

■■ To obtain specialist medical aid

urgently, taking any steps possible

to treat the casualty

YOUR AIM

■■ Do not release a casualty who

has been crushed for more than

15 minutes.

■■ Do not lift heavy objects.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

CAUTION

119

CRUSH INJURY | CUTS AND GRAZES | BRUISING

CUTS AND GRAZES

SEE ALSO Foreign object in wound p.121 | Infected wound p.120 | Internal bleeding p.116

■■ To control bleeding

■■ To minimise the risk of infection

■■ To reduce blood flow to the injury,

and so minimise swelling

YOUR AIMS

YOUR AIM

Bleeding from small cuts and grazes is normally easily

controlled by pressure and elevation. A plaster is generally all

that is required, and the wound will heal by itself in a few days.

Medical help need only be sought if: bleeding does not stop;

there is a foreign object embedded in the cut (p.121); there is a

particular risk of infection, from a human or animal bite (p.203),

or a puncture by a dirty object; an old wound shows signs of

becoming infected (p.120).

Caused by bleeding into the skin or into tissues beneath the

skin, a bruise can develop rapidly or emerge a few days after

injury. Bruising can also indicate deep injury. Elderly people and

those taking anticoagulant (anti-clotting) drugs can bruise easily.

WHAT TO DO

WHAT TO DO

If the wound is dirty, clean

it by rinsing under running

water, or use alcohol-free wipes.

Pat the wound dry using a

gauze swab and cover it with

sterile gauze.

Raise and support the

injured part above the level

of the heart, if possible. Avoid

touching the wound.

Clean the area around the

wound with soap and water.

Wipe away from the wound and

use a clean swab for each stroke.

Pat dry. Remove the wound

covering and apply a sterile

dressing. If there is a particular

risk of infection, advise the

casualty to seek medical advice.

Place a cold compress

(p.241) over the bruise for at

least ten minutes.

Raise and support the

injured part in a comfortable

position for the casualty.

2

1

3

1 2

BRUISING

Ask the casualty about tetanus

immunisation. Seek medical

advice if:

■■ He has a dirty wound

■■ He has never been immunised

■■ He is uncertain about the

number or timings of injections

■■ He has not had at least five

injections previously

CAUTION

SPECIAL CASE TETANUS

This is a dangerous infection

caused by a bacterium which

lives in soil. If the bacterium

enters a wound, it may multiply

in the damaged tissues and

release a toxin that spreads

through the nervous system,

causing muscle spasms and

paralysis. Tetanus can be

prevented by immunisation,

which is normally given during

childhood. This may need to

be repeated in adulthood.

120

WOUNDS AND BLEEDING

SEE ALSO Bleeding and types of wound pp.110–11 | Cuts and grazes p.119

■■ Increasing pain and soreness at the

site of the wound

■■ Swelling, redness and a feeling of

heat around the injury

■■ Pus within, or oozing from, the

wound

■■ Swelling and tenderness of the

glands in the neck, armpit or groin

■■ Faint red trails on the skin that lead

to the glands in the neck, armpit or

groin

If infection is advanced:

■■ Signs of fever, such as sweating,

thirst, shivering and lethargy

■■ To prevent further infection

■■ To obtain medical advice if necessary

RECOGNITION

YOUR AIMS

■■ Do not burst a blister because it

increases the risk of infection.

Blisters occur when the skin is repeatedly rubbed against another

surface or when it is exposed to heat (p.173). The damaged area of

skin leaks tissue fluid that collects under the top layer of the skin,

forming a blister.

Any open wound can become contaminated with microorganisms

(germs). The germs may come from the source

of the injury, from the environment, from breath, from the

fingers handling the wound or from particles of clothing

embedded in it (as may occur in gunshot wounds). Bleeding

may flush some dirt away; remaining germs may be destroyed

by the white blood cells. However, if dirt or dead tissue remain

in a wound, infection may spread through the body. There is also

a risk of tetanus (p.119).

Any wound that does not begin to heal within 48 hours is

likely to be infected. A casualty with a wound that is at high

risk of infection may need treatment with antibiotics and/or

tetanus immunisation (p.119).

CAUTION

BLISTERS

INFECTED WOUND

WHAT TO DO

Cover the wound with a sterile dressing or large clean, non-fluffy

pad, and bandage it in place.

Raise and support the injured part with a sling and/or bandages.

This helps to reduce the swelling around the injury.

Advise the casualty to seek medical advice. If infection is

advanced (with signs of fever, such as sweating, shivering and

lethargy), take or send the casualty to hospital.

2

1

3

WHAT TO DO

Wash the area with clean water and rinse.

Gently pat the area and surrounding skin dry

thoroughly with a sterile gauze pad. If it is

not possible to wash the area, keep it as clean

as possible.

Cover a blister caused by friction with an

adhesive dressing; make sure the pad of the

plaster is larger than the blister. Ideally use a

special blister plaster since this has a cushioned

pad that provides extra protection and comfort.

1 2

121

FOREIGN OBJECT IN A WOUND

SEE ALSO Cuts and grazes p.119 | Embedded fish hook p.195 | Severe external bleeding pp.114–15 | Splinter p.194

■■ To control bleeding without pressing

the object further into the wound

■■ To minimise the risk of infection

■■ To arrange transport to hospital if

necessary

YOUR AIMS

Ask the casualty about tetanus

immunisation. Seek medical

advice if:

■■ He has a dirty wound

■■ He has never been immunised

■■ He is uncertain about the

number or timings of injections

■■ He has not had at least five

injections previously

WHAT TO DO

Control bleeding by

applying pressure on either

side of the object (see p.115) and

raising the area above the level

of the casualty’s heart. Drape a

piece of gauze over the wound

and object.

Build up padding on either

side of the object (rolled

bandages make good padding)

until it is high enough for you

to be able to bandage over the

top of object without pressing

it further into the wound. Hold

the padding in place until the

bandaging is complete.

Arrange to take or send the

casualty to hospital.

2

3

1

It is important to remove foreign objects, such as small pieces of

glass or grit, from a wound before beginning treatment. If left in a

wound, they may cause infection or delay healing. The best way to

remove superficial pieces of glass or grit from the skin is to pick

them out with tweezers. Alternatively, rinse loose pieces off with

cold water. Do not try to remove pieces that are firmly embedded

in the wound because you may damage the surrounding tissue and

aggravate bleeding. Instead, cover the object with a dressing and

bandage around it.

CAUTION

BLISTERS | INFECTED WOUND | FOREIGN OBJECT IN A WOUND

If you cannot build padding high

enough to bandage over the top

of an object, drape a clean piece

of gauze loosely over it. Place

padding on either side of the

object and bandage above and

below the object.

SPECIAL CASE BANDAGING AROUND A LARGER OBJECT

122

WOUNDS AND BLEEDING

SEE ALSO Head injury pp.144–45 | Shock pp.112–13 | Spinal injury pp.157–59

■■ To control bleeding

■■ To arrange transport to hospital

YOUR AIMS

■■ If at any stage the casualty

becomes unresponsive, open

the airway and check breathing

(The unresponsive casualty,

pp.54–87).

The scalp has many small blood vessels running close to the

skin surface, so any cut can result in profuse bleeding, which

often makes a scalp wound appear worse than it is.

In some cases, however, a scalp wound may form part of a

more serious underlying head injury, such as a skull fracture, or

may be associated with a neck injury. For these reasons, you

should examine a casualty with a scalp wound very carefully,

particularly if it is possible that signs of a serious head injury are

being masked by alcohol or drug intoxication. If you are in any

doubt, follow the treatment for head injury (pp.144–45). In

addition, bear in mind the possibility of a neck (spinal) injury.

WHAT TO DO

If there are any displaced flaps of skin at the

injury site, carefully replace them over the

wound. Reassure the casualty.

Keep the pad in place with a roller bandage to

secure the pad and maintain pressure.

Help the casualty to lie down with her head

and shoulders slightly raised. If she feels faint

or dizzy or shows any signs of shock, call 999/112

for emergency help. Monitor and record vital signs

– breathing, pulse and level of response (pp.52–53) –

while waiting for help to arrive.

Cover the wound with a sterile dressing or a

clean, non-fluffy pad. Apply firm, direct

pressure on the pad to help control bleeding to

reduce blood loss, and minimise the risk of shock.

3

4

2

1

CAUTION

SCALP AND HEAD WOUNDS

123

SCALP AND HEAD WOUNDS | EYE WOUND | BLEEDING FROM THE EAR

EYE WOUND

BLEEDING FROM THE EAR

■■ Pain in the eye or eyelids

■■ Visible wound and/or bloodshot

appearance

■■ Partial or total loss of vision

■■ Leakage of blood or clear fluid from

a wound

RECOGNITION

The eye can be bruised or cut by direct blows or by sharp,

chipped fragments of metal, grit and glass.

All eye injuries are potentially serious because of the risk to

the casualty’s vision. Even superficial grazes to the surface

(cornea) of the eye can lead to scarring or infection, with the

possibility of permanent deterioration of vision.

WHAT TO DO

WHAT TO DO

Help the casualty to lie on his back, and hold his head to keep it

as still as possible. Tell him to keep both eyes still; movement of

the “good” eye will cause movement of the injured one, which may

damage it further.

Give the casualty a sterile

dressing or a clean, nonfluffy

pad to hold over the affected

eye. If it will take some time to

obtain medical help, secure the

pad in place with a bandage.

2

1

2

This may be due to a burst (perforated) eardrum, an ear

infection, a blow to the side of the head or an explosion.

Symptoms include sharp pain, earache, deafness and possible

dizziness. The presence of blood or blood-stained watery fluid

may indicate a more serious, underlying head injury (pp.144–45).

■■ To arrange transport to hospital

YOUR AIM

■■ If you suspect a head injury

(pp.144–45), support the

casualty’s head in the position

you found him and call 999/112

for emergency help.

CAUTION

Hold a sterile dressing or a

clean, non-fluffy pad lightly

in place on the ear. Do not plug

the ear. Send or take the

casualty to hospital.

Help the casualty into a

half-sitting position, with

his head tilted to the injured

side to allow blood to drain

from the ear.

1

■■ To prevent further damage

■■ To arrange transport to hospital

YOUR AIMS

■■ Do not touch or attempt to

remove anything that is sticking

to, or embedded in, the eyeball

or on the coloured part (iris) of

the eye.

CAUTION

Arrange to take or send

the casualty to hospital. 3

SEE ALSO Foreign object in the ear p.197 | Head injury pp.144–45

124

WOUNDS AND BLEEDING

WHAT TO DO

Tell the casualty to sit down and tilt his head

forward to allow the blood to drain from the

nostrils. Ask him to breathe through his mouth (this

will also have a calming effect) and to pinch the soft

part of his nose for up to ten minutes. Reassure and

help him if necessary.

Advise the casualty not to speak, swallow,

cough, spit or sniff since this may disturb blood

clots that have formed in the nose. Give him a clean

cloth or tissue to mop up any dribbling.

After ten minutes, tell the casualty to release

the pressure. If the bleeding has not stopped,

tell him to reapply the pressure for two further

periods of ten minutes.

2

1

3

NOSEBLEED

■■ To maintain an open airway

■■ To control bleeding

YOUR AIMS

Bleeding from the nose most commonly occurs when tiny

blood vessels inside the nostrils are ruptured, either by a blow to

the nose, or as a result of sneezing, picking or blowing the nose.

Nosebleeds may also occur as a result of high blood pressure and

anti-coagulant (anti-clotting) medication.

A nosebleed can be serious if the casualty loses a lot of blood.

In addition, if bleeding follows a head injury, the blood may

appear thin and watery. The latter is a very serious sign because

it indicates that the skull is fractured and fluid is leaking from

around the brain.

■■ Do not let the casualty tip his

head back since blood may then

run down the throat and induce

vomiting.

CAUTION

Once the bleeding has stopped, and with

the casualty still leaning forwards, clean

around his nose with lukewarm water. Advise him

to rest quietly for a few hours. Tell him to avoid

exertion and, in particular, not to blow his nose,

because this could disturb any clots.

4

If bleeding stops and then restarts, help

the casualty to reapply pressure. 5

If the nosebleed is severe, or if it lasts

longer than 30 minutes, arrange to take

or send the casualty to hospital.

6

SEE ALSO Foreign object in the nose p.197 | Head injury pp.144–45

A child may be worried

by a nosebleed. Tell her

to lean forward, and

then pinch her nose for

her, reassure her and

give her a bowl to spit

or dribble into.

SPECIAL CASE FOR A YOUNG CHILD

125

NOSEBLEED | KNOCKED-OUT ADULT TOOTH | BLEEDING FROM THE MOUTH

KNOCKED-OUT ADULT TOOTH

CAUTION

CAUTION

If a secondary (adult) tooth is knocked out, it should be

replanted in its socket as soon as possible. If this is not possible,

ask the casualty to keep the tooth inside his cheek if he feels able

to do this. Alternatively, place it in a small container of milk or

saliva to prevent it from drying out.

Cuts to the tongue, lips or lining of the mouth range from

minor injuries to more serious wounds. The cause is often the

casualty’s own teeth or dental extraction. Bleeding from the

mouth may be profuse and can be alarming. There is a risk that

blood may be inhaled into the lungs, causing breathing problems.

WHAT TO DO

WHAT TO DO

If a tooth cannot be

replaced keep it moist by

placing it in milk, or if none is

available, in the casualty’s saliva

(in the mouth, a cup or even a

piece of saliva-soaked gauze).

Send the casualty to a dentist so

the tooth can be reimplanted.

Pick up the tooth by its

crown, and wash it under

cold running water for ten

seconds. Push the tooth gently

into the socket and cover it with a

piece of gauze. Ask the casualty to

gently close his mouth over it.

If bleeding persists, replace

the pad. Tell the casualty

to let the blood dribble out; if

she swallows it, it may induce

vomiting. Do not wash the

mouth out because this may

disturb a clot. Advise her to

avoid drinking anything hot

for 12 hours.

Ask the casualty to sit

down, with her head

forwards and tilted slightly to

the injured side, to allow blood

to drain from her mouth. Place

a sterile gauze pad over the

wound. Ask the casualty to

squeeze the pad between finger

and thumb and press on the

wound for ten minutes.

1

1 2

BLEEDING FROM THE MOUTH

SPECIAL CASE

BLEEDING TOOTH SOCKET

To control bleeding from a tooth

socket, roll a gauze pad thick

enough to prevent the casualty’s

teeth meeting, place it across

the empty socket, and tell him

to bite down on it.

■■ Do not touch the root of a

knocked out tooth or store it in

anything apart from milk or

saliva as you will damage the

surface, reducing the chance of

reimplantation and healing.

■■ Keep any tooth fragments.

■■ If the wound is large, or bleeding

lasts longer than 30 minutes

or restarts, seek medical or

dental advice.

YOUR AIMS

■■ To control bleeding

■■ To safeguard the airway by

preventing any inhalation of blood

2

126

WOUNDS AND BLEEDING

SEE ALSO Amputation p.117 | Foreign object in a wound p.121

■■ To control bleeding

■■ To assess whether or not the wound

needs a medical assessment

YOUR AIMS

Injuries to the fingers are common and can vary from small cuts

and grazes to wounds with underlying damage to bones, tendons

and ligaments. Injuries to the nails are the most common. All

finger wounds need good management as the hand is a finely

coordinated part of the body that must function correctly for

many everyday activities.

A cut to a finger may go through the skin only or it can cut

through blood vessels, nerves and tendons that lie just under

the skin. There will be bleeding, which can be profuse, and

possibly bruising, deformity or loss of movement or sensation

if the underlying structures are damaged.

FINGER WOUND

Seek urgent medical advice if

there is:

■■ Severe pain

■■ Severe bleeding

■■Missing tissue or nail, or

amputation of part of finger

■■Obvious deformity

■■ A gaping wound

■■ Numbness, weakness or loss of

movement in the finger or hand

■■ A foreign object in the wound WHAT TO DO

Press a sterile dressing or

clean non-fluffy pad on the

wound and apply direct pressure

to control bleeding.

When the bleeding has

stopped, cover the wound

to protect it. Use an adhesive

dressing or for a larger wound

apply a dressing pad, secured with

a tubular gauze bandage (p.248).

Seek medical help if

necessary. If you need to

take the casualty to hospital,

support the injured arm in an

elevation sling (p.252).

Raise and support the

injured hand and maintain

pressure on the wound until the

bleeding stops.

3

4

2

1

CAUTION

127

FINGER WOUND | WOUND TO THE PALM | WOUND AT A JOINT CREASE

WOUND TO THE PALM

WOUND AT A JOINT CREASE

SEE ALSO Foreign object in a wound p.121 | Shock pp.112–13

WHAT TO DO

WHAT TO DO

Press a sterile dressing or

clean pad firmly into the

palm, and ask the casualty to

clench his fist over it or to grasp

his fist with his other hand.

Check the circulation

(p.243) in the lower part of

the limb beyond the bandage

every ten minutes. If necessary,

remove the bandage, and apply

more loosely.

Secure the dressing with a

bandage tied firmly enough

to maintain pressure. If possible,

help the casualty to lie down

with his legs raised. Take or send

the casualty to hospital.

Raise and support the hand.

Bandage the casualty’s

fingers so that they are clenched

over the pad; leave the thumb free

so that you can check circulation.

Tie the ends of the bandage over

the top of the fingers to help

maintain pressure.

Support the arm in an

elevation sling (p.252).

Arrange to take or send him to

hospital. Check the circulation

(p.243) in the thumb every ten

minutes. If necessary, remove

the bandage, and reapply.

Press a sterile dressing or

clean, non-fluffy pad on the

injury and apply direct pressure

to control bleeding. Raise and

support the injured limb.

2

2 3

3

1

1

The palm of the hand has a good blood supply, which is why a

wound there may cause profuse bleeding. A deep wound to the

palm may sever tendons and nerves in the hand and result in loss

of feeling or movement in the fingers.

Bandaging the fist can be an effective way to control bleeding.

If, however, a casualty has a foreign object embedded in a palm

wound, it will be impossible to clench the fist. In such cases, treat

the injury using the method described on p.121.

Large blood vessels pass across the inside of the elbow and

back of the knee. If severed, these vessels will bleed profusely.

The steps given below help to control bleeding and shock. Take

care to ensure that there is adequate circulation to the part of

the limb beyond the bandage.

YOUR AIMS

YOUR AIMS

■■ To control bleeding

■■ To prevent and minimise the effects

of shock

■■ To arrange transport to hospital

■■ To control bleeding and the effects

of shock

■■ To minimise the risk of infection

■■ To arrange transport to hospital

128

WOUNDS AND BLEEDING

■■ To minimise shock

■■ To arrange urgent removal

to hospital

YOUR AIMS

A stab wound, gunshot or crush injury to the abdomen may

cause a serious wound. Organs and large blood vessels can

be punctured, lacerated or ruptured. There may be external

bleeding, protruding abdominal contents and internal injury

and bleeding, so this is an emergency.

ABDOMINAL WOUND

WHAT TO DO

Help the casualty to lie down on a firm surface, on a blanket if

available. Loosen any tight clothing, such as a belt or a shirt.

Cover wound with a sterile

dressing and hold it firmly;

the casualty may be able to help.

Raise and support the casualty’s

knees to ease strain on injury.

2

1

Be sensitive to the woman’s feelings. The bleeding is most

likely to be menstrual bleeding, but it can also indicate a more

serious condition such as miscarriage, pregnancy, recent

termination of pregnancy, childbirth or injury as a result of sexual

assault. If the bleeding is severe, shock may develop.

If a woman has been sexually assaulted, it is vital to preserve

the evidence if possible. Gently advise her to refrain from

washing or using the toilet until a forensic examination has been

performed. If she wishes to remove her clothing, keep it intact in

a clean plastic bag if possible. Be aware that she may feel

vulnerable and will prefer to be treated by a woman. ■■ To make the woman comfortable and

reassure her

■■ To arrange removal to hospital if

necessary

YOUR AIMS

■■ If bleeding is severe, call

999/112 for emergency help.

■■ Treat for shock (pp.112–13).

Monitor and record vital signs –

breathing, pulse and level of

response (pp.52–53) – while

waiting for help to arrive.

CAUTION

If she has period pains, she

may take the recommended

dose of paracetamol or her own

painkillers.

2 Allow the woman privacy

and give her a sanitary

towel. Make her as comfortable

as possible in whichever position

she prefers.

1

■■ Do not touch any protruding

intestine. Cover the area

with a clean plastic bag or

kitchen film to prevent the

intestine surface from

drying out.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty

pp.54–87). If he is breathing,

support the abdomen as you put

him in the recovery position. Do

not allow the casualty to eat or

drink because an anaesthetic

may be needed.

CAUTION

Call 999/112 for emergency

help. Treat the casualty for

shock (pp.112–13). Monitor and

record vital signs – breathing,

pulse and level of respomse

(pp.52–53) – while waiting for

help to arrive.

3

SEE ALSO Shock pp.112–13

VAGINAL BLEEDING

129

ABDOMINAL WOUND | VAGINAL BLEEDING | BLEEDING VARICOSE VEIN

BLEEDING VARICOSE VEIN

WHAT TO DO

Help the casualty to lie down on his back.

Raise and support the injured leg as high as

possible immediately; this reduces the amount

of bleeding.

Rest the injured leg on your shoulder or on

a chair. Apply firm, direct pressure on the

injury, using a sterile dressing or a clean, non-fluffy

pad, until the blood loss is under control. If

necessary, carefully cut away clothing to expose

the site of the bleeding.

Remove garments such as garters or elastictopped

stockings because these may cause the

bleeding to continue.

2

1

3

■■ To control bleeding

■■ To minimise shock

■■ To arrange urgent removal

to hospital

Veins contain one-way valves that keep the blood flowing YOUR AIMS

towards the heart. If these valves fail, blood collects (pools)

behind them and makes the veins swell. This problem, called

varicose veins, usually develops in the legs.

A varicose vein has taut, thin walls and is often raised,

typically producing knobbly skin over the affected area. The vein

can be burst by a gentle knock, and this may result in profuse

bleeding. Shock will quickly develop if bleeding is not controlled.

Keeping the leg raised, put another large, soft

pad over the dressing. Bandage it firmly

enough to exert even pressure, but not so tightly

that the circulation in the limb is impaired.

4

Call 999/112 for emergency help. Keep the

injured leg raised and supported until the

ambulance arrives. Monitor and record vital

signs – breathing, pulse and level of response,

(pp.52–53) – regularly until help arrives. In addition,

check the circulation in the limb beyond the

bandage (p.243) every ten minutes.

5

SEE ALSO Shock pp.112–113

The skeleton is the supporting framework

around which the body is constructed.

It is jointed in many places, and muscles

attached to the bones enable us to move.

Most of our movements are controlled at

will and coordinated by impulses that travel

from the brain via the nerves to every

muscle and joint in the body.

It is difficult for a first aider to distinguish

between different bone, joint and muscle

injuries, so this chapter begins with an

overview of how bones, muscles and

joints function and how injuries affect

them. First aid treatments for most

injuries, from serious fractures to sprains,

strains and dislocations, are included here

in this section.

First aid for head and spinal injuries

is also covered in this chapter. There is

anatomical information about the nervous

system that explains how these injuries can

be made worse by potential damage to the

brain and spinal cord.

■■ To assess the casualty’s condition quickly and calmly

■■ To support the injured part of the body

■■ To minimise shock

■■ To call 999/112 for emergency help if you suspect

a serious injury

■■ To comfort and reassure the casualty

■■ To be aware of your own needs

AIMS AND OBJECTIVES

BONE, JOINT AND

MUSCLE INJURIES

132

THE SKELETON

The body is built on a framework of bones

called the skeleton. This structure supports the

muscles, blood vessels and nerves of the body.

Many bones of the skeleton also protect

important organs such as the brain and

heart. At many points on the skeleton, bones

articulate with each other by means of joints.

These are supported by ligaments and moved

by muscles that are attached to the

bones by tendons.

BONE, JOINT AND MUSCLE INJURIES

The skeleton

There are 206 bones in the skeleton,

providing a protective framework for

the body. The skull, spine and ribcage

protect vital body structures; the

pelvis supports the abdominal

organs; and the bones and joints

of the arms and legs enable the

body to move.

Breastbone (sternum)

Ulna

Radius

Upper arm bone

(humerus)

Collar bone

(clavicle)

Hip joint is point at

which leg bones are

connected to pelvis

Forearm bones

Thigh bone (femur)

Kneecap (patella)

Splint bone (fibula)

BONES OF THE HAND

Wrist bones

(carpals)

Hand bone

(metacarpal)

Finger bone

(phalanx)

Shin bone (tibia)

Lower leg bones

Ankle bones (tarsals)

Foot bone (metatarsal)

Shoulder blade

(scapula)

Twelve pairs of ribs form

ribcage, which protects

vital organs in chest and

moves with lungs during

breathing Spine, which is

formed from bones

(vertebrae), protects

spinal cord and enables

back to move

Skull protects brain and

supports structures of face

Collar bones

and shoulder

blades form

shoulder girdle,

to which arms

are attached

Jawbone (mandible) is hinged and

enables mouth to open and close

Pelvis is attached to

lower part of spine

and protects lower

abdominal organs

Scaphoid

133

Also known as the backbone, the spine has a

number of functions. It supports the head,

makes the upper body flexible, helps to support

the body’s weight and protects the spinal cord

(p.171). The spine is a column made up of 33

bones called vertebrae, which are connected by

joints. Between individual vertebrae are discs of

fibrous tissue, called intervertebral discs, which

help to make the spine flexible and cushion it

from jolts. Muscles and ligaments attached to

the vertebrae help to stabilise the spine and

control the movements of the back.

THE SPINE

This bony structure protects

the brain and the top of the

spinal cord. It also supports the

eyes and other facial structures.

The skull is made up of several

bones, most of which are fused at

joints called sutures. Within the

bone are air spaces (sinuses),

which lighten the skull. The

bones covering the brain form

a dome called the cranium.

Several other bones form the eye

sockets, nose, cheeks and jaw.

THE SKULL

Spinal column

The vertebrae form five groups: the

cervical vertebrae support the head

and neck; the thoracic vertebrae form

an anchor for the ribs; the lumbar

vertebrae help to support the body’s

weight and give stability; the sacrum

supports the pelvis; and the coccyx

forms the end of the spine.

Structures that make the

spine flexible

The joints connecting the vertebrae,

and the discs between the vertebrae,

allow the spine to move. There is only

limited movement between adjacent

vertebrae, but together the vertebrae,

discs and ligaments allow a range of

movements in the spine as a whole.

THE SKELETON

Structures of the skull

This illustration shows the cranium and the main

bones of the face. The lower jawbone (mandible)

is the only bone in the skull that moves.

Cervical spine

(7 bones)

Thoracic spine

(12 bones)

Lumbar spine

(5 bones)

Sacrum

(5 fused bones)

Suture

Parietal bone

Vertebra

Gelatinous

core

PORTION OF SPINE

SECTION OF

INTERVERTEBRAL

DISC

Fibrous

covering

Intervertebral disc

Frontal bone

Eye socket

Nasal bone

Lower jawbone

(mandible)

Cheekbone

(zygomatic bone)

Ligaments between

vertebrae help to

control movement

of spine

Projection provides

an anchor for

ligaments and

muscles

Coccyx

(4 fused bones)

Occipital bone

Temporal bone

Upper jaw bone

(maxilla)

134

BONE, JOINT AND MUSCLE INJURIES

BONES, MUSCLES AND JOINTS

Bone is a living tissue containing calcium and

phosphorus; minerals that make it hard, rigid

and strong. From birth to early adulthood,

bones grow by laying down calcium on the

outside. They are also able to generate new

tissue after injury.

Age and certain diseases can weaken

bones, making them brittle and susceptible to

breaking or crumbling, either under stress or

spontaneously. Inherited problems, or bone

disorders such as rickets, cancer and infections,

can cause bones to become distorted and

weakened. Damage to the bones during

adolescence can also shorten a bone or

impair movement. In older people, a disorder

called osteoporosis can cause the bones to

lose density, making them brittle and prone

to breaking.

Muscles cause various parts of the body to

move. Skeletal (voluntary) muscles control

movement and posture. They are attached to

bones by bands of strong, fibrous tissue

(tendons), and many operate in groups. As one

group of muscles contracts, its paired group

relaxes. Involuntary muscles operate the

internal organs, such as the heart, and work

constantly, even while we are asleep. They are

controlled by the autonomic nerves (p.143).

THE MUSCLES

Parts of a bone

Each bone is covered by a

membrane (periosteum),

which contains nerves and blood

vessels. Under this membrane is

a layer of compact, dense bone;

at the core is spongy bone. In

some bones, there is a cavity at

the centre containing soft tissue

called bone marrow.

Straightening the arm

The triceps muscle, at

the back of the upper

arm, shortens

(contracts) to pull

down the bones of the

forearm. The biceps

muscle, at the front of

the arm, relaxes.

Bending the arm

The biceps muscle,

at the front of the

arm, shortens

(contracts), pulling

the bones of the

forearm upwards

to bend the arm.

At the same time,

the triceps muscle

relaxes and

lengthens.

Spongy bone

Compact bone

Bone marrow

Vein

Artery Nerve Periosteum

Triceps muscle

contracts

Biceps muscle

relaxes

Tendon

Triceps muscle

relaxes

Biceps muscle

contracts

135

BONES, MUSCLES AND JOINTS

THE JOINTS

A joint is where one bone meets another. In

a few joints (immovable joints), the bone edges

fit together or are fused. Immovable joints are

found in the skull and pelvis. Most joints are

movable, and the bone ends are joined by

fibrous tissue called ligaments, which form

a capsule around the joint. The capsule

lining (synovial membrane) produces fluid

to lubricate the joint; the ends of the bones

are also protected by smooth cartilage. Muscles

that move the joint are attached to the bones

by tendons. The degree and type of movement

depends on the way the ends of the bones fit

together, the strength of the ligaments and the

arrangement of muscles.

Structures of a movable joint

Cartilage covers the bone ends

and minimises friction. Bands of

tissue (ligaments) hold the ends

together. The joint is enclosed in

a lubricant-filled capsule.

Pivot joint

One bone

rotates within

a fixed collar

formed by

another,

as at the base

of the skull.

Saddle joint

Bone ends meet at

right angles in this

joint. The only

example is at the

base of the thumb.

Hinge joint

This joint allows bending

and straightening in only

one plane, as in the knees

and elbows.

Plane joint

Surfaces of this type

of joint are almost

flat and slide over

each other. This joint

is found in the wrist

and foot.

Ball-and-socket joint

This joint allows

movement in all

directions. Examples are

the hip and shoulder.

Ellipsoidal joint

In this type of joint, movement

can occur in most directions. The

wrist joint is an example.

Bone

Ligament

Cartilage

Synovial

membrane

Synovial fluid

136

BONE, JOINT AND MUSCLE INJURIES

■■ To prevent movement at the

injury site

■■ To arrange removal to hospital, with

comfortable support during

transport

YOUR AIMS

FRACTURES

There may be:

■■ Deformity, swelling and bruising at

the fracture site

■■ Pain and/or difficulty in moving

the area

■■ Shortening, bending or twisting of

a limb

■■ Coarse grating (crepitus) of the bone

ends that can be heard or felt (by

casualty) – do not try to seek this

■■ Signs of shock, especially if the thigh

bone or pelvis are fractured

■■ Difficulty in moving a limb normally

or at all (for example, inability to

walk)

■■ A wound, possibly with bone ends

protruding (What to do for an open

fracture, p.138)

RECOGNITION A break or crack in a bone is called a fracture. Considerable

force is needed to break a bone, unless it is diseased or old.

However, bones that are still growing are supple and may split,

bend or crack like a twig. A bone may break at the point where a

heavy blow is received. Fractures may also result from a twist or

a wrench (indirect force).

In an open fracture, one of the broken bone ends may pierce the

skin surface, or there may be a wound at the fracture site. An

open fracture carries a high risk of becoming infected.

In a closed fracture, the skin around the fracture is intact.

However, bones may be displaced (unstable) causing internal

bleeding and the casualty may develop shock (pp.112–13).

OPEN AND CLOSED FRACTURES

A stable fracture occurs when the broken bone ends do not

move because they are not completely broken or they are

impacted. Such injuries are common at the wrist, shoulder, ankle

and hip. Usually, these fractures can be gently handled without

further damage.

In an unstable fracture, the broken bone ends can easily move.

There is a risk that they may damage blood vessels, nerves and

organs around the injury. Unstable injuries can occur if the bone is

broken or the ligaments are torn (ruptured). They should be handled

carefully to prevent further damage.

STABLE AND UNSTABLE FRACTURES

Closed fracture

The skin is not

broken, although

the bone ends may

damage nearby

tissues and blood

vessels. Internal

bleeding is a risk.

Open fracture

Bone is exposed at

the surface where it

breaks the skin. The

casualty may suffer

bleeding and shock.

Infection is a risk.

Stable fracture

Although the bone

is fractured, the

ends of the injury

remain in place. The

risk of bleeding or

further damage is

minimal.

Unstable fracture

In this type of

fracture, the broken

bone ends can

easily be displaced

by movement or

muscle contraction.

Pelvis

Femur

137

FRACTURES

SEE ALSO Crush injury p.118 | Internal bleeding p.116 | Shock pp.112–13

WHAT TO DO FOR A CLOSED FRACTURE

Advise the casualty to keep still. Support the joints above and

below the injured area with your hands, or ask a helper to do this,

until it is immobilised with a sling or bandages.

Place padding around the injury for extra support. Take or send

the casualty to hospital; an arm injury may be transported by car;

call 999/112 for emergency help for a leg injury.

For firmer support and/or if removal to hospital is likely to be

delayed, secure the injured part to an unaffected part of the

body. For upper limb fractures, immobilise the arm with a sling

(pp.251–52). For lower limb fractures, move the uninjured leg to

the injured one and secure with broad-fold bandages (p.249).

Always tie the knots on the uninjured side.

Treat for shock if necessary (pp.112–13) . Do not raise the injured

leg; elevate the uninjured limb if shock is present. Monitor and

record vital signs (pp.52–53) while waiting for help. Check the

circulation beyond a sling or bandage (p.243) every ten minutes. If

the circulation is impaired, loosen the bandages.

1

2

3

4

■■ Do not move the casualty until

the injured part is secured and

supported, unless she is in

immediate danger.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

CAUTION

»

138

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Severe external bleeding pp.114–115 | Shock pp.112–13

■■ To prevent blood loss, movement

and infection at the site of injury

■■ To arrange removal to hospital,

with comfortable support during

transport

YOUR AIMS

WHAT TO DO FOR AN OPEN FRACTURE

Cover the wound with a sterile dressing or large, clean, non-fluffy

pad. Apply pressure around the injury to control bleeding

(pp.114–15); be careful not to press on a protruding bone.

1

Carefully place a sterile wound dressing or more clean padding

over and around the first dressing. 2

Secure the dressing and padding with a bandage. Bandage

firmly, but not so tightly that it impairs the circulation beyond

the bandage.

3

Treat the casualty for shock (pp.112–13) if necessary. Do not raise

the injured leg; elevate the uninjured limb if shock is present.

Monitor and record vital signs – breathing, pulse and level of response

(pp.52–53) – while waiting for help to arrive. Check the circulation

beyond the bandage (p.243) every ten minutes.

5

Immobilise the injured part as for a closed fracture (p.137), and

arrange to transport the casualty to hospital. 4

■■ Do not move the casualty until

the injured part is secured and

supported, unless he is in

immediate danger.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Do not press directly on a

protruding bone end.

CAUTION

«FRACTURES

If a bone end is protruding,

build up pads of clean, soft,

non-fluffy material around the

bone, until you can bandage

over it without pressing on

the injury.

SPECIAL CASE

PROTRUDING BONE

FRACTURES | DISLOCATED JOINT

139

DISLOCATED JOINT

■■ “Sickening”, severe pain

■■ Inability to move the joint

■■ Swelling and bruising around the

affected joint

■■ Shortening, bending or deformity

of the area

RECOGNITION

■■ To prevent movement at the

injury site

■■ To arrange removal to hospital, with

comfortable support during

transport

YOUR AIMS

SEE ALSO Fractures pp.136–38 | Strains and sprains pp.140–41

WHAT TO DO

Advise the casualty to keep

still. If, for example, he has a

dislocated shoulder, help him to

support the injured arm in the

position he finds most

comfortable.

1

Arrange to take or send the casualty to hospital. Treat for shock if

necessary – do not raise an injured leg; elevate the uninjured one.

Monitor and record vital signs (pp.52–53) while waiting for help.

■■ Do not try to replace a

dislocated bone into its socket

as this may cause further injury.

■■ Do not move the casualty until

the injured part is secured and

supported, unless she is in

immediate danger.

■■ For a hand or arm injury remove

bracelets, rings and watches in

case of swelling.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

This is a joint injury in which the bones are partially or CAUTION

completely pulled out of their normal position. Dislocation

can be caused by a strong force wrenching the bone into an

abnormal position, or by violent muscle contraction. This very

painful injury most often affects the shoulder, knee, jaw or joints

in the thumbs or fingers. Dislocations may be associated with

torn ligaments (pp.140–41), or with damage to the synovial

membrane that lines the joint capsule (p.135).

Joint dislocation can have serious consequences. If vertebrae are

dislocated, the spinal cord can be damaged. Dislocation of the

shoulder or hip may damage the large nerves that supply the

limbs and result in paralysis. A dislocation of any joint may

also fracture the bones involved. It is difficult to distinguish a

dislocation from a closed fracture (p.136). If you are in any doubt,

treat the injury as a fracture.

For extra support for an injured arm, secure the limb to the chest

by tying a broad-fold bandage (p.249) right around the chest and

the sling.

3

Check the circulation beyond the bandages (p.243) every

ten minutes. 5

Immobilise the injured

arm with a sling (p.251)

or use padding and/or broadfold

bandages (p.249) for a

leg injury, whichever is most

comfortable.

2

4

140

BONE, JOINT AND MUSCLE INJURIES

STRAINS AND SPRAINS

The softer structures around bones and joints

– the ligaments, muscles and tendons – can be

injured in several ways. Injuries to these soft

tissues are commonly called strains and sprains.

They occur when the tissues are overstretched

and partially or completely torn (ruptured) by

violent or sudden movements. For this reason,

strains and sprains are frequently associated

with sporting activities.

Strains and sprains should be treated initially by

the “RICE” procedure:

R – Rest the injured part

I – Apply Ice pack or a cold pad

C – Provide Comfortable support

E – Elevate the injured part

This procedure may be sufficient to relieve the

symptoms, but if you are in any doubt as to the

severity of the injury, treat it as a fracture

(pp.136–38).

Muscles and tendons may be strained, ruptured

or bruised. A strain occurs when the muscle is

overstretched; it may be partially torn, often at

the junction between the muscle and the tendon

that joins it to a bone. In a rupture, a muscle or

tendon is torn completely; this may occur in the

main bulk of the muscle or in the tendon. Deep

bruising can be extensive in parts of the body

where there is a large bulk of muscle. Injuries

in these areas are usually accompanied by

bleeding into the surrounding tissues, which

can lead to pain, swelling and bruising.

MUSCLE AND TENDON INJURY

Muscle tears

Vigorous movements may cause muscle fibres,

such as the hamstring in the leg, to tear. Muscle

tears can cause severe pain and swelling.

Ruptured tendon

The Achilles heel tendon attaches the calf muscle

to the heel bone. It can snap after sudden exertion

and may need surgery and immobilisation.

One common form of ligament injury is a

sprain. This is the tearing of a ligament at

or near a joint. It is often due to a sudden

or unexpected wrenching motion that

pulls the bones in the joint too far

apart and tears the

surrounding tissues.

LIGAMENT INJURY

Sprained ankle

This is due to overstretching

or tearing of a ligament –

the fibrous cords that

connect bones at a joint.

In this example, one of the

ligaments in the ankle is

partially torn.

Ruptured

Achilles

tendon

Normal

muscle fibres

Torn muscle

fibres produce

localised pain

and swelling

Tibialis anterior

tendon

Tibia Fibula

Sprained

ligament

Heel

bone

141

STRAINS AND SPRAINS

There may be:

■■ Pain and tenderness

■■ Difficulty in moving the injured part,

especially if it is a joint

■■ Swelling and bruising in the area

RECOGNITION

■■ To reduce swelling and pain

■■ To obtain medical help if necessary

YOUR AIMS

SEE ALSO Cold compresses p.241 | Fractures pp.136–38

WHAT TO DO

Help the casualty to sit or

lie down. Support the

injured part in a comfortable

position, preferably raised.

Cool the area by applying a

cold compress, such as an

ice pack or cold pad (p.241), to

the injury. This helps to reduce

swelling, bruising and pain.

1 2

Apply comfortable support to the injured part.

Leave the cold compress in place or wrap a

layer of soft padding, such as cotton wool, around

the area. Secure it with a conforming bandage that

extends to the next joint; for an ankle injury, the

bandage should extend from the base of the toes

to the knees; make sure it is not too tight.

3 Support the injured part in a raised position to

help minimise bruising and swelling in the area.

Check the circulation beyond the bandages (p.243)

every ten minutes. If the circulation is impaired,

undo the bandage and reapply more loosely.

4

If the pain is severe, or the casualty is unable

to use the injured part, arrange to take or send

him to hospital. Otherwise, advise the casualty

to rest the injury and to seek medical advice

if necessary.

5

142

BONE, JOINT AND MUSCLE INJURIES

THE BRAIN AND NERVES

The nervous system is the body’s

information-gathering, storage and control

system. It consists of a central processing

unit – the brain – and a network of nerve cells

and fibres.

There are two main parts to the nervous

system: the central nervous system,

consisting of the brain and spinal cord, and

the peripheral nervous system, which

consists of all the nerves that connect the

brain and the spinal cord to the rest of the

body. In addition, the autonomic (involuntary)

nervous system controls body functions such

as digestion, heart rate and breathing. The

central nervous system receives and analyses

information from all parts of the body. The

nerves carry messages, in the form of highspeed

electrical impulses, between the brain

and the rest of the nervous system.

Spinal cord protection

The spinal cord is

protected by the

vertebral column. Nerves

from the spinal cord

emerge between

vertebrae.

Brain

Structure of the

nervous system

The system consists

of the brain, spinal

cord and a network

of nerves that carry

electrical impulses

between the brain

and the body.

Cross-section

through a nerve

Each nerve is made up

of bundles of nerve fibres

(fascicles). A fatty substance

(myelin) surrounds and

insulates larger nerve fibres.

Cranial nerves (12 pairs)

extend directly from the

underside of the brain; most

serve the head, face, neck

and shoulders

Vagus nerve, longest of the

cranial nerves, serves organs

in chest and abdomen; it

controls the heart rate

Radial nerve

controls

muscles that

straighten

elbow and

fingers

Tibial nerve

serves calf

muscles

Sciatic nerve serves

hip and hamstring

muscles

Body of

vertebra

Spinal nerve

Spinal cord

Nerve fibre

Myelin sheath

Nerve

fascicle

143

THE BRAIN AND NERVES

Structure of the brain

The brain is enclosed within the skull. It has

three main parts: the cerebrum, which has an

outer layer called the cortex; the cerebellum;

and the brain stem.

THE BRAIN AND SPINAL CORD

Together the brain and spinal cord make up

the central nervous system (CNS). This system

contains billions of interconnected nerve cells

(neurons) and is enclosed by three

membranes called meninges. A clear fluid

called cerebrospinal fluid flows around the

brain and spinal cord. It functions as a shock

absorber, provides oxygen and nutrients and

removes waste products.

The brain has three main structures:

the cerebrum, which is concerned with

thought, sensation and conscious

movement; the cerebellum, which

coordinates movement, balance and

posture; and the brain stem, which

controls basic functions such as

breathing. The main function of the

spinal cord is to convey signals between

the brain and the peripheral nervous

system (below).

AUTONOMIC NERVES

Some of the cranial nerves, and several small

spinal nerves, work together as the autonomic

nervous system. This system is concerned with

vital body functions such as heart rate and

breathing. The system’s two parts – the

sympathetic and parasympathetic systems –

counterbalance each other. The sympathetic

nerves prepare the body for action by releasing

hormones that raise the heart rate and reduce

the blood flow to the skin and intestines. The

parasympathetic nerves release hormones with

a calming effect.

PERIPHERAL NERVES

The peripheral nervous system consists of two

sets of paired nerves – the cranial and spinal

nerves – connecting the CNS to the body.

The cranial nerves emerge in 12 pairs from the

underside of the brain. The 31 pairs of spinal

nerves branch off at intervals from the spinal

cord, passing into the rest of the body. Nerves

comprise bundles of nerve fibres that can

relay both incoming (sensory) and outgoing

(motor) signals.

Spinal cord extends

from brain stem to

lower end of spine

Vertebral column

protects delicate

spinal cord

Brain

stem

Cerebrum

Cerebellum

Skull

Cerebrospinal

fluid

Meninges (membranes)

surround brain and

spinal cord

144

BONE, JOINT AND MUSCLE INJURY

HEAD INJURY

Head injuries are common. They are potentially serious because

they can lead to damage to the brain. There may also be injuries

to the spine in the neck, scalp wounds and/or a skull fracture.

If a casualty has sustained a minor injury such as a bruise or

scalp wound, he is likely to be responding normally. If he has

suffered a more serious blow to the head, such as in a sporting

impact, responsiveness may be temporarily impaired.

The brain lies inside the skull, cushioned by fluid and can

therefore be shaken by a blow to the head. This is called

concussion and it may produce a temporary period of

unresponsiveness, but is not usually associated with any lasting

damage to the brain. The casualty may be confused, but this lasts

only a short time and is followed by a full recovery.

If a casualty has suffered a severe blow to his head, this may

cause bleeding or swelling inside the skull that can press on the

brain (compression). This is a serious condition. The pressure can

rise immediately after the impact or it may develop a few hours

or even days later. The severity of the head injury is related to

the mechanism of injury and its impact on the head. A serious

head injury is likely after a high speed motor collision or a fall

from a height.

Seek medical advice if you

notice signs of a worsening head

injury such as:

■■ Increasing drowsiness

■■ Persistent headache

■■ Confusion, dizziness, loss of

balance and/or loss of memory

■■ Difficulty speaking

■■ Difficulty walking

■■ Vomiting episodes after the

injury

■■ Double vision

■■ Seizure

CAUTION

Causes of head injury

The brain can be literally “shaken” inside

the skull with concussion (below). Injury that

results in bleeding can cause pressure to

build up inside the skull and damage the

tissues of the brain (below right).

Skull

Brain

Indirect force from

blow shakes brain

within skull

Skull

Accumulated blood

Brain presses on brain

Assess a casualty’s level of

response using the AVPU scale.

Check the casualty at regular

intervals. Make a note

of your findings at each

assessment, paying particular

attention to any change – the

casualty’s condition may improve

or deteriorate while you are

looking after him.

A – Is the casualty Alert? Are his

eyes open and does he respond

to questions?

V – Does the casualty respond to

Voice? Can he answer simple

questions and obey commands

P – Does the casualty respond to

Pain? Does he move or open his

eyes if you pinch his earlobe?

U – Is he Unresponsive to any

stimulus?

ASSESSING THE LEVEL OF

RESPONSE

CONCUSSION COMPRESSION

Direction of force

145

HEAD INJURY

There may be:

■■ Brief period of impaired response or

unresponsiveness

■■ Scalp wound

■■ Dizziness or nausea

■■ Loss of memory of events at the

time of, or immediately preceding

the injury

■■Mild generalised headache

■■ Confusion

For severe head injury there may

also be:

■■ History of a severe blow to the head

■■ Deteriorating level of response

■■ Loss of responsiveness

■■ Leakage of blood or blood-stained

watery fluid from the ear or nose

■■ Unequal pupil size

RECOGNITION

■■ To place the casualty in the care of a

responsible person

■■ To obtain medical help if necessary;

for serious head injury arrange

urgent removal to hospital

YOUR AIMS

SEE ALSO Facial injury p.146 | Scalp and head wounds p.122 | The unresponsive casualty pp.54–87

Regularly monitor and record vital signs – breathing, pulse and

level of response (pp.52–53). Watch especially for changes in his

level of response.

Sit the casualty down and give him a cold compress to hold

against the injury. Carry out an assessment of the casualty’s level

of response using the AVPU scale (opposite). Treat any scalp wounds

by applying direct pressure to the wound (p.122).

When the casualty has recovered, ask a responsible person to

look after him.

If a casualty’s injury is the result of a sporting incident, do not

allow him to return to the sport until he has been fully assessed

by a medical practitioner.

Advise the casualty to seek medical help if he develops signs and

symptoms of a worsening head injury (see CAUTION, opposite),

or if ANY of the following apply:

He is over 65 years of age

He has had previous brain surgery

He is taking anti-coagulant (anti-clotting) medication

The head injury is accompanied by drug or alcohol intoxication

There is no responsible person to look after him

Call 999/112 for emergency help – tell the operator that you suspect

head injury. Maintain an open and clear airway. Do this in the position

the casualty was found – try not to move him because of the additional

risk of spinal injury (pp.158–59). If this is not possible, use the jaw thrust

method to open the airway (p.159). Regularly monitor and record vital

signs – breathing, pulse and level of response (pp.52–53) – while waiting

for help to arrive. Watch especially for changes in his level of response.

SPECIAL CASE SEVERE HEAD INJURY

WHAT TO DO

2

3

4

5

1

146

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Head injury pp.144–45 | Knocked out adult tooth p.125 | Shock pp.112–13 | Spinal injury pp.157–59

| The unresponsive casualty pp.54–87

There may be:

■■ Pain around affected area; if the jaw

is affected, difficulty speaking,

chewing or swallowing

■■ Difficulty breathing

■■ Swelling and distortion of the face

■■ Bruising and/or a black eye

■■ Blood or bloodstained watery fluid

leaking from the nose or ear

RECOGNITION

■■ Never place a bandage around

the lower part of the face or

lower jaw in case the casualty

vomits or has difficulty

breathing.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

■■ If an unresponsive casualty is

breathing, place him in the

recovery position (pp.64–65)

with his injured side

downwards so that blood or

other body fluids can drain

away. Place soft padding

under his head. Be aware of

the risk of neck (spinal) injury.

Fractures of facial bones are usually due to hard impacts.

Serious facial fractures may appear frightening. There may be

distortion of the eye sockets, general swelling and bruising, as

well as bleeding from displaced tissues or from the nose and

mouth. The main danger with any facial fracture is that blood,

saliva or swollen tissue may obstruct the airway and cause

breathing difficulties.

When you are examining a casualty with a facial injury,

assume that there is damage to the skull, brain or neck. There is

also a danger that you may misinterpret the symptoms of a facial

fracture as a black eye.

CAUTION

FACIAL INJURY

■■ To keep the airway open

■■ To minimise pain and swelling

■■ To arrange urgent removal to

hospital

YOUR AIMS

WHAT TO DO

Call 999/112 for

emergency help.

Help the casualty to sit

down and make sure the

airway is open and clear.

Ask the casualty to spit out

any blood, displaced teeth

or dentures from his mouth.

Keep any teeth to send to

hospital with him.

1

4

2

Gently place a cold

compress (p.241) against the

casualty’s face to help reduce

pain and minimise swelling.

Treat for shock (pp.112–13)

if necessary.

3

Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

5

147

FACIAL INJURY | LOWER JAW INJURY | CHEEKBONE AND NOSE INJURY

CHEEKBONE AND NOSE INJURY

SEE ALSO Facial injury opposite | Head injury pp.144–45 | Knocked out adult tooth p.125 | Nosebleed p.124

WHAT TO DO

WHAT TO DO

There may be:

■■ Pain, swelling and bruising

■■ Obvious wound or bleeding from the

nose or mouth

RECOGNITION

■■ If there is blood or bloodstained

watery fluid leaking from the

casualty’s nose, treat the

casualty as for a head injury

(pp.144–45).

■■ Do not allow the casualty

to eat or drink because an

anaesthetic may be needed.

CAUTION

■■ To minimise pain and swelling

■■ To arrange transport to hospital

YOUR AIMS

Fractures of the cheekbone and nose are usually the result of

direct blows to the face. Swollen facial tissues are likely to cause

discomfort, and the air passages in the nose may become

blocked, making breathing difficult. These injuries should always

be examined in hospital.

Gently place a cold

compress, such as a cold pad

or ice pack (p.241), against the

injured area to help reduce pain

and minimise swelling.

1

If the casualty has a

nosebleed, try to pinch the

nose to stop the bleeding

(p.124). Arrange to take or send

the casualty to hospital.

2

LOWER JAW INJURY

There may be:

■■ Difficulty speaking, swallowing and

moving the jaw

■■ Pain and nausea when moving

the jaw

■■ Displaced or loose teeth and

dribbling from the mouth

■■ Swelling and bruising inside and

outside the mouth

RECOGNITION

■■ To protect the airway

■■ To arrange transport to hospital

YOUR AIMS

Jaw fractures are usually the result of direct force, such as a

heavy blow to the chin. In some situations, a blow to one side

of the jaw produces indirect force, which causes a fracture on

the other side of the face. A fall on to the point of the chin can

fracture the jaw on both sides. The lower jaw may also be

dislocated by a blow to the face, or is sometimes dislocated

by yawning.

If the face is seriously injured, with the jaw fractured in more

than one place, treat as for a facial injury (opposite).

If the casualty is not

seriously injured, help him

to sit with his head forward to

allow fluids to drain from his

mouth. Encourage the casualty

to spit out loose teeth, and

keep them to send to hospital

with him.

1 Give the casualty a soft pad

to hold firmly against his

jaw in order to support it.

2

Arrange to take or send the

casualty to hospital. Keep

his jaw supported throughout.

3

148

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Fractures pp.136–38 | Upper arm injury p.150

■■ To immobilise the injured shoulder

and arm

■■ To arrange transport to hospital

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

The collar bones (clavicles) form “struts” between the shoulder

blades and the top of the breastbone to help support the arms. It

is rare for a collar bone to be broken by a direct blow. Usually, a

fracture results from an indirect force transmitted from an

impact at the shoulder or passing along the arm, for example,

from a fall onto an outstretched arm.

Collar bone fractures often occur in young people as a result

of sports activities. The broken ends of the collar bone may be

displaced, causing swelling and bleeding in the surrounding

tissues as well as distortion of the shoulder.

WHAT TO DO

Help the casualty to sit down. Gently place the injured arm across

her body in the position that she finds most comfortable. Ask her

to support the elbow on the injured side with her other hand, or help

her to do it.

Support the arm on the

affected side with an arm

sling (p.251). Make sure the knot

is clear of the site of injury.

For extra support, secure

the arm to the chest by

tying a broad-fold bandage

(p.249) around the chest and

the sling. Once the arm is

supported the casualty will

be more comfortable.

2

1

3

CAUTION

COLLAR BONE INJURY

There may be:

■■ Pain and tenderness, increased by

movement

■■ Swelling and deformity of the

shoulder

■■ Attempts by the casualty to relax

muscles and relieve pain; she may

support her arm at the elbow, and

incline her head to her injured side

RECOGNITION

Arrange to take or send

the casualty to hospital

in the position she finds most

comfortable.

4

149

COLLAR BONE INJURY | SHOULDER INJURY

SHOULDER INJURY

■■ To support and immobilise the

injured limb

■■ To arrange transport to hospital

YOUR AIMS

■■ Do not attempt to replace a

dislocated bone into its socket.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

A fall on to the shoulder or an outstretched arm, or a wrenching

force may pull the head of the upper arm bone (humerus) out of

the joint socket – dislocation of the shoulder. At the same time,

ligaments around the shoulder joint may be torn. This injury

can be extremely painful. Some people experience repeated

dislocations and may need a strengthening operation on the

affected shoulder.

A fall onto the point of the shoulder may damage the ligaments

bracing the collar bone at the shoulder. Other shoulder injuries

include damage to the joint capsule and to the tendons around

the shoulder; these injuries tend to be common in older people.

To treat a shoulder sprain, follow the RICE procedure – Rest the

affected part, cool the injury with Ice, provide Comfortable

support with bandaging and Elevate the injury (pp.140–41).

WHAT TO DO

Help the casualty to sit

down. Gently place the arm

on the injured side across her

body in the position that is most

comfortable. Ask the casualty to

support her elbow on the injured

side, or help her to do it.

For extra support if

necessary, secure the arm to

the chest by tying a broad-fold

bandage (p.249) around the

chest and the sling.

Support the arm on the

injured side with an arm

sling (p.251).

Arrange to take or send

the casualty to hospital

in the position she finds most

comfortable.

3

1 2

4

CAUTION

There may be:

■■ Severe pain, increased by movement;

the pain may make the casualty

reluctant to move

■■ Attempts by the casualty to relieve

pain by supporting the arm and

inclining the head to the injured side

■■ A flat, angular look to the shoulder

RECOGNITION

SEE ALSO Fractures pp.136–38

150

There may be:

■■ Pain, increased by movement

■■ Tenderness and deformity over the

site of a fracture

■■ Rapid swelling

■■ Bruising, which may develop more

slowly

■■ To immobilise the arm

■■ To arrange transport to hospital

RECOGNITION

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

The most serious form of upper arm injury is a fracture of

the long bone in the upper arm (humerus). The bone may be

fractured across the centre by a direct blow. However, it is much

more common, especially in elderly people, for the arm bone

to break at the shoulder end, usually in a fall.

A fracture at the top of the bone is usually a stable injury

(p.136), as the broken bone ends stay in place. For this reason,

it may not be immediately apparent that the bone is broken,

although the arm is likely to be painful. There is a possibility

that the casualty will cope with the pain and leave the

fracture untreated for some time.

WHAT TO DO

Help the casualty to sit

down. Remove all jewellery

such as bracelets, rings and

watches. Gently place the

forearm horizontally across her

body in the position that is most

comfortable. Ask her to support

her elbow if possible.

Slide a triangular bandage

in position between the arm

and the chest, ready to make an

arm sling (p.251). Place soft

padding between the injured

arm and the body, then support

the arm and its padding in an

arm sling.

For extra support, or if

the journey to hospital is

prolonged, secure the arm by

tying a broad-fold bandage

(p.249) around the chest and

over the sling; make sure that

the broad-fold bandage is below

the fracture site.

Arrange to take or send the

casualty to hospital.

1 2 3

4

CAUTION

UPPER ARM INJURY

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Fractures pp.136–38

151

UPPER ARM INJURY | ELBOW INJURY

ELBOW INJURY

There may be:

■■ Pain, increased by movement

■■ Tenderness over the site of a fracture

■■ Swelling, bruising and deformity

■■ Fixed elbow

■■ To immobilise the arm without

further injury to the joint

■■ To arrange transport to hospital

RECOGNITION

YOUR AIMS

■■ If the casualty feels faint, help her

to lie down.

■■ Do not allow the casualty to eat or

drink because an anaesthetic may

be needed.

■■ Do not try to move the injured

arm.

WHAT TO DO

If the elbow can be bent, treat as for upper arm injury opposite.

Remove all jewellery such as bracelets, rings and watches.

If the casualty cannot bend her arm, help her to sit down.

Place padding, such as a towel, around the elbow for comfort

and support.

Secure the arm in the most comfortable position for the casualty

using broad-fold bandages. Keep the bandages clear of the

fracture site.

Arrange to take or send the

casualty to hospital.

Check the wrist pulse

(p.53) in the injured arm

every ten minutes until medical

help arrives. If you cannot feel a

pulse, gently undo the bandages

and straighten the arm until the

pulse returns. Support the arm

in this position.

2

1

3

4

5

Fractures or dislocations at the elbow usually result from

a fall on to the hand. Children often fracture the upper arm bone

just above the elbow. This is an unstable fracture (p.136), and the

bone ends may damage blood vessels. Circulation in the arm

needs to be checked regularly. In any elbow injury, the elbow

will be stiff and difficult to straighten. Never try to force a

casualty to bend it.

CAUTION

SEE ALSO Fractures pp.136–38

152 SEE ALSO Fractures pp.136–38 | Severe external bleeding pp.114–15

There may be:

■■ Pain, increased by movement

■■ Swelling, bruising and deformity

■■ Possible bleeding with an open

fracture

■■ To immobilise the arm

■■ To arrange transport to hospital

RECOGNITION

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

The bones of the forearm (radius and ulna) can be fractured by

an impact such as a heavy blow or a fall. As the bones have little

fleshy covering, the broken ends may pierce the skin, producing

an open fracture (p.136 and p.138).

A fall onto an outstretched hand can result in a fracture of the

wrist. This is called a Colles fracture and commonly occurs in

elderly people.

The wrist joint is rarely dislocated, but is often sprained.

It can be difficult to distinguish between a sprain and a fracture,

especially if the tiny scaphoid bone (at the base of the thumb)

is injured. If you are in any doubt about the injury always treat

as a fracture.

WHAT TO DO

Ask the casualty to sit

down. Steady and support

the injured forearm and place it

across his body; ask the casualty

to support it if he can. Expose

and treat any wound. For extra support, or if

the journey to hospital is

likely to be prolonged, secure

the arm to the body by tying a

broad-fold bandage (p.249) over

the sling and body. Position the

bandage as close to the elbow as

you can. Arrange to take or send

the casualty to hospital.

Slide a triangular bandage

in position between the

arm and the chest, ready to

make an arm sling (p.251).

Surround the forearm in

soft padding, such as a

small towel.

Support the arm and the

padding with an arm sling;

make sure the knot is tied on the

injured side.

4

2

1 3

CAUTION

FOREARM AND WRIST INJURIES

BONE, JOINT AND MUSCLE INJURIES

153

FOREARM AND WRIST INJURIES | HAND AND FINGER INJURIES

HAND AND FINGER INJURIES

SEE ALSO Crush injury p.118 | Dislocated joint p.139 | Fractures pp.136–38 | Wound to the palm p.127

There may be:

■■ Pain, increased by movement

■■ Swelling, bruising and deformity

■■ Possible bleeding with an open

fracture

■■ To elevate the hand and immobilise it

■■ To arrange transport to hospital

RECOGNITION

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

WHAT TO DO

Help the casualty to sit

down and ask her to raise

and support the affected wrist

and hand; help her if necessary.

Treat any bleeding and losely

cover the wound with a sterile

dressing or large clean, nonfluffy

pad.

For extra support, or if

the journey to hospital is

likely to be prolonged, secure

the arm by tying a broad-fold

bandage (p.249) around the

chest and over the sling; keep it

away from the injury. Arrange to

take or send the casualty

to hospital.

Remove any rings before

the hand begins to swell,

and keep the hand raised to

minimise swelling. Wrap the

hand in soft, non-fluffy padding

for extra protection.

Gently support the affected

arm across the casualty’s

body by placing it in an elevation

sling (p.252).

4

2

1 3

The bones and joints in the hand can suffer various types

of injury, such as fractures, cuts and bruising. Minor fractures are

usually caused by direct force. A fracture of the knuckle often

results from a punch.

Multiple fractures, affecting many or all of the bones in the

hand, are usually caused by crushing injuries. The fractures may

be open, with severe bleeding and swelling, needing immediate

first aid treatment.

The joints in the fingers or thumb are sometimes dislocated or

sprained as a result of a fall onto the hand (for example, while

someone is skiing or ice skating).

Always compare the suspected fractured hand with the

uninjured hand because finger fractures result in deformities that

may not be immediately obvious.

CAUTION

154

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Abdominal wound p.128 | Penetrating chest wound pp.104–05 | Shock pp.112–13

■■ To support the chest wall

■■ To arrange transport to hospital

YOUR AIMS

■■ Do not allow the casualty

to eat or drink because an

anaesthetic may be needed.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty

pp.54–87). If he needs to be

placed in the recovery position,

lay him on his injured side to

allow the lung on the uninjured

side to work to its full capacity.

One or more ribs can be fractured by direct force to the

chest from a blow or a fall, or by a crush injury (p.118). If there

is a wound over the fracture, or if a broken rib pierces a lung,

the casualty’s breathing may be seriously impaired.

An injury to the chest can cause an area of fractured ribs

to become detached from the rest of the chest wall, producing

what is called a “flail-chest” injury. The detached area moves

inwards when the casualty breathes in, and outwards as he

breathes out. This “paradoxical” breathing causes severe

breathing difficulties.

Fractures of the lower ribs may injure internal organs such as

the liver and spleen, and may cause internal bleeding.

CAUTION

RIB INJURY

■■ Pain at the site of injury

■■ Pain on taking a deep breath

■■ Bruising, swelling or a wound at the

fracture site

■■ Shallow breathing

■■ Paradoxical chest movement

■■ Signs of internal bleeding (p.116) and

shock (pp.112–13)

RECOGNITION WHAT TO DO

Help the casualty to sit

down and ask him to

support the arm on the injured

side. For extra support if

necessary, place the arm on the

injured side in a sling (pp.251–52).

1 Arrange to take or send the

casualty to hospital. 2

155

RIB INJURY | PELVIC INJURY

PELVIC INJURY

■■ To minimise the risk of shock

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Keep movements of the casualty

to a minimum to prevent

worsening the injury.

■■ Do not bandage the casualty's

legs together if this increases

the pain. In such cases,

surround the injured area

with soft padding, such as

clothing or towels.

CAUTION

SEE ALSO Fractures pp.136–38 | Internal bleeding p.116 | Shock pp.112–13

There may be:

■■ An inability to walk or even stand,

although the legs appear uninjured

■■ Pain and tenderness in the region of

the hip, groin or back, which increases

with movement

■■ Difficulty or pain passing urine, and

bloodstained clothing

■■ Signs of shock and internal bleeding

RECOGNITION

WHAT TO DO

Help the casualty to lie

down on her back with her

head flat/low to minimise shock.

Keep her legs straight and flat.

Call 999/112 for

emergency help. Treat the

casualty for shock (pp.112–13).

Do not raise her legs.

1 3

Place padding between the

bony points of her knees

and ankles. Immobilise her legs

by bandaging them together

with folded triangular bandages

(p.249); secure her feet and

ankles with a narrow-fold

bandage (1), and her knees with

a broad-fold bandage (2).

Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

2 4

Injuries to the pelvis are usually caused by forces such as a car

crash, a fall from a height or by crushing. These incidents can

result in a stable or unstable fracture of the pelvis. An unstable

fracture can be life-threatening.

A fracture of the pelvic bones may also be complicated by

injury to the tissues and organs in the pelvis, such as the bladder

and the urinary passages. The bleeding from large organs and

blood vessels in the pelvis may be severe and can lead to shock.

2

1

156

BONE, JOINT AND MUSCLE INJURIES

BACK PAIN

SEE ALSO Fractures pp.136–38 | Spinal injury pp.157–59

■■ To relieve pain

YOUR AIM

If any of the following symptoms

or signs are present, call 999/112

for emergency help:

■■ Acute back pain in a casualty

under 20 or over 55

■■ Recent history of injury, such as

a road traffic incident or fall from

a height

■■Other symptoms of illness, such

as fever, as well as back pain

■■ Numbness and tingling down

the back of both legs

■■ Swelling or deformity along the

spine

■■ Difficulty with bladder and/or

bowel function

Lower back pain is common and most adults may experience

it at some point in their lives. It may be acute (sudden onset)

or chronic (long term). It is usually caused by age-related

degenerative changes or results from minor injury affecting

muscles, ligaments, vertebrae, discs or nerves. It may be the

result of heavy manual work, a fall or a turning or twisting

movement. Serious conditions causing back pain are rare and

beyond the scope of first aid.

Most cases are simple backache, often in the lower back, in

people aged 20–55 who are otherwise well. In a small number

of casualties, the pain may extend down one leg. This is called

sciatica and is caused by pressure on the nerve root (a so-called

“trapped nerve”).

Spine injuries in those under 20 or over 55, or that result

from a more serious injury, require investigation and treatment

(Spinal injury, opposite and pp.157–59).

WHAT TO DO

Advise the casualty to stay active to mobilise the injured area.

Encourage him to return to normal activity as soon as possible.

An adult casualty may take the recommended dose of

paracetamol tablets, or his own painkillers. 2

1

CAUTION

■■ Pain in the lower back following

lifting or manual work

■■ Possible pain radiating down the

back of one leg with numbness or

tingling in the affected leg – sciatica

RECOGNITION

3 Advise the casualty to seek medical advice if necessary.

157

Injuries to the spine can involve one or more parts of the back

and/or neck: the bones (vertebrae), the discs of tissue that

separate the vertebrae, the surrounding muscles and ligaments,

or the spinal cord and the nerves that branch off from it.

The most serious risk associated with spinal injury is damage

to the spinal cord. Such damage can cause loss of power and/or

sensation below the injured area. The spinal cord or nerve roots

can suffer temporary damage if they are pinched by displaced or

dislocated discs, or by fragments of broken bone. If the cord is

partly or completely severed, damage may be permanent.

CAUSES OF SPINAL INJURY

The most important indicator is the mechanism of the injury.

Suspect spinal injury if abnormal forces have been exerted on the

back or neck, and particularly if a casualty complains of any

changes in sensation or difficulties with movement. If the

incident involved violent forward or backward bending, or

twisting of the spine, you must assume that the casualty has a

spinal injury. You must take particular care to avoid unnecessary

movement of the head, neck and spine at all times.

Although spinal cord injury may occur without any damage to

the vertebrae, spinal fracture greatly increases the risk. The areas

that are most vulnerable are the bones in the neck and those

in the lower back.

Any of the following incidents should alert you to the

possibility of a spinal injury:

■■Falling from a height, such as a ladder

■■Falling awkwardly, for instance, while doing

gymnastics or trampolining

■■Diving into a shallow pool and hitting

the bottom

■■Falling from a horse or motorbike

■■Collapsed rugby scrum

■■Sudden deceleration in a motor vehicle

■■A heavy object falling across the back

■■Injury to the head or the face

When the vertebrae are damaged,

there may be:

■■ Pain in the neck or back at the injury

site. This may be masked by other,

more painful, injuries

■■ Step, irregularity or twist in the

normal curve of the spine

■■ Tenderness and/or bruising in the

skin over the spine

■■When the spinal cord is damaged,

there may be:

■■ Loss of control over limbs –

movement may be weak or absent

■■ Loss of sensation, or abnormal

sensations such as burning or

tingling; a casualty may tell you that

his limbs feel stiff, heavy or clumsy

■■ Loss of bladder and/or bowel control

■■ Breathing difficulties

RECOGNITION

BACK PAIN | SPINAL INJURY

Spinal cord protection

The spinal cord is protected

by the bony vertebral (spinal) column.

Nerves branching from the cord emerge

between adjacent vertebrae.

Intervertebral

disc

Vertebra

Spinal cord

Nerve root

SPINAL INJURY

»

158

BONE, JOINT AND MUSCLE INJURY

■■ To prevent further spinal damage

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ Do not move the casualty from

the position in which you found

her unless she is in immediate

danger and it is safe for you to

move her.

■■ If the casualty has to be moved,

use the log-roll technique

(opposite).

Ask a helper to place rolledup

blankets, towels or items

of clothing on either side of the

casualty’s head while you keep

her head in the neutral position.

Continue to support the casualty’s

head until emergency services

take over, no matter how long

this may be.

Kneel or lie behind the casualty’s head. Rest your elbows on

the ground or on your knees to keep your arms steady. Grasp

the sides of the casualty’s head. Spread your fingers so that you do

not cover her ears – she needs to be able to hear you. Steady and

support her head in this neutral position, in which the head, neck

and spine are aligned.

3

2

CAUTION

SPINAL INJURY

Get your helper to monitor

and record vital signs –

breathing, pulse and level of

response (pp.52–53) – while

waiting for help to arrive.

4

«

WHAT TO DO FOR A RESPONSIVE CASUALTY

Reassure the casualty and advise her not to move. Call 999/112

for emergency help, or ask a helper to do this. 1

159

SPINAL INJURY

■■ To maintain an open airway

■■ To begin CPR if necessary

■■ To prevent further spinal damage

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ If the casualty has to be moved

and you have help, use the logroll

technique (below).

■■ If you are alone and you need

to leave the casualty to call

for emergency help, and the

casualty is unable to maintain

an open airway, you should

place her in the recovery

position (pp.64–65) before

you leave her.

WHAT TO DO FOR AN UNRESPONSIVE CASUALTY

Kneel or lie behind the casualty’s head. Rest your elbows on the

ground or on your knees to keep your arms steady. Grasp the

sides of her head. Support her head so that her head, trunk and legs

are in a straight line.

Check the casualty’s

breathing. If she is

breathing, continue to support

her head. Call 999/112 for

emergency help or ask a helper

to do this.

Open the casualty’s airway using the jaw-thrust technique. Place

your fingertips at the angles of her jaw. Gently lift the jaw to open

the airway. Take care not to tilt the casualty’s neck.

If the casualty is not

breathing, begin CPR

(pp.66–67). If you need to turn

the casualty, use the log-roll

technique (below).

3

2

1

4

CAUTION

Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

5

This technique should be used to turn a

casualty with a spinal injury. While you

support the casualty’s head and neck,

ask your helpers to straighten her

limbs gently. Position three people

along one side to pull the casualty

towards them, and two on the other

to guide her forwards. The person at

the legs should place her hands under

the furthest leg. The middle helper

supports the casualty’s leg and hip.

Direct your helpers to roll the

casualty. Keep the casualty’s head,

trunk and legs in a straight line at all

times; the upper leg should be

supported in a slightly raised position

to keep the spine straight.

SPECIAL CASE LOG-ROLL TECHNIQUE

SEE ALSO The unresponsive casualty pp.54–87

POSITIONING FIRST AIDERS TURNING CASUALTY

160

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Dislocated joint p.139 | Fractures pp.136–38 | Internal bleeding p.116 | Shock pp.112–13

There may be:

■■ Pain at the site of the injury

■■ An inability to walk

■■ Signs of shock

■■ Shortening of the leg and turning

outwards of the knee and foot

RECOGNITION

■■ Do not allow the casualty

to eat or drink because an

anaesthetic may be needed.

■■ Do not raise the casualty’s legs,

even if she shows signs of shock,

because you may cause further

internal damage.

The most severe injury of the thigh bone (femur) is a fracture.

It takes a considerable force, such as a car crash or a fall from a

height, to fracture the shaft of the femur. This is a serious injury

because the broken bone ends can pierce major blood vessels,

causing severe blood loss, and shock may result.

Fracture of the neck of the femur is common in elderly people,

particularly women, whose bones become less dense and more

brittle with age (osteoporosis). This fracture is usually a stable

injury in which the bone ends are impacted together. The

casualty may be able to walk with a fractured neck of the femur

for some time before the fracture is discovered.

In the hip joint, the most serious, though much less common,

type of injury is dislocation.

CAUTION

HIP AND THIGH INJURIES

■■ To immobilise the limb

■■ To arrange urgent removal to

hospital

YOUR AIMS

2 3

5

6

4

7 1

SPECIAL CASE PREPARING A CASUALTY FOR A LONG JOURNEY

If the journey to hospital is likely to be long and

rough, more sturdy support for the leg and feet will

be needed. Use a purpose-made malleable splint

or a long, solid object, such as a fence post or long

walking stick, which reaches from the armpit to the

foot. Place the splint against the injured side. Insert

padding between the casualty’s legs and between the

splint and her body. Tie the feet together with a

narrow-fold bandage (1). Secure the splint to the body

with broad-fold bandages in the following order: at

the chest (2), pelvis (3), knees (4), above and below

the fracture site (5 and 6), and at one extra point (7).

Do not bandage over the fracture site. Once the

casualty’s leg is fully immobilised, she should be

moved onto the stretcher using the log-roll

technique (p.159).

HIP AND THIGH INJURIES

161

WHAT TO DO

Help the casualty to lie

down and make her as

comfortable as possible.

If the ambulance is not expected to arrive

quickly, immobilise the leg by securing it

to the uninjured one. Gently bring the sound leg

alongside the injured one. Position a narrow-fold

bandage (p.249) at the ankles and feet (1), then a

broad-fold one at the knees (2). Add additional

bandages above (3) and below (4) the fracture site.

Place soft padding between the legs to prevent the

bony parts from rubbing. Secure the bandages on

the uninjured side.

Suport the injured leg

at the knee and ankle.

If possible, ask someone else

to help you.

Take any steps possible to treat the casualty

for shock (pp.112–13): insulate her from the cold

with blankets or clothing. Do not raise her legs.

Monitor and record her vital signs – breathing,

pulse and level of response – while waiting for

help to arrive.

4

2

1

5

2 1

3

4

Call 999/112 for emergency

help. If the ambulance is

expected to arrive quickly, keep

the leg supported in the same

position until it arrives.

3

162

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Fractures pp.136–38 | Severe external bleeding pp.114–15 | Strains and sprains pp.140–41

There may be:

■■ Localised pain

■■ Swelling, bruising and deformity of

the leg

■■ An open wound

■■ Inability to stand on the injured leg

RECOGNITION

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Do not raise the casualty’s legs,

even if he shows signs of shock,

because you may cause further

internal damage.

Injuries to the lower leg include fractures of the shin bone

(tibia) and the splint bone (fibula), as well as damage to the soft

tissues (muscles, ligaments and tendons).

Fractures of the tibia are usually due to a heavy blow (for

example, from the bumper of a moving vehicle). As there is little

flesh over the tibia, a fracture is more likely to produce a wound.

The fibula can also be broken by the twisting forces that sprain

an ankle.

WHAT TO DO

Help the casualty to lie down and make him comfortable. Steady

and support the injured leg by hand at the knee and ankle to

prevent any movement. If there is a wound, carefully expose it and

treat the bleeding. Place a dressing over the wound to protect it.

Call 999/112 for emergency help. Maintain support until the

ambulance arrives. Treat for shock if necessary (pp.112-13). Do not

raise the injured leg; elevate the uninjured leg if shock is present.

2

1

CAUTION

LOWER LEG INJURIES

■■ To immobilise the leg

■■ To arrange transport to hospital

YOUR AIMS

LOWER LEG INJURIES

163

Steady and support the injured leg by hand

at the knee and foot (not over the fracture

site) to prevent any movement. If there is a wound,

treat the bleeding and place a dressing over the

wound to protect it. Call 999/112 for emergency

help. Maintain support until the ambulance arrives.

Treat the casualty for shock if necessary (pp.112–13).

Do not raise the injured leg; elevate the uninjured

leg if shock is present.

If the ambulance is delayed, splint the injured

leg to the other leg – ask a helper to maintain

support while you secure bandages. Bring the

uninjured leg to the injured one. Position a narrowfold

bandage (p.249) at the feet. Slide two broadfold

bandages under both knees; leave one at the

knee (2) and slide the other down to just above the

fracture site (3). Insert padding between the lower

legs and tie the feet together (1). Then secure the

other two bandages (2 then 3). Tie all knots on the

uninjured side.

If the ambulance is delayed, support the injured

leg by splinting it to the other leg. Bring the

uninjured leg alongside the injured one and slide

bandages under both legs. Position a narrow-fold

bandage (p.249) at the feet and ankles (1), then

broad-fold bandages at the knees (2) and above and

below the fracture site (3 and 4). Insert padding

between the lower legs. Tie a figure-of-eight

bandage around the feet and ankles, then secure the

other bandages; tie knots on the uninjured side.

If the casualty’s journey to hospital is likely to

be long and uncomfortable, place additional

soft padding on the outside of the injured leg, from

the knee to the foot. Secure the legs with broad-fold

bandages as above. Treat the casualty for shock

(pp.112–13) if necessary, but do not raise his legs.

1 2

3

4

3 4 1 2

1

3 2

SPECIAL CASE IF THE FRACTURE IS NEAR THE ANKLE

164

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Strains and sprains pp.140–41

■■ To protect the knee in the most

comfortable position for the casualty

■■ To arrange urgent removal to

hospital

YOUR AIMS

■■ Do not attempt to straighten

the knee forcibly. Displaced

cartilage or internal bleeding

may make it impossible to

straighten the knee joint safely.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

■■ Do not allow the casualty

to walk.

The knee is the hinge joint between the thigh bone (femur) and

shin bone (tibia). It is capable of bending, straightening and, in

the bent position, slight rotation.

The knee joint is supported by strong muscles and ligaments

and is protected at the front by a disc of bone called the kneecap

(patella). Discs of cartilage protect the end surfaces of the major

bones. Direct blows, violent twists or sprains can damage these

structures. Possible knee injuries include fracture of the patella,

sprains and damage to the cartilage.

A knee injury may make it impossible for the casualty to bend

or straighten the joint, and you should ensure that the casualty

does not try to walk on the injured leg. Bleeding or fluid in the

knee joint may cause marked swelling around the knee.

WHAT TO DO

Help the casualty to lie down, preferably on a blanket to insulate

him from the floor or ground. Place soft padding, such as pillows,

blankets or coats, under his injured knee to support it in the most

comfortable position.

Wrap soft padding around the joint. Secure the padding with a

roller bandage that extends from the middle of the casualty's

lower leg to mid-thigh.

Call 999/112 for emergency help. The casualty needs to remain

in the position he finds most comfortable and should be

transported to hospital by ambulance.

2

1

3

CAUTION

KNEE INJURY

There may be:

■■ Pain on attempting to move the knee

■■ Swelling at the knee joint

RECOGNITION

165

KNEE INJURY | ANKLE INJURY

ANKLE INJURY

SEE ALSO Strains and sprains pp.140–41 | Lower leg injuries pp.162–63

■■ To relieve pain and swelling

■■ To obtain medical aid if necessary

YOUR AIMS

■■ If the casualty has pain and

swelling in the bony areas of the

ankle, suspect a break. Secure

and support the lower leg as

described for fracture near the

ankle (p.163), and arrange to

take or send him to hospital.

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

A sprain is the most common ankle injury. It is usually caused

by a twist to the ankle and can be treated using the RICE

procedure (pp.140–41):

■■Rest the affected part

■■Cool the injury with Ice

■■Provide Comfortable support with bandages

■■Elevate the injury

If the casualty cannot bear any weight on the injured leg or there

is severe pain swelling and/or deformity at the ankle, suspect a

break and treat it as a fracture of the lower leg near the ankle

(p.163). Be aware too, however, that a casualty may have a

fracture and still be able to walk and move his toes. If you are in

any doubt about an ankle injury, treat it as a fracture.

WHAT TO DO

Support the ankle in the most comfortable position for the

casualty, preferably raised.

Apply comfortable support to the ankle. Leave

the cold compress in place or wrap a layer of

soft padding around the area. Bandage the ankle

with a support bandage that extends from the base

of the foot to the knee; it should not be too tight.

Apply a cold compress, such as an ice pack or a cold pad (p.241),

to the site to reduce swelling and bruising.

Raise and support the injured limb. Check the

circulation beyond the bandage (p.243) every

ten minutes. If the circulation is impaired, loosen the

bandage. Advise the casualty to rest the ankle and

seek medical advice if necessary.

3

2

1

4

CAUTION

■■ Pain, increased either by movement

or by putting weight on the foot

■■ Swelling at the site of injury

RECOGNITION

166

BONE, JOINT AND MUSCLE INJURIES

SEE ALSO Crush injury p.118

■■ To minimise swelling

■■ To arrange transport to hospital

YOUR AIMS

■■ Do not allow the casualty to eat

or drink because an anaesthetic

may be needed.

The bones and joints in the foot can suffer various types of

injury, such as fractures, cuts and bruising. Minor fractures are

usually caused by direct force. Always compare the injured foot

with the uninjured foot, especially toes, because fractures can

result in deformities that may not be immediately obvious.

Multiple fractures, affecting many or all of the bones in the foot,

are usually caused by crushing injuries. These fractures may be

open, with severe bleeding and swelling, needing immediate first

aid treatment. Foot and toe injures must be treated in hospital.

CAUTION

FOOT AND TOE INJURIES

■■ Difficulty in walking

■■ Stiffness of movement

■■ Bruising and swelling

■■ Deformity

RECOGNITION

WHAT TO DO

Help the casualty to lie down, and carefully

steady and support the injured leg. If there is a

wound, carefully expose it and treat the bleeding.

Place a dressing over the wound to protect it.

Remove any foot jewellery before the area

begins to swell. 2

1

Apply a cold compress, such as an ice pack or a

cold pad (p.241). This will also help to relieve

swelling and reduce pain.

3

Arrange to take or send the casualty to

hospital. If he is not being taken by ambulance,

try to ensure that the injured foot remains elevated

during travel. Check the circulation beyond the

bandage (p.243) every ten minutes. If the

circulation is impaired, loosen the bandage.

5

Place padding around the casualty’s foot and

secure it with a bandage. 4

167

FOOT AND TOE INJURIES | CRAMP

CRAMP

SEE ALSO Dehydration p.182

■■ To relieve the spasm and pain

This condition is a sudden painful spasm in one or more muscles. YOUR AIM

Cramp commonly occurs during sleep. It can also develop after

strenuous exercise, due to a build-up of chemical waste products

in the muscles, or to excessive loss of salts and fluids from the

body through sweating or dehydration. Cramp can often be

relieved by stretching and massaging the affected muscles.

Cramp in the foot

Help the casualty stand with his weight on the

front of his foot (or rest the foot on your knee)

to stretch the affected muscles. Once the spasm

has passed, massage the affected part of the foot

with your fingers.

Cramp in the calf muscles

Help the casualty straighten his knee, and support

his foot. Flex his foot upwards towards his shin to

stretch the calf muscles, then massage the affected

area on the back of the calf.

Cramp in the front of the thigh

Help the casualty to lie down. Raise the leg and bend

the knee to stretch the muscles. Massage the affected

muscles once the spasm has passed.

Cramp in the back of the thigh

Help the casualty to lie down. Raise the leg and

straighten the knee to stretch the muscles. Massage

the area once the spasm has passed.

This chapter deals with the effects of

injuries and illnesses caused by

environmental factors such as extremes

of heat and cold.

The skin protects the body and helps to

maintain body temperature within a normal

range. It can be damaged by fire, hot liquids

or caustic substances. This chapter contains

advice on how to assess burns, whether

minor or severe.

The effects of temperature extremes can

also impair skin and other body functions.

Injuries may be localised – such as frostbite

or sunburn – or generalised, as in heat

exhaustion or hypothermia. Young children

and the elderly are most susceptible to

problems caused by extremes of

temperature.

■■ To assess the casualty’s condition quickly and calmly

■■ To comfort and reassure the casualty

■■ To call 999/112 for emergency help if you suspect a

serious illness or injury

■■ To be aware of your own needs

For burns:

■■ To protect yourself and the casualty

from danger

■■ To assess the burn, prevent further damage and

relieve symptoms

For extremes of temperature:

■■ To protect the casualty from heat or cold

■■ To restore normal body temperature

AIMS AND OBJECTIVES

EFFECTS OF

HEAT AND COLD

170

EFFECTS OF HEAT AND COLD

THE SKIN

One of the largest organs, the skin plays key

roles in protecting the body from injury and

infection and in maintaining the body at a

constant temperature.

The skin consists of two layers of tissue –

an outer layer (epidermis) and an inner layer

(dermis) – which lie on a layer of fatty tissue

(subcutaneous fat). The top part of the

epidermis is made up of dead, flattened skin

cells, which are constantly shed and replaced

by new cells made in the lower part of this layer.

The epidermis is protected by an oily substance

called sebum – secreted from glands called

sebaceous glands – which keeps the skin supple

and waterproof.

The lower layer of the skin, the dermis, contains

the blood vessels, nerves, muscles, sebaceous

glands, sweat glands and hair roots (follicles). The

ends of sensory nerves within the dermis register

sensations from the body’s surface, such as heat,

cold, pain and even the slightest touch. Blood

vessels supply the skin with nutrients and help

to regulate body temperature by preserving or

releasing heat (opposite).

Structure of the skin

The skin is made up of two layers: the thin, outer

epidermis and the thicker dermis beneath it. Most

of the structures of the skin, such as blood vessels,

nerves and hair roots, are contained within the dermis.

Hair follicle

Pore releases sweat

at the skin surface

Erector pili muscle

contracts to pull the

hair upright

Hair

Tiny structures called

papillae form the

junction between the

dermis and epidermis

Nerve

Epidermis

Dermis

Layer of

fatty tissue

Nerve ending

Sweat gland

secretes sweat onto

the skin surface

Sebaceous gland

produces oily

secretion (sebum)

Arteriole supplies

oxygenated blood

Venule carries

away waste

171

THE SKIN

One of the major functions of the skin is to

help maintain the body temperature within its

optimum range of 36–37°C (97–99°F). An organ

in the brain called the hypothalamus regulates

body temperature. If the temperature of blood

passing through this thermostat falls or rises

to a level outside the optimum range, various

mechanisms are activated to either warm or

cool the body as necessary.

HOW THE BODY KEEPS WARM

When the body becomes too cold, changes

take place to prevent heat from escaping. Blood

vessels at the body surface narrow (constrict)

to keep warm blood in the main part (core)

of the body. The activity of the sweat glands

is reduced, and hairs stand on end to “trap”

warm air close to the skin. In addition to the

mechanisms that prevent heat loss, other

body systems act to produce more warmth.

The rate of metabolism is increased. Heat is

also generated by muscle activity, which may

be either voluntary (for example, during

physical exercise) or, in cold conditions,

involuntary (shivering).

HOW THE BODY LOSES HEAT

In hot conditions, the body activates a number

of mechanisms to encourage heat loss and thus

prevent the body temperature from becoming

too high. Blood vessels that lie in or just under

the skin widen (dilate). As a result, blood flow

to the body surface increases and more heat is

lost. In addition, the sweat glands become more

active and secrete more sweat. This sweat then

cools the skin as it evaporates.

MAINTAINING BODY TEMPERATURE

How skin responds to low

body temperature

Blood vessels narrow (constrict) to reduce

blood flow to the skin. The erector pili

muscles contract, making the hairs stand

upright and trap warm air close to the skin.

How skin responds to high body

temperature

Blood vessels widen (dilate), making the

skin appear flushed, and heat is lost. Sweat

glands become active and produce sweat

droplets, which evaporate to cool the skin.

Constricted

blood vessel Contracted erector Dilated blood vessel

pili muscle Sweat

gland

“Goose pimple”

Sweat droplet

Erect hair

Hair

Relaxed erector

pili muscle

Dermis

Layer of

fatty tissue

Epidermis

172

EFFECTS OF HEAT AND COLD

ASSESSING A BURN

When skin is damaged by burning, it can

no longer function effectively as a natural

barrier against infection. In addition, body fluid

may be lost because tiny blood vessels in the

skin leak tissue fluid (serum). This fluid either

collects under the skin to form blisters or leaks

through the surface.

There may be related injuries, significant fluid

loss and infection may develop later.

WHAT TO ASSESS

It is particularly important to consider the

circumstances in which the burn has occurred;

whether or not the airway is likely to have been

affected; and the extent, location and depth

of the burn.

There are many possible causes of burns

(see below). By establishing the cause of the

burn, you may be able to identify any other

potential problems that could result. For

example, a fire in an enclosed space is likely to

have produced poisonous carbon monoxide gas,

or other toxic fumes may have been released if

burning material was involved. If the casualty’s

airway has been affected, he may have difficulty

breathing and will need urgent medical

attention and admission to hospital.

The extent of the burn will also indicate

whether or not shock is likely to develop. Shock is

a life-threatening condition that occurs whenever

there is a serious loss of body fluids (p.116). In a

burn that covers a large area of the body, fluid

loss will be significant and the risk of shock high.

If the burn is on a limb, fluid may collect in the

tissues around it, causing swelling and pain. This

build-up of fluid is particularly serious if the limb

is being constricted, for example by tight clothing

or footwear.

Burns allow germs to enter the skin and so

carry a serious risk of infection.

■ Flames ■ Contact with hot objects, such as domestic appliances or

cigarettes ■ Friction – for example, rope burns

Dry burn

TYPE OF BURN

TYPES OF BURN AND POSSIBLE CAUSES

CAUSES

Scald

Electrical burn

Cold injury

Chemical burn

Radiation burn

■ Steam ■ Hot liquids, such as tea and coffee, or hot fat

■ Low-voltage current, as used by domestic appliances

■ High-voltage currents, as carried in mains overhead cables

■ Lightning strikes

■ Frostbite ■ Contact with freezing metals ■ Contact with freezing

vapours, such as liquid oxygen or liquid nitrogen

■ Industrial chemicals, including inhaled fumes and corrosive gases

■ Domestic chemicals and agents, such as paint stripper, caustic soda, weed killers,

bleach, oven cleaner or any other strong acid or alkali chemical

■ Sunburn ■ Over-exposure to ultraviolet rays from a sunlamp

■ Exposure to a radioactive source, such as an X-ray

173

ASSESSING A BURN

Burns are classified according to the depth of

skin damage. There are three depths: superficial,

partial-thickness and full-thickness. A casualty

may suffer burns of more than one or more

depths of burn in a single incident.

A superficial burn involves only the

outermost layer of skin, the epidermis. It

usually heals well if first aid is given promptly

and if blisters do not form. Sunburn is one of

the most common types of superficial burn.

Other causes include minor domestic incidents.

Partial-thickness burns are very painful. They

destroy the epidermis and cause the skin to

become red and blistered. They usually heal

well, but if they affect more than 20 per cent of

the body in an adult or 10 per cent in a child

they can be life-threatening.

In full-thickness burns, pain sensation is lost,

which can mask the severity of the injury. The skin

may look waxy, pale or charred and needs urgent

medical attention. There are likely to be areas of

partial and superficial burns around them.

DEPTH OF BURNS

If the casualty is a child, seek medical advice or

take the child to hospital, however small the

burn appears. For adults, medical attention

should be sought for any serious burn. Such

burns include:

■■All full-thickness burns.

■■All burns involving the face, hands, feet or

genital area.

■■All burns that extend right around an

arm or a leg.

■■All partial-thickness burns larger than

one per cent of the body surface (an area

the size of the palm of the casualty’s hand).

■■All superficial burns larger than five per cent

of the casualty’s body surface (equivalent to

five palm areas).

■■Burns comprising a mixed pattern of varying

depths.

If you are unsure about the severity of any burn,

seek medical advice.

BURNS THAT NEED HOSPITAL TREATMENT

Superficial burn

This type of burn involves only

the outermost layer of skin.

Superficial burns are

characterised by redness,

swelling and tenderness.

Partial-thickness burn

This affects the epidermis, and

the skin becomes red and raw.

Blisters form over the skin due

to fluid released from the damaged

tissues beneath.

Full-thickness burn

With this type of burn, all the layers

of the skin are affected; there may

be some damage to nerves, fat

tissue, muscles and blood vessels.

Burn Tissue fluid Blister Damaged tissues

174

EFFECTS OF HEAT AND COLD

SEVERE BURNS AND SCALDS

SEE ALSO Burns to the airway p.177 | Fires pp.32–33 | Shock pp.112–13

There may be:

■■ Possible areas of superficial, partial

thickness and/or full-thickness burns

■■ Pain

■■ Difficulty breathing

■■ Features of shock (pp.112–13)

■■ To stop the burning as soon as

possible and relieve pain

■■ To maintain an open airway

■■ To treat associated injuries

■■ To minimise the risk of infection

■■ To minimise the risk of shock

■■ To arrange urgent removal to

hospital

■■ To gather information for the

emergency services

RECOGNITION

YOUR AIMS

■■ Do not remove anything

sticking to the burn; you may

cause further damage and

introduce infection into the

burnt area.

■■ Do not burst any blisters.

■■ Do not apply any type of lotion

or ointment to the burnt area;

it may damage tissues and

increase the risk of infection.

■■ The use of specialised dressings,

sprays and gels to cool burns is

not recommended.

■■ Do not use adhesive dressings

or apply adhesive tape to the

skin; a burn may be more

extensive than it first appears.

■■ If the casualty has a burn on his

face, do not cover the injury;

you could cause the casualty

distress and obstruct the airway.

■■ Do not allow the casualty to eat

or drink because he may need

an anaesthetic.

Take great care when treating burns. The longer the burning

continues, the more severe the injury will be, and the longer it

will take to heal. If the casualty has been injured in a fire, assume

that smoke or hot air has also affected his breathing.

Your priority is to cool the burn as soon as possible (which

stops the burning process and relieves the pain) and continue

cooling for at least 10 minutes, or until the pain is relieved. A

casualty with a severe burn or scald injury will almost certainly

be suffering from shock because of the fluid loss and will need

urgent hospital treatment.

The possibility of non-accidental injury must always be

considered, no matter what the age of the casualty. Keep an

accurate record of what has happened and any treatment you

have given. If you have to remove or cut away clothing, keep it

in case of future investigation.

WHAT TO DO

Start cooling the injury as soon as possible. Flood the burn with

plenty of cold water, but do not delay the casualty’s removal to

hospital. Help the casualty to sit or lie down. If possible, try to prevent

the burnt area from coming into contact with the ground to keep the

burn as clean as possible.

Call 999/112 for emergency help. If possible, get someone to do

this while you continue cooling the burn.

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CAUTION

175

SEVERE BURNS AND SCALDS

Continue cooling the affected area for at least 10 minutes, or

until the pain is relieved. Watch for signs of breathing difficulty.

Do not over-cool the casualty because you may lower the body

temperature to a dangerous level, causing hypothermia. This is

a particular hazard for babies and elderly people.

Do not touch or otherwise interfere with the burn. Gently

remove any rings, watches, belts, shoes and burnt or smouldering

clothing before the tissues begin to swell. A helper can do this while

you are cooling the burn. Do not remove any clothing that is stuck

to the burn.

When the burn is cooled, cover the injured area with kitchen film

to protect it from infection. Discard the first two turns from the

roll and then apply it lengthways over the burn. A clean plastic bag

can be used to cover a hand or foot; secure it with a bandage or

adhesive tape applied over the plastic, not the damaged skin. If there

is no plastic film available, use a sterile dressing, or improvise with

non-fluffy material, such as a folded triangular bandage (p.249).

Reassure the casualty and treat him for shock (pp.112–13) if

necessary. Record details of the casualty’s injuries. Monitor

and record his vital signs – breathing, pulse and level of response

(pp.52–53) – while waiting for help to arrive.

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176

EFFECTS OF HEAT AND COLD

MINOR BURNS AND SCALDS

■■ Reddened skin

■■ Pain in the area of the burn

Later there may be:

■■ Blistering of the affected skin

■■ To stop the burning

■■ To relieve pain and swelling

■■ To minimise the risk of infection

RECOGNITION

YOUR AIMS

Small, superficial burns and scalds are often due to domestic

incidents, such as touching a hot iron or oven shelf. Most minor

burns can be treated successfully by first aid and will heal

naturally. However, you should advise the casualty to seek

medical advice if you are at all concerned about the severity

of the injury (Assessing a burn, pp.172–73).

After a burn, blisters may form. These thin “bubbles”

are caused by tissue fluid leaking into the burnt area just

beneath the skin’s surface. You should never break a blister

caused by a burn because you risk introducing infection

into the wound.

WHAT TO DO

Flood the injured part

with cold water for at least

ten minutes or until the pain is

relieved. If there is no water

available, any cold, harmless

liquid, such as milk or canned

drinks, can be used.

Seek medical advice if the

casualty is a child, or if you

are in any doubt about the

casualty’s condition.

Gently remove any

jewellery, watches, belts

or constricting clothing from

the injured area before it begins

to swell.

When the burn is cooled,

cover it with kitchen film or

place a clean plastic bag over a

foot or hand. Apply the kitchen

film lengthways over the burn,

not around the limb because the

tissues swell. If you do not have

kitchen film or a plastic bag, use a

sterile dressing or a non-fluffy pad,

and bandage loosely in place.

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3

■■ Do not break blisters or

otherwise interfere with the

injured area.

■■ Do not apply adhesive dressings

or adhesive tape to the skin;

removing them may tear

damaged skin.

■■ Do not apply ointments or fats;

they may damage tissues and

increase the risk of infection.

■■ The use of specialised dressings,

sprays and gels to cool burns is

not recommended.

■■ Do not put blister plasters on

blisters caused by a burn.

CAUTION

Never burst a blister; they

usually need no treatment.

However, if a blister breaks or

is likely to burst, cover it with

a non-adhesive sterile dressing

that extends well beyond the

edges of the blister. Leave

the dressing in place until

the blister subsides.

SPECIAL CASE BLISTERS

SEE ALSO Assessing a burn pp.172–73

177

MINOR BURNS AND SCALDS | BURNS TO THE AIRWAY

BURNS TO THE AIRWAY

SEE ALSO Hypoxia p.92 | Shock pp.112–13 | The unresponsive casualty pp.54–87

There may be:

■■ Soot around the nose or mouth

■■ Singeing of the nasal hairs

■■ Redness, swelling or actual burning

of the tongue

■■ Damage to the skin around the

mouth

■■ Hoarseness of the voice

■■ Breathing difficulties

■■ To maintain an open airway

■■ To arrange urgent removal

to hospital

RECOGNITION

YOUR AIMS

WHAT TO DO

Call 999/112 for emergency help. Tell ambulance control that

you suspect burns to the casualty’s airway.

Reassure the casualty. Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – while waiting for

emergency help to arrive.

Take any steps possible to improve the casualty’s air supply, such

as loosening clothing around his neck.

Offer the casualty ice or small sips of cold water to reduce

swelling and pain.

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3

Any burn to the face, mouth or throat is very serious because

the air passages rapidly become swollen. Usually, signs of

burning will be evident. Always suspect damage to the airway if

a casualty sustains burns in a confined space since he is likely to

have inhaled hot air or gases.

There is no specific first aid treatment for an extreme case of

burns to the airway; the swelling will rapidly block the airway,

and there is a serious risk of hypoxia. Immediate and specialised

medical help is required.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

CAUTION

178

EFFECTS OF HEAT AND COLD

ELECTRICAL BURN

SEE ALSO Electrical injury pp.34–35 | Severe burns and scalds pp.174–75 | Shock pp.112–13 |

The unresponsive casualty pp.54–87

There may be:

■■ No response from casualty

■■ Full-thickness burns, with swelling,

scorching and charring

■■ Burns at points of entry and exit of

electricity

■■ Signs of shock

■■ To treat the burns and shock

■■ To arrange urgent removal to

hospital

RECOGNITION

YOUR AIMS

■■ Do not approach a casualty of

high-voltage electricity until you

are officially told that the

current has been switched off

(pp.34–35).

■■ If the casualty is unresponsive,

open the airway and check his

breathing (The unresponsive

casualty, pp.54–87).

Burns may occur when electricity passes through the body.

There may be surface damage along the point of contact, or

at the points of entry and exit of the current. In addition, there

may also be internal damage between the entry and exit points;

the position and direction of wounds will alert you to the likely

site and extent of hidden injury, and to the degree of shock that

the casualty may suffer.

Burns may be caused by a lightning strike or by a low- or highvoltage

electric current. Electric shock can cause cardiac arrest. If

the casualty is unresponsive, your priority, once the area is safe, is

to open his airway and check his breathing.

WHAT TO DO

Gently remove any jewellery, watches, belts or constricting

clothing from the injured area before it begins to swell. Do not

touch the burn.

Make sure that contact with the electrical source is broken before

you touch the casualty (pp.34–35).

Flood the injury with cold

water (at the entry and exit

points if both are present) for at

least 10 minutes or until pain

is relieved. If water is not

available, any cold, harmless

liquid can be used.

When the burn is cooled,

place a clean plastic bag

over a burn on a foot or hand –

tape the bag loosely in place

(attach tape to the the bag, not the

skin). Or, cover it with kitchen film

– lay the film along the length of

the limb not around it. If neither is

available, cover the burn with a

sterile dressing or a clean, nonfluffy

pad, and bandage loosely.

Call 999/112 for emergency help. Reassure the casualty and

treat him for shock (pp.112–13). Monitor and record vital signs –

breathing, pulse and level of response (pp.52–53) – while waiting

for help to arrive.

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CAUTION

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5

179

ELECTRICAL BURN | CHEMICAL BURN

CHEMICAL BURN

SEE ALSO Chemical burn to the eyes p.180 | Inhalation of fumes pp.98–99

There may be:

■■ Evidence of chemicals in

the vicinity

■■ Intense, stinging pain

Later:

■■ Discoloration, blistering

and peeling

■■ Swelling of the affected area

■■ To make the area safe and inform the

relevant authority

■■ To disperse the harmful chemical

■■ To arrange transport to hospital

RECOGNITION

YOUR AIMS

■■ Never attempt to neutralise acid

or alkali burns unless trained to

do so.

■■ Do not delay starting treatment

by searching for an antidote.

■■ If the incident occurs in the

workplace, notify the safety

officer and/or emergency

services.

WHAT TO DO

Make sure that the area around the casualty is safe. Ventilate the

area to disperse fumes. Wear protective gloves to prevent you

from coming into contact with the chemical. If it is safe to do so, seal

the chemical container. Move the casualty if necessary. If the chemical

is in powder form, it can be brushed off the skin.

Arrange to take or send

the casualty to hospital.

Monitor vital signs – breathing,

pulse and level of response

(pp.52–53) – while waiting for

medical help. Pass on details of

the chemical to medical staff if

you can identify it.

Flood the burn with water for at least 20 minutes to disperse the

chemical and stop the burning. If treating a casualty lying on the

ground, ensure that the contaminated water does not collect

underneath her. Pour water away from yourself to avoid splashes.

Gently remove any

contaminated clothing while

flooding the injury.

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Certain chemicals may irritate, burn or penetrate the skin,

causing widespread and sometimes fatal damage. Most strong,

corrosive chemicals are found in industry, but chemical burns can

also occur in the home; for instance from dishwasher products

(the most common cause of alkali burns in children), oven

cleaners, pesticides and paint stripper.

Chemical burns are always serious, and the casualty will

need hospital treatment. If possible, note the name or brand of

the burning substance. Before treating the casualty, ensure the

safety of yourself and others because some chemicals give off

poisonous fumes, which can cause breathing difficulties.

CAUTION

2

180

EFFECTS OF HEAT AND COLD

CHEMICAL BURN TO THE EYE

Splashes of chemicals in the eye can cause serious injury if not

treated quickly. Some chemicals damage the surface of the eye,

resulting in scarring and even blindness.

Your priority is to wash out (irrigate) the eye so that the

chemical is diluted and dispersed. When irrigating the eye, be

careful that the contaminated rinsing water does not splash you

or the casualty. Before beginning to treat the casualty, put on

protective gloves if available.

WHAT TO DO

Put on protective gloves. Hold the casualty’s affected eye under

gently running cold water for at least ten minutes. Irrigate the

eyelid thoroughly both inside and out; if the casualty’s eye is shut in

a spasm of pain, gently, but firmly, try to pull the eyelid open.

Arrange to take or send

the casualty to hospital.

Identify the chemical if possible

and pass on details to

medical staff.

Make sure that contaminated water does not splash the

uninjured eye. You may find it easier to pour the water over the

eye using an eye irrigator or a glass.

Ask the casualty to hold a

clean, non-fluffy pad over

the injured eye. If it will be

some time before the casualty

receives medical attention,

bandage the pad loosely

in position.

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There may be:

■■ Intense pain in the eye

■■ Inability to open the injured eye

■■ Redness and swelling around the eye

■■ Copious watering of the eye

■■ Evidence of chemical substances or

containers in the immediate area

■■ To disperse the harmful chemical

■■ To arrange transport to hospital

■■ Do not allow the casualty to

touch the injured eye.

■■ Do not forcibly remove a

contact lens.

■■ If the incident occurs in the

workplace, notify the safety

officer and/or emergency

services.

CAUTION

RECOGNITION

YOUR AIMS

181

CHEMICAL BURN TO THE EYE | FLASH BURN TO THE EYE | INCAPACITANT SPRAY EXPOSURE

FLASH BURN TO THE EYE

SEE ALSO Allergy p.222 | Asthma p.102

WHAT TO DO

Move the casualty to a well-ventilated area with a free flow of air

to ensure rapid dispersal of the spray.

Put on gloves if you are handling contaminated items such as

clothing. Advise the casualty to remove contact lenses – he may

need help. Remove wet clothing and put it in a sealed plastic bag.

If necessary, the casualty may wash his skin with soap and

water paying particular attention to skin folds and ears.

Showering may release spray particles trapped in the hair and

cause transient irritation.

2

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3

This condition occurs when the surface (cornea) of the eye is

damaged by exposure to ultraviolet light, such as prolonged

glare from sunlight reflected off snow. Symptoms usually develop

gradually, and recovery can take up to a week. Flash burns can

also be caused by glare from a welder’s torch.

■■ Intense pain in the affected eye(s)

There may also be:

■■ A “gritty” feeling in the eye(s)

■■ Sensitivity to light

■■ Redness and watering of the eye(s)

■■ To prevent further damage

■■ To arrange transport to hospital

■■ Do not remove the casualty's

contact lenses.

CAUTION

RECOGNITION

YOUR AIMS

Reassure the

casualty. Ask him

to hold an eye pad against

each injured eye. If it is

likely to take some time

to obtain medical

attention, lightly bandage

the pad(s) in place.

Arrange to take or

send the casualty

to hospital.

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1

There are two types of incapacitant spray – CS spray and

pepper spray. Both sprays are used by police forces for riot

control and self-protection, and both have been used by

unauthorised people as weapons in assault situations. They are

both aerosols and have the same effects. The effects usually wear

off 15–20 minutes after a person has been exposed to the spray.

There may be:

■■ Burning sensation and watering of

the eyes

■■ Sneezing and runny nose

■■ Stinging sensation on the skin with

redness and possibly blistering

■■ Difficulty breathing

■■ To remove the casualty from the

spray area

■■ If the casualty suffers from

asthma the spray may trigger

an attack.

■■ If the casualty’s symptoms

persist seek medical advice.

CAUTION

RECOGNITION

YOUR AIM

INCAPACITANT SPRAY EXPOSURE

WHAT TO DO

182

EFFECTS OF HEAT AND COLD

DEHYDRATION

This condition occurs when the amount of fluids lost from the

body is not adequately replaced. Dehydration can begin to

develop when a person loses as little as one per cent of his

bodyweight through fluid loss. A two to six per cent loss can

occur during a typical period of exercise on a warm day; the

average daily intake of fluids is 2.5 litres (4 pints). This fluid loss

needs to be replaced. In addition to fluid, the body loses essential

body salts through sweating.

Dehydration is mainly the result of: excessive sweating during

sporting activities, especially in hot weather; prolonged exposure

to sun, or hot, humid conditions; sweating through raised body

temperature during a fever; and loss of fluid through severe

diarrhoea and vomiting. Young children, older people or those

involved in prolonged periods of activity are particularly at risk.

Severe dehydration can cause muscle cramps through the loss of

body salts. If untreated, dehydration can lead to heat exhaustion.

The aim of first aid is to replace the lost water and salts

through rehydration. Water is usually sufficient but oral

rehydration solutions can help to replace lost salt.

SEE ALSO Cramp p.167 | Heat exhaustion p.184

WHAT TO DO

Reassure the casualty. Help

him to sit down. Give him

plenty of fluids to drink. Water

is usually sufficient, but oral

rehydration solutions can help

with salt replacement.

If the casualty is suffering

from cramp, stretch and

massage the affected muscles

(p.167). Advise the casualty

to rest.

1

2

Monitor and record the

casualty’s condition. If he

continues to be unwell, seek

medical advice straightaway.

3

There may be:

■■ Dry mouth and dry eyes

■■ Dry and/or cracked lips

■■ Headaches (light- headedness)

■■ Dizziness and confusion

■■ Dark urine

■■ Reduction in the amount of urine

passed

■■ Cramp, with a feeling of tightness

in the most used muscles, such as

the calves

■■ In babies and young children, pale

skin with sunken eyes. In young

babies the soft spot on the head

(the fontanelle) may be sunken

■■ To replace the lost body fluids

and salts

RECOGNITION

YOUR AIM

183

DEHYDRATION | SUNBURN

Over-exposure to the sun or a sunlamp can result in sunburn.

At high altitudes, sunburn can occur even on an overcast

summer’s day, or in the snow. Some medicines can trigger

severe sensitivity to sunlight. Rarely, sunburn can be caused

by exposure to radioactivity.

Sunburn can be prevented by staying in the shade,

wearing protective clothing and by regularly applying a high

factor sunscreen.

Most sunburn is superficial; in severe cases, the skin is

lobster-red and blistered. In addition, the casualty may suffer

from heat exhaustion or heatstroke.

Cover the casualty’s skin

with light clothing or a

towel. Help her to move out

of the sun or, if at all possible,

indoors.

Encourage the casualty

to have frequent sips of

cold water. Cool the affected skin

by dabbing with cold water. If the

area is extensive, the casualty may

prefer to soak the affected skin in

a cold bath for ten minutes.

If the burns are mild,

calamine or an after-sun

lotion may soothe them. Advise

the casualty to stay inside or in

the shade. If sunburn is severe,

for example, if there is blistering

or other skin damage, seek

medical advice.

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3

■■ Reddened skin

■■ Pain in the area of the burn

Later there may be:

■■ Blistering of the affected skin

■■ To move the casualty out of the sun

as soon as possible

■■ To relieve discomfort and pain

■■ If there is extensive blistering,

or other skin damage, seek

medical advice.

CAUTION

RECOGNITION

YOUR AIMS

SEE ALSO Dehydration opposite | Heat exhaustion p.184 | Heatstroke p.185 | Minor burns and scalds p.176

SUNBURN

WHAT TO DO

184

EFFECTS OF HEAT AND COLD

HEAT EXHAUSTION

This disorder is caused by loss of salt and water from the body

through excessive sweating. It usually develops gradually and

often affects people who are not acclimatised to hot, humid

conditions. People who are unwell, especially those with illnesses

that cause vomiting and diarrhoea, are more susceptible than

others to developing heat exhaustion.

A dangerous and common cause of heat exhaustion occurs

when the body produces more heat than it can cope with. Some

non-prescription drugs, such as ecstasy, can affect the body’s

temperature regulation system. This, combined with the exertion

of dancing in a warm environment, can result in a person

becoming overheated and dehydrated. These effects can lead to

heatstroke and even death.

As the condition develops, there

may be:

■■ Headache, dizziness and confusion

■■ Loss of appetite and nausea

■■ Sweating, with pale, clammy skin

■■ Cramps in the arms, legs or

abdomen

■■ Rapid, weakening pulse and

breathing

■■ To cool the casualty down

■■ To replace lost body fluids and salts

■■ To obtain medical help if necessary

RECOGNITION

YOUR AIMS

SEE ALSO Dehydration p.182 | Heatstroke opposite | The unresponsive casualty pp.54–87

WHAT TO DO

Help the casualty to a cool, shady place.

Encourage him to lie down and raise and

support his legs.

If the casualty’s vital signs worsen, call

999/112 for emergency help. Monitor and

record vital signs – breathing, pulse, level of

response and temperature (pp.52–53) – while

you are waiting for help to arrive.

Give him plenty of water to drink. Oral

rehydration salts or isotonic drinks will help

with salt replacement.

Monitor and record vital signs – level of

response, breathing and pulse (pp.52–53). Even

if the casualty recovers quickly, advise him to seek

medical help.

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185

HEAT EXHAUSTION | HEATSTROKE

HEATSTROKE

SEE ALSO Drug poisoning p.201 | The unresponsive casualty pp.54–87

WHAT TO DO

Quickly move the casualty to a cool place. Remove as

much of his outer clothing as possible. Call 999/112 for

emergency help.

Monitor and record vital signs – breathing,

pulse, level of response and temperature

(pp.52–53) – while waiting for help to arrive. If the

casualty’s temperature rises again, repeat the

cooling process.

Help the casualty to sit down, supported with cushions.

Wrap him in a cold, wet sheet until his temperature falls to 38°C

(100.4°F) under the tongue, or 37.5°C (99.5°F) under the armpit. Keep

the sheet wet by continually pouring cold water over it. If there is no

sheet available, fan the casualty, or sponge him with cold water.

Once the casualty’s temperature appears to

have returned to normal, replace the wet sheet

with a dry one.

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3

This condition is caused by a failure of the “thermostat” in the

brain, which regulates body temperature. The body becomes

dangerously overheated, usually due to a high fever or prolonged

exposure to heat. Heatstroke can also result from the use of

drugs such as ecstasy. In some cases, heatstroke follows heat

exhaustion when sweating ceases, and the body then cannot be

cooled by the evaporation of sweat.

Heatstroke can develop with little warning; the casualty may

become unresponsive within minutes of feeling unwell.

There may be:

■■ Headache, dizziness and discomfort

■■ Restlessness and confusion

■■ Hot, flushed and dry skin

■■ Rapid deterioration in the level of

response

■■ Full, bounding pulse

■■ Body temperature above 40°C

(104°F)

■■ To lower the casualty’s body

temperature as quickly as possible

■■ To arrange urgent removal to

hospital

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

CAUTION

RECOGNITION

YOUR AIMS

186

EFFECTS OF HEAT AND COLD

HYPOTHERMIA

This is a condition that develops when the body temperature

falls below 35°C (95°F). The effects vary depending on the speed

of onset and the level to which the body temperature falls. The

blood supply to the superficial blood vessels in the skin, for

example, shuts down to maintain the function of the vital organs

such as the heart and brain. Moderate hypothermia can usually

be reversed. Severe hypothermia – when the core body

temperature falls below 30°C (86°F) – is often, although not

always, fatal. No matter how low the body temperature becomes,

persist with life-saving procedures until emergency help arrives

because in cases of hypothermia, survival may be possible even

after prolonged periods of resuscitation.

WHAT CAUSES HYPOTHERMIA

Hypothermia can be caused by prolonged exposure to cold.

Moving air has a much greater cooling effect than still air, so a

high “wind-chill factor” in cold weather can substantially increase

the risk of a person developing hypothermia. Immersion in cold

water can cause death from hypothermia. When surrounded by

cold water, the body can cool up to 30 times faster than in dry

air, and body temperature falls rapidly.

Hypothermia may also develop indoors in poorly heated

houses. Elderly people, infants, homeless people and those who

are thin and frail are particularly vulnerable. Lack of activity,

chronic illness and fatigue all increase the risk; alcohol and drugs

can exacerbate the condition.

SEE ALSO Drowning p.100 | The unresponsive casualty pp.54–87 | Water rescue p.36

As hypothermia develops there

may be:

■■ Shivering, and cold, pale, dry skin

■■ Apathy, disorientation or irrational

behaviour

■■ Lethargy or impaired responsiveness

■■ Slow and shallow breathing

■■ Slow and weakening pulse. In

extreme cases, the heart may stop

■■ To prevent the casualty losing more

body heat

■■ To re-warm the casualty

■■ To obtain emergency help

if necessary

RECOGNITION

YOUR AIMS

■■ Do not give the casualty alcohol

because it dilates superficial

blood vessels and allows heat

to escape, making hypothermia

worse.

■■ Do not place any direct heat

sources, such as hot-water

bottles or fires, next to the

casualty because these may

cause burns.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty, pp.54–

87). Persist with CPR until

emergency help arrives to

assess the casualty’s condition.

■■ It is important that you stay

warm yourself.

CAUTION

187

HYPOTHERMIA

TREATING HYPOTHERMIA WHEN OUTDOORS

Take the casualty to a sheltered place as

quickly as possible. Shield the casualty

from the wind.

Call 999/112 or send for emergency help.

Ideally, two people should go for help and stay

together if you are in a remote area. It is important

that you do not leave the casualty by himself;

someone must remain with him at all times.

To help re-warm a casualty who is fully alert,

give him warm drinks and high-energy foods

such as chocolate, if available.

Monitor and record the casualty’s vital

signs – breathing, pulse, level of response

and temperature (pp.52–53) – while waiting for

help to arrive.

Remove and replace any wet clothing if

possible; do not give him your clothes. Make

sure his head is covered.

Protect the casualty from the ground.

Lay him on a thick layer of dry insulating

material, such as pine branches, heather or

bracken. Put him in a dry sleeping bag and/or cover

him with blankets or newspapers. Wrap him in a

plastic or foil survival bag, if available. You can

shelter and warm him with your body.

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188

EFFECTS OF HEAT AND COLD

HYPOTHERMIA

TREATING HYPOTHERMIA WHEN INDOORS

The casualty must be re-warmed. Cover him

casualty with layers of blankets and warm the

room to about 25°C (77°F).

Monitor and record the casualty’s vital signs –

breathing, pulse, level of response and

temperature (pp.52–53) – as he is rewarmed.

Give the casualty a warm drink such as soup

and/or high-energy foods such as chocolate to

help re-warm him.

Seek medical advice. Be aware that

hypothermia may also be disguising the

symptoms of a serious underlying illness such as

a stroke (pp.212–13), heart attack (p.211) or

underactive thyroid gland (hypothyroidism).

4

1 2

SPECIAL CASE HYPOTHERMIA IN INFANTS

A baby’s mechanisms for regulating

body temperature are underdeveloped,

so she may develop

hypothermia in a cold room. The

baby’s skin may look healthy but feel

cold, and she may be limp, unusually

quiet and refusing to feed. Re-warm a

cold baby by wrapping her in blankets

and warming the room. You should

always seek medical advice if you

suspect a baby has hypothermia.

«

3

189

HYPOTHERMIA | FROSTBITE

FROSTBITE

SEE ALSO Hypothermia pp.186–88

WHAT TO DO

Advise the casualty to put his hands in his armpits. Move

the casualty into warmth before you thaw the affected

part further.

Raise the affected limb to

reduce swelling. An adult

may take the recommended

dose of paracetamol or her own

painkillers. A child may have the

recommended dose of

paracetamol syrup (not aspirin).

Take or send the casualty

to hospital.

Once inside, gently remove

gloves, rings and any other

constrictions, such as boots.

Warm the affected part with

your hands, in your lap or

continue to warm them in

the casualty’s armpits. Avoid

rubbing the affected area

because this can damage skin

and other tissues.

Place the affected parts in

warm water at around

40°C (104°F). Dry carefully, and

apply a light dressing of dry

gauze bandage.

4

2

1

3

With this condition, the tissues of the extremities – usually the

fingers and toes – freeze due to low temperatures. In severe

cases, this freezing can lead to permanent loss of sensation and,

eventually, tissue death and gangrene as the blood vessels and

soft tissues become permanently damaged.

Frostbite usually occurs in freezing or cold and windy

conditions. People who cannot move around to increase their

circulation are particularly susceptible.

In many cases, frostbite is accompanied by hypothermia

(pp.186–87), and this should be treated accordingly.

There may be:

■■ At first, “pins-and-needles”

■■ Paleness (pallor) followed by

numbness

■■ Hardening and stiffening of

the skin

■■ A colour change to the skin of the

affected area: first white, then

mottled and blue. On recovery, the

skin may be red, hot, painful and

blistered. Where gangrene occurs,

the tissue may become black due

to loss of blood supply

■■ To warm the affected area slowly to

prevent further tissue damage

■■ To arrange transport to hospital

■■ Do not put the affected part

near direct heat.

■■ Do not attempt to thaw the

affected part if there is danger

of it refreezing.

CAUTION

RECOGNITION

YOUR AIMS

Objects that find their way into the

body, either through a wound in the

skin or via an orifice, are known as “foreign

objects”. These range from grit in the eye to

small objects that young children may push

into their noses and ears. These injuries can

be distressing but do not usually cause

serious problems for the casualty.

Poisoning may result from exposure to

or ingestion of toxic substances, chemicals

and contaminated food. The effects of

poisons vary but medical advice will be

needed in most cases.

Insect stings and marine stings can often

be treated with first aid. However, multiple

stings can produce a reaction that requires

urgent medical help. Animal and human

bites always require medical attention due

to the risk of infection.

■■ To ensure the safety of yourself and the casualty

■■ To assess the casualty’s condition quickly and calmly

■■ To assess the potential danger of a foreign object

■■ To identify the poisonous substance

■■ To comfort and reassure the casualty

■■ To look for and treat any injuries associated with

the condition

■■ To obtain medical help if necessary. Call 999/112

for emergency help if you suspect a serious illness

or injury

■■ To be aware of your own needs AIMS AND OBJECTIVES

FOREIGN OBJECTS,

POISONING, BITES & STINGS

192

FOREIGN OBJECTS, POISONING, BITES & STINGS

THE SENSORY ORGANS

The body is covered and protected by the skin.

This is one of the body’s largest organs and is

made up of two layers: the outer layer called

the epidermis, and an inner layer, the dermis.

The skin forms a barrier against harmful

substances and germs. It is also an important

sense organ, containing nerves that ensure the

body is sensitive to heat, cold, pain and touch.

These complex organs enable us to see the

world around us. Each eye consists of a coloured

part (iris) with a small opening (pupil) that

allows rays of light to enter the eye. The size of

the pupil changes according to the amount of

light that is entering the eye.

Light rays are focused by the transparent lens

onto a “screen” (retina) at the back of the eye.

Special cells in the retina convert this

information into electrical impulses that then

travel, via the optic nerve that leads from the

eye, to the part of the brain where the impulses

are analysed.

Each eye is protected by a bony socket in the

skull (p.133). The eyelids and delicate

membranes called conjunctiva protect the front

of the eyes.

Tears form a protective film across the front

of the conjunctiva, lubricating the surface and

flushing away dust and dirt.

Structure of the eye

The eyes are fluid-filled, spherical structures about

2.5cm (1in) in diameter. They have focusing parts

(cornea and lens), and light- and colour-sensitive cells

in the retina.

Structure of the skin

The skin consists of the thin epidermis and the

thicker dermis, which sit on a layer of fatty tissue

(subcutaneous fat). Blood vessels, nerves, muscles,

sebaceous (oil) glands, sweat glands and hair roots

(follicles) lie in the dermis.

THE SKIN

THE EYES

Hair

Nerve

Epidermis

Dermis

Fatty tissue

Blood vessel

Muscle

Lens focuses light

onto retina

Cornea directs

light entering

eye onto lens

Sclera maintains

eyeball’s shape

Iris adjusts

size of pupil

Blood

vessel

Pupil allows

light to enter

eyeball

Conjunctiva

protects eye

surface

Muscle

Retina

Optic

nerve

193

THE SENSORY ORGANS

These cavities form the entrances to the

digestive and respiratory tracts respectively.

The nasal cavities connect with the throat.

They are lined with blood vessels and

membranes that secrete mucus to trap debris

as it enters the nose. Food enters the digestive

tract via the mouth, which leads into the gullet

(oesophagus). The epiglottis, a flap at the back

of the throat, prevents food from entering the

windpipe (trachea).

Structure of the mouth and nose

The nostrils lead into the two nasal cavities,

which are lined with mucous membranes and blood

vessels. The nasal cavities connect directly with the

top of the throat, which is at the back of the mouth.

Structure of the ear

The ear is divided into three main parts:

the outer, middle and inner ear. The

eardrum separates the outer and middle

ear. The inner ear contains the organs of

hearing and balance.

As well as being the organs of hearing, the ears

also play an important role in balance. The

visible part of each ear, the auricle, funnels

sounds into the ear canal to vibrate the

eardrum. Fine hairs in the ear canal filter out

dust, and glands secrete ear wax that traps any

other small particles.

The vibrations of the eardrum pass across the

middle ear to the hearing apparatus (cochlea) in

the inner ear. This structure converts the

vibrations into nerve impulses and transmits

them to the brain via the auditory nerve. The

vestibular apparatus within the inner ear is

involved in balance.

THE EARS

THE MOUTH AND NOSE

Vestibular apparatus

Auricular regulates balance

cartilage

Ear

canal

Eardrum vibrates in

response to sound

Eustachian tube connects

middle ear with back of

nose and throat

Cochlea contains

receptor for hearing

Outer ear Inner ear

Auditory nerve transmits

sound impulses to brain

Middle ear

Pinna

(ear flap)

Nasal cavity is lined

with blood vessels and

mucous membranes

Salivary gland

Tongue

Throat

Epiglottis

Larynx

Oesophagus

Trachea

Scalp muscle

194

FOREIGN OBJECTS, POISONING, BITES & STINGS

SPLINTER

■■ To remove the splinter

■■ To minimise the risk of infection

Ask the casualty about tetanus

immunisation. Seek medical

advice if:

■■ He has a dirty wound

■■ He has never been immunised

■■ He is uncertain about the

number or timings of injections

■■ He has not had at least five

injections previously

Small splinters of wood, metal or glass may enter the skin.

They carry a risk of infection because they are rarely clean. Often

a splinter can be successfully withdrawn from the skin using

tweezers. However, if the splinter is deeply embedded, lies over

a joint, or is difficult to remove, you should leave it in place and

advise the casualty to seek medical help.

CAUTION

If a splinter is embedded or

difficult to dislodge, do not probe

the area with a sharp object,

such as a needle, or you may

introduce infection. Pad around

the splinter until you can

bandage over it without pressing

on it, and seek medical help.

SPECIAL CASE EMBEDDED

SPLINTER

WHAT TO DO

Gently clean the area around the splinter with soap

and warm water.

Draw the splinter out in

a straight line at the same

angle that it went into the skin;

make sure it does not break.

Hold the tweezers close to

the end for a better grip.

Grasp the splinter with tweezers

as close to the skin as possible.

Carefully squeeze the

wound to encourage a little

bleeding. This will help to flush

out any remaining dirt. Clean and

dry the wound and cover with

a dressing.

2 3

1

4

YOUR AIMS

195

SPLINTER | EMBEDDED FISH-HOOK | SWALLOWED FOREIGN OBJECT

EMBEDDED FISH-HOOK

SWALLOWED FOREIGN OBJECT

■■ To obtain medical help

■■ To minimise the risk of infection

■■ If help is delayed, remove the fishhook

without causing the casualty

any further injury and pain

■■ To obtain medical advice as soon as

possible

■■ Do not try to pull out a fishhook

unless you can cut off the

barb. If you cannot, seek

medical help.

Ask the casualty about tetanus

immunisation. Seek medical

advice if:

■■ He has a dirty wound

■■ He has never been immunised

■■ He is uncertain about the

number or timings of injections

■■ He has not had at least five

injections previously

A fish-hook that is embedded in the skin is difficult to remove

because of the barb at the end of the hook. If possible, you

should ensure that the hook is removed by a healthcare

professional. Only attempt to remove a hook yourself if medical

help is not readily available. Embedded fish-hooks carry a risk of

infection, including tetanus.

Children may put small items in their mouths when playing. An

adult may swallow a bone by mistake or ingest unlikely objects

on purpose. Most objects will pass through the digestive system,

but some can cause a blockage or perforation.

CAUTION

CAUTION

WHAT TO DO

WHAT TO DO

Support the injured area.

If possible, cut off the

fishing line as close to the

hook as possible.

Reassure the casualty and

find out what he swallowed.

If medical help is not

available, you can try to

remove the hook if you can see

the barb. Cut off the barb with

wirecutters, then carefully

withdraw the hook back through

the skin by its eye.

Seek medical advice.

If medical help is readily

available, build up pads of

gauze around the hook until you

can bandage over the top

without pushing it in further.

Bandage over the padding and

the hook and arrange to take or

send the casualty to hospital.

Clean and dry the wound

and cover with a dressing.

3

2

2

1

1

4

■■ Do not let the casualty make

himself vomit as the object

could damage the gullet.

YOUR AIMS

YOUR AIM

196

FOREIGN BODIES, POISONING, BITES & STINGS

FOREIGN OBJECT IN THE EYE

There may be:

■■ Blurred vision

■■ Pain or discomfort

■■ Redness and watering of the eye

■■ Eyelids screwed up in spasm

■■ To prevent injury to the eye

RECOGNITION

YOUR AIM

■■ Do not touch anything that is

sticking to, or embedded in, the

eyeball. Cover the eye (p.123)

and arrange to take or send

casualty to hospital.

Foreign objects such as grit, a loose eyelash or a contact lens

that are floating on the surface of the eye can easily be rinsed

out. However, you must not attempt to remove anything that

sticks to the eye or penetrates the eyeball because this may

damage the eye. Instead, make sure that the casualty receives

urgent medical attention.

WHAT TO DO

Stand beside, or just behind,

the casualty. Gently

separate her eyelids with your

thumbs or finger and thumb. Ask

her to look right, left, up and

down. Examine every part of her

eye as she does this.

If you can see a foreign

object on the white of the

eye, wash it out by pouring clean

water from a glass or jug, or by

using a sterile eyewash if you have

one. Put a towel around the

casualty’s shoulders. Hold her eye

open and pour the water from the

inner corner so that it drains on to

the towel.

If this is unsuccessful, try lifting the object off with a moist swab

or the damp corner of a clean handkerchief or tissue. If you still

cannot remove the object, seek medical help.

Advise the casualty not to rub her eye. Ask her to sit down facing

a light.

3

4

1

2

CAUTION

Ask the casualty to grasp the

lashes on her upper eyelid and

pull the upper lid over the lower

lid; the lower lashes may brush

the particle clear. If this is

unsuccessful, ask her to try

blinking under water since this

may also make the object float

off. Do not attempt to do this if

the object is large or abrasive.

SPECIAL CASE IF OBJECT IS

IN UPPER EYELID

SEE ALSO Eye wound p.123

197

FOREIGN OBJECT IN THE EYE | FOREIGN OBJECT IN THE EAR | FOREIGN OBJECT IN THE NOSE

FOREIGN OBJECT IN THE EAR

FOREIGN OBJECT IN THE NOSE

There may be:

■■ Difficult or noisy breathing through

the nose

■■ Swelling of the nose

■■ Smelly or blood-stained discharge,

indicating that an object may have

been lodged for a while

■■ To arrange transport to hospital

RECOGNITION

YOUR AIM

■■ Do not attempt to remove any

object that is lodged in the ear.

You may cause serious injury

and push the foreign object

in further.

■■ Do not attempt to remove the

foreign object, even if you can

see it.

WHAT TO DO

WHAT TO DO

Arrange to take or send the

casualty to hospital as soon

as possible. Do not try to remove

a lodged foreign object yourself.

Try to keep the casualty

quiet and calm. Tell him to

breathe through his mouth at a

normal rate. Advise him not to

poke inside his nose to try to

remove the object himself.

Reassure the casualty

during the journey or until

medical help arrives.

Arrange to take or send the

casualty to hospital, so that

the object can be safely removed

by medical staff.

2

2

1

1

If a foreign object becomes lodged in the ear, it may cause

temporary deafness by blocking the ear canal. In some cases,

a foreign object may damage the eardrum. Young children

frequently push objects into their ears. The tips of cotton wool

buds are often left in the ear. Insects can fly or crawl into the ear

and may cause distress.

Young children may push small objects up their noses. Objects

can block the nose and cause infection. If the object is sharp it

can damage the tissues, and “button” batteries can cause burns

and bleeding. Do not try to remove a foreign object; you may

cause injury or push it further into the airway.

CAUTION

CAUTION

■■ To prevent injury to the ear

■■ To remove a trapped insect

■■ To arrange transport to hospital if a

foreign object is lodged in the ear

YOUR AIMS

Reassure the casualty and ask

him to sit down. Support his

head, with the affected ear

uppermost. Gently flood the

ear with tepid water; the insect

should float out. If this flooding

does not remove the insect, seek

medical help.

SPECIAL CASE INSECT INSIDE THE EAR

198

FOREIGN OBJECTS, POISONING, BITES & STINGS

HOW POISONS AFFECT THE BODY

A poison (toxin) is a substance that,

if taken into or absorbed into the body in

sufficient quantity, can cause either temporary

or permanent damage.

Poisons can be swallowed, absorbed

through the skin, inhaled, splashed into

the eyes or injected. Once in the body,

they may enter the bloodstream and

be carried swiftly to all organs and tissues.

Signs and symptoms of poisoning vary with

the poison. They may develop quickly or over

a number of days. Vomiting is common,

especially when the poison has been

ingested. Inhaled poisons often

cause breathing difficulties.

Effects of poisons on the body

Poisons can enter the body through

the skin, digestive system, lungs or

bloodstream. Once there, they can be

carried to all parts of the body and

cause multiple side effects.

Poisons reaching the brain may cause

confusion, delirium, seizures and

unresponsiveness

Swallowed corrosive chemicals can burn

the mouth, lips and food

passage (oesophagus)

Some poisons disturb the

action of the heart

by interrupting its normal

electrical activity

Poisons reaching the

kidneys (situated towards

the back of the body behind

the large intestine) from

the bloodstream can

cause serious damage

to these organs

Injected poisons and

drugs rapidly enter

the bloodstream;

some prevent blood

cells from carrying

oxygen to body tissues

Corrosive chemicals can

burn the skin. Pesticides

and plant toxins may be

absorbed through the

skin, causing local or

general reactions

Poisons in the digestive

system can cause

vomiting, abdominal pain

and diarrhoea

Poisons can seriously

damage the liver

Poisonous gases, solvents,

vapours or fumes can be inhaled

and affect the airways and lungs,

causing severe breathing

problems

199

HOW POISONS AFFECT THE BODY | TYPES OF POISON

TYPES OF POISON

Some poisons are man-made – for example,

chemicals and drugs – and these are found in

the home as well as in industry. Almost every

household contains substances that are

potentially poisonous, such as bleach and paint

stripper, as well as prescribed or over-thecounter

medicines, which may be dangerous

if taken in excessive amounts.

Other poisons occur in nature: for example,

plants produce poisons that may irritate the

skin or cause more serious symptoms if

ingested, and various insects and creatures

produce venom in their bites and stings.

Contamination of food by bacteria may result

in food poisoning – one of the most common

forms of poisoning.

■ Monitor casualty

■ Call emergency help

■ Commence CPR if

necessary (pp.54–87)

■ Use a face mask to protect

yourself if you need to give

rescue breaths

■ Remove contaminated

clothing

■ Wash with cold water for

20 minutes

■ Seek medical help

■ Commence CPR if

necessary (pp.54-87)

■ Help casualty into the

fresh air

■ Call emergency help

■ Commence CPR if

necessary (pp.54–87)

■ Irrigate the eye for ten

minutes (p.180)

■ Call emergency help

■ Commence CPR if

necessary (pp.54–87)

For sting/venom:

■ Remove sting, if possible

■ Call emergency help

■ Commence CPR if

necessary (pp.54–87)

For injected drugs:

■ Call emergency help

■ Commence CPR if

necessary (pp.54–87)

■ Nausea and vomiting

■ Abdominal pain

■ Seizures

■ Irregular, or fast or slow

heartbeat

■ Impaired level of response

■ Pain

■ Swelling

■ Rash

■ Redness

■ Itching

■ Difficulty breathing

■ Hypoxia

■ Grey-blue skin (cyanosis)

■ Pain and watering of

the eye

■ Blurred vision

■ Pain, redness and swelling

at injection site

■ Blurred vision

■ Nausea and vomiting

■ Difficulty breathing

■ Seizures

■ Impaired level of response

■ Anaphylactic shock

■ Drugs and alcohol

■ Cleaning products

■ DIY and gardening

products

■ Plant poisons

■ Bacterial food poisons

■ Viral food poisons

■ Cleaning products

■ DIY and gardening

products

■ Industrial poisons

■ Plant poisons

■ Fumes from cleaning

and DIY products

■ Industrial poisons

■ Fumes from fires

■ Cleaning products

■ DIY and gardening

products

■ Industrial poisons

■ Plant poisons

■ Venom from stings

and bites

■ Drugs

Swallowed

(injested)

Absorbed

through the

skin

Inhaled

Splashed in

the eye

Injected

through the

skin

RECOGNISING THE EFFECTS OF DRUG POISONING

ROUTE OF ENTRY

INTO BODY

POISON POSSIBLE EFFECTS ACTION

200

FOREIGN OBJECTS, POISONING, BITES & STINGS

SWALLOWED POISONS

SEE ALSO Alcohol poisoning p.202 | Chemical burn p.179 | Drug poisoning p.201 | Inhalation of fumes pp.98–99

| The unresponsive casualty pp.54–87

Chemicals that are swallowed may harm the digestive tract, or

cause more widespread damage if they enter the bloodstream and

are transported to other parts of the body. Hazardous chemicals

include some household substances such as bleach and paint

stripper, which are poisonous or corrosive if swallowed.

Drugs, both prescribed or those bought over the counter, can

also be harmful if an overdose is taken. Some plants and their

berries can also be poisonous.

■■ To maintain an open airway,

breathing and circulation

■■ To remove any contaminated

clothing

■■ To identify the poison

■■ To arrange urgent removal to

hospital

■■ History of ingestion/exposure

Depending on what has been

swallowed, there may be:

■■ Vomiting, sometimes bloodstained,

later diarrhoea

■■ Cramping abdominal pains

■■ Pain or a burning sensation

■■ Empty containers in the vicinity

■■ Impaired level of response

■■ Seizures

YOUR AIMS

RECOGNITION

■■ Never attempt to induce

vomiting.

■■ If a casualty is contaminated

with chemicals, wear

protective gloves, goggles

and/or a mask.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

■■ If there are any chemicals on the

casualty’s mouth, protect

yourself by using a face shield or

pocket mask (adult p.71, child

p.79) to give rescue breaths.

CAUTION

WHAT TO DO

If the casualty is responding, ask her what she has swallowed,

and if possible how much and when. Look for clues – for example,

poisonous plants, berries or empty containers. Try to reassure her.

Call 999/112 for emergency help. Give ambulance control as

much information as possible about the poison. This information

will assist the medical team to treat the casualty.

Monitor and record the casualty’s vital signs (pp.52–53) while

waiting for help. Keep samples of any vomited material. Give

these samples, containers and any other clues to the ambulance crew.

1

2

3

SPECIAL CASE IF LIPS ARE BURNT

If the casualty’s lips are burnt by

corrosive substances, give him

frequent sips of cold milk or water

while waiting for help to arrive.

201

SWALLOWED POISONS | DRUG POISONING

DRUG POISONING

SEE ALSO The unresponsive casualty pp.54–87

Poisoning can result from an overdose of prescribed drugs, or

drugs that are bought over the counter. It can also be caused by

drug abuse or drug interaction. The effects may vary depending

on the type of drug and how it is taken (below). When you call

the emergency services, give as much information as possible.

While waiting for help to arrive, look for containers that might

help you to identify the drug.

■■ To maintain breathing and circulation

■■ To arrange removal to hospital

YOUR AIMS

■■ Do not induce vomiting.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing, (The

unresponsive casualty,

pp.54–87).

CAUTION

WHAT TO DO

If the casualty

is responding,

help him into a

comfortable

position and ask him

what he has taken.

Reassure him while

you talk to him.

Call 999/112 for

emergency

help. Tell ambulance

control you suspect

drug poisoning.

Monitor and record

casualty’s vital signs

(pp.52–53) while

waiting for help to

arrive.

Keep samples

of any vomited

material. Look for

evidence that helps

identify the drug,

such as empty

containers. Give

evidence or samples

to the ambulance

personnel.

1 2 3

■ Lethargy and sleepiness, leading to

unresponsiveness ■ Shallow breathing ■ Weak,

irregular or abnormally slow or fast pulse

■ Excitable, hyperactive behaviour, agitation

■ Sweating ■ Tremor of the hands

■ Hallucinations in which the casualty may claim

to “hear voices” or “see things” ■ Dilated pupils

■■Small pupils ■ Sluggishness and confusion,

and casualty may become unresponsive ■ Slow,

shallow breathing, which may stop altogether

■ Needle marks which may be infected

■ Nausea and vomiting ■ Headaches

■ Hallucinations ■ Casualty may be unresponsive

■ Rarely, cardiac arrest

■ Drowsiness ■ Shallow breathing ■ Hallucinations

■ Upper abdominal pain, nausea and vomiting

■ Ringing in the ears ■ “Sighing” when breathing

■ Confusion and delerium ■ Dizziness

■ Barbiturates and

benzodiazepines (swallowed)

■ Amphetamines (including

ecstasy) and LSD (swallowed)

■ Cocaine (inhaled or injected)

■ “Legal highs”

■ Morphine, heroin (commonly

injected

■ Glue, lighter fuel (inhaled)

■ Ketamine

■ Paracetamol (swallowed)

Painkillers ■ Aspirin (swallowed)

Nervous system

depressants and

tranquillisers

Stimulants and

hallucinogens

Narcotics

Solvents

Anaesthetic

RECOGNISING THE EFFECTS OF DRUG POISONING

CATEGORY DRUG EFFECTS OF POISONING

■ Little effect at first, but abdominal pain, nausea

and vomiting may develop ■ Irreversible liver

damage may occur within three days (alcohol and

malnourishment increase the risk)

202

FOREIGN OBJECTS, POISONING, BITES & STINGS

ALCOHOL POISONING

Alcohol is a drug that depresses the activity of the

central nervous system – in particular, the brain (pp.142–43).

Prolonged or excessive intake of alcohol can severely impair

all physical and mental functions, and the person may

become unresponsive.

There are other risks to a casualty from alcohol poisoning,

for example: an unresponsive casualty may inhale and choke

on vomit; alcohol widens (dilates) the blood vessels so the

body loses heat, and hypothermia may develop.

An unresponsive casualty who smells of alcoholic drink may

be misdiagnosed and not receive appropriate treatment for the

underlying cause of his condition, such as a head injury, stroke,

heart attack or hypoglycaemia.

WHAT TO DO

Cover the casualty with a coat or blanket to protect him from the

cold and reassure him.

Assess the casualty for any injuries, especially head injuries, or

other medical conditions.

Monitor and record vital signs – level of response, pulse and

breathing (pp.52–53) – until the casualty recovers or is placed in

the care of a responsible person. If you are in any doubt about the

casualty’s condition, call 999/112 for emergency help.

2

1

3

■■ To maintain an open airway

■■ To assess for other conditions

■■ To seek medical help if necessary

There may be:

■■ A strong smell of alcoholic drink

■■ Empty bottles or cans

■■ Impaired level of response: the

casualty may respond if roused, but

will quickly relapse

■■ Flushed and moist face

■■ Deep, noisy breathing

■■ Full, bounding pulse

In the later stages:

■■ Shallow breathing

■■Weak, rapid pulse

■■ Dilated pupils that react poorly

to light

■■ No response

YOUR AIMS

RECOGNITION

■■ Do not induce vomiting.

■■ If the casualty becomes

unresponsive, open the airway

and check his breathing (The

unresponsive casualty,

pp.54–87).

CAUTION

SEE ALSO Head injury pp.144–45 | Heart attack p.211 | Hypoglycaemia p.215 | Hypothermia pp.186–88 |

Stroke pp.211–13 | The unresponsive casualty pp.54–87

203

ALCOHOL POISONING | ANIMAL AND HUMAN BITES

ANIMAL AND HUMAN BITES

WHAT TO DO

Wash the bite wound thoroughly with soap and warm water in

order to minimise the risk of infection.

Raise and support the wound and pat dry with clean gauze swabs.

Then cover with a sterile wound dressing.

Arrange to take or send the casualty to hospital if the wound is

large or deep.

2

1

3

Bites from sharp, pointed teeth cause deep puncture wounds

that can damage tissues and introduce germs. Bites also crush

the tissue. Any bite that breaks the skin needs prompt first aid

because there is a high risk of infection.

A serious infection risk is rabies, a potentially fatal viral

infection of the nervous system. The virus is carried in the saliva

of infected animals. If bitten in an area where there is a risk of

rabies, seek medical advice since the casualty must be given antirabies

injections. Try to identify the animal.

Tetanus is also a potential risk following any animal bite. There

is probably only a small risk of hepatitis viruses being

transmitted through a human bite – and an even smaller risk of

transmission of the HIV/AIDS virus. However, medical advice

should be sought straight away.

YOUR AIMS

■■ If you suspect rabies, arrange to

take or send the casualty to

hospital immediately.

Ask the casualty about tetanus

immunisation. Seek medical

advice if he:

■■ Has a dirty wound

■■ Has never been immunised

■■ Is uncertain about the number

and timing of injections

■■ Has not had at least five

injections previously

CAUTION

SPECIAL CASE

FOR A DEEP WOUND

If the wound is deep, control

bleeding by applying direct

pressure over a sterile pad and

raise the injured part. Cover the

wound and pad with a sterile

dressing or large, clean

non-fluffy pad and bandage

firmly in place. Treat the casualty

for shock and call 999/112 for

emergency help.

SEE ALSO Cuts and grazes p.119 | Infected wound p.120 | Severe external bleeding pp.114–15 | Shock pp.112–13

■■ To control bleeding

■■ To minimise the risk of infection

■■ To seek medical help if necessary

204

FOREIGN OBJECTS, POISONING, BITES & STINGS

INSECT STING

SEE ALSO Allergy p.222 | Anaphylactic shock p.223 | The unresponsive casualty pp.54–87

Usually, a sting from a bee, wasp or hornet is painful rather

than dangerous. An initial sharp pain is followed by mild swelling,

redness and soreness.

However, multiple insect stings can produce a serious

reaction. A sting in the mouth or throat is potentially dangerous

because swelling can obstruct the airway. With any bite or sting,

it is important to watch for signs of an allergic reaction, which

can lead to anaphylactic shock (p.223).

■■ Pain at the site of the sting

■■ Redness and swelling around the site

of the sting

■■ To relieve swelling and pain

■■ To arrange removal to hospital if

necessary

RECOGNITION

YOUR AIMS

■■ Call 999/112 for emergency

help if the casualty shows signs

of anaphylactic shock (p.223),

such as breathing difficulties

and/or swelling of the face and

neck. Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

WHAT TO DO

Reassure the casualty. If

the sting is visible, brush

or scrape it off sideways with

the edge of a credit card or your

fingernail. Do not use tweezers

because you could squeeze the

sting and inject more poison into

the casualty.

Raise the affected part and

apply a cold compress such

as an ice pack (p.241) to

minimise swelling. Advise the

casualty to keep the compress in

place for at least ten minutes.

Tell her to seek medical advice if

the pain and swelling persist.

Monitor vital signs –

breathing, pulse and level

of response (pp.52–53). Watch

for signs of an allergic reaction,

such as as wheezing and/or

reddened, swollen, itchy skin.

2

3

1

CAUTION

If a casualty has been stung in

the mouth, there is a risk that

swelling of tissues in the mouth

and/or throat may occur, causing

the airway to become blocked. To

help prevent this, give the

casualty an ice cube to suck or a

glass of cold water to sip. Call

999/112 for emergency help if

swelling starts to develop.

SPECIAL CASE

STINGS IN THE MOUTH

AND THROAT

205

INSECT STING | TICK BITE | OTHER BITES AND STINGS

TICK BITE

OTHER BITES AND STINGS

SEE ALSO Allergy p.222 | Anaphylactic shock p.223 | The unresponsive casualty pp.54–87

Scorpion stings as well as bites from some spiders and

mosquitoes can cause serious illness, and may be fatal.

Bites or stings in the mouth or throat are potentially

dangerous because swelling can obstruct the airway. Be alert

to an allergic reaction, which may lead the casualty to suffer

anaphylactic shock (p.223).

Ticks are tiny, spider-like creatures found in grass or

woodlands. They attach themselves to passing animals (including

humans) and bite into the skin to suck blood. When sucking

blood, a tick can swell to about the size of a pea, and it can then

be seen easily. Ticks can carry disease, so they should be

removed as soon as possible.

Depends on the species, but

generally:

■■ Pain, redness and swelling at site

of sting

■■ Nausea and vomiting

■■ Headache

■■ To relieve pain and swelling

■■ To arrange removal to hospital if

necessary

■■ To remove the tick

RECOGNITION

YOUR AIMS

YOUR AIM

■■ Call 999/112 for emergency

help if a scorpion or a red back

or funnel web spider has stung

the casualty, or if the casualty is

showing signs of anaphylactic

shock (p.223).

■■ Do not try to remove the tick

with butter or petroleum jelly or

burn or freeze it, since it may

regurgitate infective fluids into

the casualty.

WHAT TO DO

WHAT TO DO

Raise the affected part

if possible. Place a cold

compress such as an ice pack

(p.241) on the affected area for

at least ten minutes to minimise

the risk of swelling.

Reassure the casualty and

help him to sit or lie down.

Using tweezers, grasp

the tick’s head as close to

the casualty’s skin as you can.

Gently pull the head upwards

using steady even pressure. Do

not jerk the tick as this may leave

the mouth parts embedded, or

cause it to regurgitate infective

fluids into the skin.

Monitor vital signs –

breathing, pulse and level of

response (pp.52–53). Watch for

signs of an allergic reaction, such

as wheezing and/or reddened,

swollen, itchy skin.

Save the tick for

identification; place it in

a sealed plastic bag and give

it to the casualty. The casualty

should seek medical advice;

tell him to take the tick with

him since it may be required

for analysis.

3

2

2

1

1

CAUTION

CAUTION

206

FOREIGN OBJECTS, POISONING, BITES & STINGS

SNAKE BITE

SEE ALSO Anaphylactic shock p.223 | The unresponsive casualty pp.54–87

Snake bites are uncommon in the UK. The only poisonous

snake native to mainland Britain is the adder, and its bite is rarely

fatal. However, poisonous snakes are sometimes kept as pets and

people can be exposed to venomous snakes through travel.

While a snake bite is not usually serious, it is safer to assume

that a snake is venomous. Serious reactions similar to

anaphylaxis are rare but can occur within minutes or several

hours later. Immediate sharp pain is usually followed by a

sensation of tingling and local swelling that spreads up the limb.

Note the time of the bite, as well as the snake’s appearance to

help doctors identify the correct antivenom. If possible (and it is

safe), take a digital photograph that can be sent by email or

message. Take precautions to prevent others being bitten. Notify

the authorities who will deal with the snake.

Help the casualty to sit down and make her comfortable.

Reassure her and advise her not to move her limbs to prevent

venom spreading. Immobilise an upper limb in a sling and apply

broad-fold bandage around limb and body; secure a lower limb to the

other leg with broad- and narrow-fold bandages (p.249). Call 999/112

for emergency help. Keep the casualty immobilised throughout.

If the casualty sustains a

painless bite from an exotic

snake, place a pad on the site

and apply a pressure bandage on

top; extend the bandage as far

up the limb as possible. Do not

interfere with clothing at the site

as movement increases the

absorption of the venom into

the bloodstream.

Apply another pressure bandage to extend

from the bite as far up the limb as possible.

Check circulation after bandaging (p.243). If

possible, mark the site of the bite. Immobilise the

limb by securing it to the other leg with broad- and

narrow-fold bandages (p.249). If the bite is on the

trunk a pressure bandage should still be applied.

Monitor and record the casualty's vital signs

(pp.52–53) while waiting for help to arrive.

1

2

3

4

■■ To prevent venom spreading

■■ To arrange urgent removal to

hospital

There may be:

■■ A pair of puncture marks – the bite

may be painless

■■ Severe pain, redness and swelling at

the bite; the whole limb may become

swollen and bruised within 24 hours

■■ Nausea and vomiting

■■ Disturbed vision

■■ Increased salivation and sweating

■■ Laboured breathing; it may stop

altogether

YOUR AIMS

RECOGNITION

■■ Do not apply a tourniquet,

slash the wound with a knife

or try to suck out the venom.

■■ If the casualty becomes

unresponsive, open the

airway and check breathing

(The unresponsive casualty,

pp.54–87).

CAUTION

WHAT TO DO

207

SNAKE BITE | STINGS FROM SEA CREATURES | MARINE PUNCTURE WOUND

STINGS FROM SEA CREATURES

MARINE PUNCTURE WOUND

SEE ALSO Allergy p.222 | Anaphylactic shock p.223

■■ To relieve pain and discomfort

YOUR AIM

WHAT TO DO

Encourage the casualty

to sit or lie down. Immerse

the affected area in hot water

(40–41ºC/104–106ºF) for

ten minutes to relieve pain

and swelling. Alternatively, wash

the area in copious quantities of

cold water.

Help the casualty to sit

down. Immerse the injured

part in water as hot as he can

tolerate for about 30 minutes.

Take or send the casualty to

hospital so that the spines

can be safely removed.

Monitor vital signs –

breathing, pulse and level of

response (pp.52–53). Watch for

signs of an allergic reaction, such

as wheezing and itchy skin.

1

2

2

1

Jellyfish, Portuguese men-of-war, sea anemones and corals can

all cause stings. Their venom is contained in stinging cells that

stick to the skin. Most marine species found in temperate

regions of the world are not dangerous. However, some tropical

marine creatures can cause severe poisoning. Occasionally, death

results from paralysis of the chest muscles and, very rarely, from

anaphylactic shock (p.223).

Many marine creatures have spines that provide a mechanism

against attack from predators but that can also cause painful

wounds if trodden on. Sea urchins and weever fish have sharp

spines that can become embedded in the sole of the foot.

Wounds may become infected if the spines are not removed.

The hot water breaks down fish venom.

■■ To relieve pain and discomfort

■■ To seek medical help

if necessary

Depends on the species, but

generally:

■■ Pain, redness and swelling at site

of sting

■■ Nausea and vomiting

■■ Headache

YOUR AIMS

RECOGNITION

■■ If the injury is extensive or there

is a severe reaction, call 999/112

for emergency help. Monitor

and record vital signs –

breathing, pulse and level of

response (pp.52–53) – while

waiting for help to arrive.

■■ Do not bandage the wound.

■■ Do not scald the casualty.

CAUTION

CAUTION

SPECIAL CASE

JELLYFISH STING

Pour copious amounts of

vinegar or sea water over the

area of the injury to incapacitate

the stinging cells. Help the

casualty to sit down and treat as

for a snake bite (opposite). Call

999/112 for emergency help.

WHAT TO DO

Many everyday conditions, such as

fever and headache, need prompt

treatment and respond well to first aid.

However, a minor complaint can be the

start of a serious illness, so you should

always be alert to this and seek medical

advice if you are in doubt about the

casualty’s condition.

Other conditions such as heart attack,

stroke, diabetes-related hypoglycaemia

(lower than normal blood sugar levels),

severe allergic reaction (anaphylaxis) and

meningitis are potentially life-threatening

and require urgent medical attention.

Childbirth is a natural process and often

takes many hours. When a woman goes into

labour unexpectedly, while it is important

to call for emergency help as soon as

possible, there is usually plenty of time to

seek help and get her to hospital. In the

rare event of a baby arriving quickly, do not

try to deliver the baby – the birth will

happen naturally without intervention.

Miscarriage, however, is a potentially

serious problem due to the risk of severe

bleeding. A woman who is miscarrying

needs urgent medical help.

■■ To assess the casualty’s condition quietly and calmly

■■ To comfort and reassure the casualty

■■ To call 999/112 for emergency help if you suspect

a serious illness

AIMS AND OBJECTIVES

MEDICAL

CONDITIONS

210

■■ Vice-like central chest pain, which

may spread to the jaw and down one

or both arms

■■ Pain that eases with rest

■■ Shortness of breath

■■ Tiredness, which is often sudden and

extreme

■■ Feeling of anxiety

■■ To ease strain on the heart by

ensuring that the casualty rests

■■ To help the casualty with any

medication

■■ To obtain medical help if necessary

RECOGNITION

YOUR AIMS

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

WHAT TO DO

Help the casualty to stop what he is doing and sit down. Make

sure that he is comfortable and reassure him; this should

help the pain to ease.

If the casualty has angina medication, such as tablets or a pumpaction

or aerosol spray, let him administer it himself. If necessary,

help him to take it.

If the pain is not relieved five minutes after taking the angina

medication, advise him to take a second dose.

Encourage the casualty to rest, and keep any bystanders away.

If the casualty is still in pain five minutes after the second dose,

or it returns, suspect a heart attack (opposite). Call 999/112 for

emergency help.

If the pain subsides within 15 minutes after rest and/or

medication, the casualty will usually be able to resume what he

was doing. If he is concerned, tell him to seek medical advice.

2

1

3

4

5

6

The term angina literally means a constriction of the chest.

Angina occurs when coronary arteries that supply the heart

muscle with blood become narrowed and cannot carry sufficient

blood to meet increased demands during exertion or excitement.

An attack forces the casualty to rest; the pain should ease

soon afterwards.

CAUTION

ANGINA

MEDICAL CONDITIONS

SEE ALSO Heart attack opposite

211

ANGINA | HEART ATTACK

HEART ATTACK

■■ Persistent, vice-like central chest

pain, which may spread to the jaw

and down one or both arms. Unlike

angina (opposite), the pain does not

ease when the casualty rests

■■ Breathlessness

■■ Discomfort occurring high in the

abdomen, which may feel similar to

severe indigestion

■■ Collapse, often without any warning

■■ Sudden faintness or dizziness

■■ Casualty feels a sense of impending

doom

■■ “Ashen” skin and blueness at the lips

■■ A rapid, weak or irregular pulse

■■ Profuse sweating

■■ Extreme gasping for air (“air hunger”)

■■ To ease the strain on the heart by

ensuring that the casualty rests

■■ To call for urgent medical help

without delay

RECOGNITION

YOUR AIMS

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

■■ Do not give the casualty aspirin

if you know that he is allergic

to it or if he is under 16 years

of age.

A heart attack is most commonly caused by a sudden

obstruction of the blood supply to part of the heart muscle –

for example, because of a clot in a coronary artery (coronary

thrombosis). It can also be called a myocardial infarction. The

main risk is that the heart will stop beating.

The effects of a heart attack depend on how much of the heart

muscle is affected; many casualties recover completely. Aspirin

can be used to try to restrict the size of the clot.

WHAT TO DO

Call 999/112 for emergency help. Tell ambulance control that

you suspect a heart attack.

Make the casualty as comfortable as possible to ease the strain

on his heart. A half-sitting position, with his head and shoulders

supported and his knees bent, is often best. Place cushions behind

him and under his knees.

Assist the casualty to take

one full dose aspirin tablet

(300mg in total). Advise him to

chew it slowly.

If the casualty has angina

medication, such as tablets

or a pump-action or aerosol

spray, let him administer it; help

him if necessary. Encourage him

to rest.

Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

Stay calm to avoid undue stress.

1

2

3

4

5

CAUTION

SEE ALSO The unresponsive casualty pp.54–87

Coronary thrombosis

Coronary arteries supply

blood to the heart muscle.

When an artery is blocked, for

example by a blood clot, the

muscle beyond the blockage

is deprived of oxygen and

other nutrients carried by the

blood and begins to die.

Area deprived of oxygen

and nutrients

Coronary arteries

Site of

blockage in

coronary

artery

212

MEDICAL CONDITIONS

STROKE

■■ Facial weakness – the casualty is

unable to smile evenly and the mouth

or eye may be droopy

■■ Arm weakness – the casualty is only

able to raise one arm

■■ Speech problems – the casualty is

unable to speak clearly

There may also be:

■■ Sudden weakness or numbness of

the face, arm or leg on one or both

sides of the body

■■ Sudden loss or blurring of vision in

one or both eyes

■■ Sudden difficulty with speech or

understanding the spoken word

■■ Sudden confusion

■■ Sudden severe headache with no

apparent cause

■■ Dizziness, unsteadiness or sudden fall

RECOGNITION

A stroke, or brain attack, is a medical emergency that occurs

when the blood supply to the brain is disrupted. Strokes are the

third most common cause of death in the UK and many people

live with long-term disability as a result of a stroke. This

condition is more common later in life and is associated with

disorders of the circulatory system, such as high blood pressure.

The majority of strokes are caused by a clot in a blood vessel

that blocks the flow of blood to part of the brain. However, some

strokes are the result of a ruptured blood vessel that causes

bleeding into the brain. If a stroke is due to a blood clot, it may

be possible to give drugs to limit the extent of damage to the

brain and improve recovery. Call 999/112 for emergency help

immediately if you think a casualty has had a stroke.

Use the FAST (Face–Arm–Speech–Time) guide if you suspect a

casualty has had a stroke:

F – Facial weakness – the casualty is unable to smile evenly and

the mouth or eye may be droopy

A – Arm weakness – the casualty is only able to raise one of

his arms

S – Speech problems – the casualty is unable to speak clearly

or may not understand the spoken word

T – Time to call 999/112 for emergency help if you suspect

that the casualty has had a stroke

TRANSIENT ISCHAEMIC ATTACK (TIA)

A transient ischaemic attack, or TIA, is sometimes called

a mini-stroke. It is similar to a full stroke, but the symptoms may

only last a few minutes, will improve and eventually disappear. If

you suspect a TIA, it is important to seek medical advice to

confirm the casualty’s condition. If there is any doubt assume

that it is a stroke.

■■ To arrange urgent admission to

hospital

■■ To reassure and comfort the casualty

YOUR AIMS

■■ If the person becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty,

pp.54–87).

CAUTION

Bleeding into brain

Site of clot

BLOCKED BLOOD VESSEL BURST BLOOD VESSEL

Area deprived

of oxygen

Damaged

blood vessel

Causes of a stroke

Any disruption to the flow of blood

to the brain starves the affected

part of the brain of oxygen and

nutrients. This can cause temporary

or permanent loss of function in

that area of the brain. A stroke can

result from a blood clot that blocks

an artery supplying blood to the

brain (right), or from a burst blood

vessel that causes bleeding which

presses on the brain (far right).

SEE ALSO The unresponsive casualty pp.54–87

213

STROKE

WHAT TO DO

Look at the

casualty’s face. Ask

him to smile: if he has

had a stroke he may only

be able to smile on one

side – the other side of

his mouth may droop.

Ask the casualty to raise both his arms: if he

has had a stroke, he may only be able to lift

one arm.

2

1

Find out whether the person can speak clearly

and understand what you say. When you ask a

question does he respond appropriately?

3

Call 999/112 for emergency help and tell

ambulance control that you have used the

FAST guide and you suspect a stroke.

4

Keep the casualty comfortable and supported.

If the casualty is responding, you can help him

to lie down. Reassure him that help is on its way.

5

Regularly monitor and record vital signs

– breathing, pulse and level of response

(pp.52–53) – while waiting for help to arrive.

Do not give the casualty anything to eat or drink

because it may be difficult for him to swallow.

6

214

MEDICAL CONDITIONS

This is a long-term (chronic) condition in

which the body fails to produce sufficient

insulin. Insulin is a chemical produced by the

pancreas (a gland that lies behind the stomach),

which regulates the blood sugar (glucose) level

in the body. This condition can result in higher

than normal blood sugar (hyperglycaemia) or

lower than normal blood sugar

(hypoglycaemia). If a person with diabetes is

unwell, giving him sugar will rapidly correct

hypoglycaemia and is unlikely to do harm in

cases of hyperglycaemia.

TYPES OF DIABETES

There are two types: Type 1, or insulindependent

diabetes, and Type 2, also known

as non-insulin-dependent diabetes.

In Type 1 diabetes, the body produces little

or no insulin. People with Type 1 diabetes need

regular insulin injections throughout their lives.

Type 1 diabetes is sometimes referred to as

juvenile diabetes or early onset diabetes

because it usually develops in childhood or

teenage years. Insulin can be administered

via an injection pen (insulin pen) or a special

pump. The pump is a small device about the

size of a pack of cards that is strapped to

the person’s body. The insulin is delivered

via a piece of tubing that leads from the

pump to a needle that sits just under the

person’s skin.

In Type 2 diabetes, the body does not

make enough insulin or cannot use it properly.

This type is usually linked with obesity, and is

also known as maturity-onset diabetes, as it is

more common in people over the age of 40.

The risk of developing this type of diabetes

is increased if it runs in your family. Type 2

diabetes can normally be controlled with diet,

weight loss and regular exercise. However, oral

medication and, in some cases, insulin

injections may be needed.

WHAT TO DO

DIABETES MELLITUS

High blood sugar (hyperglycaemia) may develop slowly over a

period of hours or days. If it is not treated, hyperglycaemia will

result in the person becoming unresponsive (diabetic coma) and

so requires urgent treatment in hospital. Those who suffer from

hyperglycaemia may wear medical warning bracelets, cards or

medallions alerting a first aider to the condition.

■■Warm, dry skin

■■ Rapid pulse and breathing

■■ Fruity sweet breath and excessive

thirst

■■ Possible medical warning bracelet

■■ Drowsiness, leading to

unresponsiveness if untreated

RECOGNITION

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty, pp.54–87).

CAUTION

Monitor and record vital

signs – breathing, pulse and

level of response (pp.52–53) –

while waiting for help to arrive.

2 Call 999/112 for

emergency help; tell

ambulance control that you

suspect hyperglycaemia.

1

SEE ALSO The unresponsive casualty pp.54–87

■■ To arrange urgent removal to hospital

YOUR AIM

HYPERGLYCAEMIA

215

DIABETES MELLITUS | HYPERGLYCAEMIA | HYPOGLYCAEMIA

HYPOGLYCAEMIA

WHAT TO DO

Help the casualty to sit down. If he has an emergency sugar

supply such as glucose gel, help him to take it. If not give him the

equivalent of 15–20g of glucose – for example, a 150ml glass of nondiet

fizzy drink or fruit juice, three teaspoons of sugar (or sugar lumps)

or three sweets such as jelly babies.

If the casualty responds quickly, give him more sugary food

or drink and let him rest until he feels better. Help him find his

glucose testing kit so that he can check his glucose level. Monitor

him until he has completely recovered.

If casualty’s condition does not improve, look for other possible

causes. Call 999/112 for emergency help and monitor and record

vital signs – breathing, pulse and level of response (pp.52–53) – while

waiting for help to arrive.

2

1

There may be:

■■ A history of diabetes – the casualty

himself may recognise the onset of

a hypoglycaemic episode

■■Weakness, faintness or hunger

■■ Confusion and irrational behaviour

■■ Sweating with cold, clammy skin

■■ Rapid pulse

■■ Palpitations and muscle tremors

■■ Deteriorating level of response

■■Medical warning bracelet or necklace

and glucose gel or sweets

■■Medication such as an insulin pen

or tablets and a glucose testing kit

RECOGNITION

This condition occurs when the blood sugar level falls below

normal. It is characterised by a rapidly deteriorating level of

response. Hypoglycaemia develops if the insulin–sugar balance

is incorrect; for example, when a person with diabetes misses a

meal or takes too much exercise. It is common in a person with

newly diagnosed diabetes while he is learning to balance sugar

levels. More rarely, hypoglycaemia may develop following an

epileptic seizure (pp.216–17) or after an episode of binge drinking.

People with diabetes normally carry their own blood-testing

kits to check their blood sugar levels, as well as their insulin

medication and sugary food for use in an emergency. For

example, a person may have sugar lumps or a tube of glucose gel.

If the hypoglycaemic episode is at an advanced stage, his level

of response may be affected (p.52) and you must call 999/112

for emergency help.

SEE ALSO Alcohol poisoning p.202 | Head injury pp.144–45 | The unresponsive casualty pp.54–87

■■ To raise the sugar content of the

blood as quickly as possible

■■ To obtain appropriate medical help

YOUR AIMS

■■ If the person is not fully alert

(p.52), do not give him

anything to eat or drink.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty

pp.54–87).

CAUTION

3

216

MEDICAL CONDITIONS

SEIZURES IN ADULTS

■■ Do not move the casualty unless

he is in immediate danger.

■■ Do not put anything in his

mouth or attempt to restrain

him during a seizure.

Call 999/112 for emergency

help if:

■■ The casualty is having repeated

seizures or it is his first seizure

■■ The casualty is not aware of any

reason for the seizure

■■ The seizure continues for more

than five minutes

■■ The casualty is unresponsive for

more than ten minutes

■■ The casualty has sustained

an injury to another part of

the body

CAUTION A seizure – also called a convulsion or fit – consists of

involuntary contractions of many of the muscles in the body.

The condition is due to a disturbance in the electrical activity

of the brain. Seizures usually result in the person becoming

unresponsive or his response is impaired. The most common

cause is epilepsy. Other causes include head injury, some braindamaging

diseases, shortage of oxygen or glucose in the brain

and the intake of certain poisons, including alcohol or drugs.

Epileptic seizures result from recurrent, major disturbances

of brain activity and they can be sudden and dramatic. Just

before a seizure, a casualty may have a brief warning (aura)

with, for example, a strange feeling or a special smell or taste.

No matter what the cause of the seizure, care must always

include maintaining an open, clear airway and monitoring

of the casualty’s vital signs – breathing, pulse and level of

response. You will also need to protect the casualty from

further harm during a seizure and arrange appropriate

aftercare once he has recovered.

■■ Help him to sit down in a quiet

place

■■ Remove any potentially dangerous

items such as hot drinks or sharp

objects

■■ Talk to him in a calm and

reassuring way and stay with him

until he has fully recovered

■■ Advise him to seek medical advice

if he is unaware of his condition or

does not fully recover

Some people experience a mild

form of epilepsy known as

absence seizures, during which

they appear distant and unaware

of their surroundings. These

seizures tend to affect children

more than adults and a full one

may follow. A casualty may

suddenly “switch off” and stare

blankly ahead. You may notice

slight or localised twitching or

jerking of the lips, eyelids, head

or limbs and/or odd “automatic”

movements, such as lip-smacking

or making noises. If a casualty

has an absence seizure:

SPECIAL CASE ABSENCE SEIZURES

217

SEIZURES IN ADULTS

WHAT TO DO

Make space around the casualty; ask bystanders to move away.

Remove potentially dangerous items, such as hot drinks and sharp

objects. Note the time that the seizure started.

Protect the casualty’s head from objects nearby; place soft

padding such as rolled towels underneath or around his neck

if possible. Loosen tight clothing around his neck if necessary.

2

1

In epilepsy, the following sequence

is common:

■■ Sudden loss of responsiveness

■■ Casualty becomes rigid, arching his

back

■■ Breathing may be noisy and become

difficult – the lips may show a greyblue

tinge (cyanosis)

■■ Convulsive movements begin

■■ Saliva may appear at the mouth

and may be bloodstained if the

lips or tongue have been bitten

■■ Possible loss of bladder or bowel

control

■■Muscles relax and breathing

becomes normal; the casualty

recovers and is responsive again,

usually within a few minutes. He may

feel dazed or act strangely. He may

be unaware of his actions

■■ After a seizure, the casualty may feel

tired and fall into a deep sleep

RECOGNITION

■■ To protect the casualty from injury

during the seizure

■■ To care for the casualty when he is

responsive again and arrange

removal to hospital if necessary

YOUR AIMS

When the convulsive movements have ceased, open the

casualty’s airway and check breathing. If he is breathing, place

him in the recovery position.

Monitor and record vital signs – breathing, pulse and level of

response (pp.52–53) – until he recovers. Make a note of how long

the seizure lasted.

4

3

SEE ALSO Head injury pp.144–45 | The unresponsive casualty pp.54–87

218 SEE ALSO Unresponsive child pp.72–79 | Unresponsive infant pp.80–83

■■ Loss of or impaired response

■■ Vigorous shaking, with clenched fists

and an arched back

There may also be:

■■ Obvious signs of fever: hot, flushed

skin and perhaps sweating

■■ Twitching of the face and squinting,

fixed or upturned eyes

■■ Breath-holding, with red, “puffy” face

and neck and drooling at the mouth

■■ Possible vomiting

■■ Loss of bowel or bladder movement

■■ To protect the child from injury

during the seizure

■■ To cool the child

■■ To reassure the parents

■■ To arrange removal to hospital

RECOGNITION

YOUR AIMS

In young children, seizures – sometimes called fits or

convulsions – are most often the result of a raised body

temperature associated with a throat or ear infection or other

infections. This type of seizure, also known as a febrile seizure,

occurs because the electrical systems in the brain are not mature

enough to deal with the body’s high temperature.

Although seizures can be alarming, they are rarely dangerous

if properly dealt with. However, you should always seek medical

advice for the child to rule out any serious underlying condition.

WHAT TO DO

Place pillows or soft padding around the child so that even

violent movement will not result in injury. Do not restrain the

child in any way.

Reassure the child as well as the parents or

carer. Monitor and record vital signs –

breathing, pulse and level of response (pp.52–53) –

until emergency help arrives.

Once the seizure has stopped, place the child

in the recovery position to maintain an open

airway. Call 999/112 for emergency help.

Cool the child. Remove any bedding and

clothes, for example T-shirt or pyjama top; you

may have to wait until the seizure stops. Ensure a

good supply of fresh air, but be careful not to

overcool the child.

1

4

2 3

SEIZURES IN CHILDREN

MEDICAL CONDITIONS

■■ Do not over- or under-dress a

child with fever; do not sponge

a child to cool her as there is a

risk of overcooling.

CAUTION

219

FEVER

SEE ALSO Meningitis p.220 | Seizures in children opposite

■■ Raised body temperature above

37ºC (98.6ºF)

■■ Pallor – casualty may feel cold with

goose pimples, shivering and

chattering teeth

Later:

■■ Hot, flushed skin and sweating

■■ Headache

■■ Generalised aches and pains

■■ To bring down the fever

■■ To obtain medical aid if necessary

RECOGNITION

YOUR AIMS

■■ If you are concerned about the

casualty’s condition, seek

medical advice.

■■ Do not over- or underdress a

child with fever; do not sponge

a child to cool her as there is a

risk of overcooling.

■■ Do not give aspirin to any

person under 16 years of age.

WHAT TO DO

Keep casualty cool and comfortable – preferably in bed with a

light covering.

Monitor and record a casualty’s vital signs – breathing, pulse,

temperature and level of response (pp.52–53) – until she recovers.

Give her plenty of cool drinks to replace any body fluids lost

through sweating.

If the child appears distressed or unwell, she may have the

recommended dose of paracetamol syrup (not aspirin). An adult

may take the recommended dose of paracetamol tablets.

4

2

1

3

A sustained body temperature above the normal level of

37ºC (98.6ºF) is known as fever. It is usually caused by a bacterial

or viral infection, and may be associated with earache, sore

throat, measles, chickenpox, meningitis (p.220) or a local

infection, such as an abscess. The infection may have been

acquired during overseas travel.

In young children a temperature above 39ºC (102.2ºF) can be

dangerous and may trigger seizures (opposite). If you are in any

doubt about a casualty’s condition, seek medical advice.

CAUTION

SEIZURES IN CHILDREN | FEVER

220

MEDICAL CONDITIONS

The symptoms and signs are

usually not all present at the same

time. They include:

■■ Flu-like illness with a high

temperature

■■ Cold hands and feet

■■ Joint and limb pain

■■Mottled or very pale skin

As the infection develops:

■■ Severe headache

■■ Neck stiffness (the casualty will

not be able to touch her chest with

her chin)

■■ Vomiting

■■ Eyes become very sensitive to any

light – daylight, electric light or even

the television

■■ Drowsiness

■■ In infants, there may also be highpitched

moaning or a whimpering

cry, floppiness and a tense or bulging

fontanelle (soft part of the skull)

Later:

■■ A distinctive rash of red or purple

spots that do not fade when pressed

■■ To obtain urgent medical help

RECOGNITION

YOUR AIM

This is a condition in which the linings that surround the brain

and the spinal cord become inflamed. It can be caused by

bacteria or a virus and can affect any age group.

Meningitis is potentially a very serious illness and the casualty

may deteriorate very quickly. If you suspect meningitis, you must

seek urgent medical assistance as prompt treatment in hospital

is vital. For this reason it is important that you are able to

recognise the symptoms of meningitis, which may include a

high temperature, headache and a distinctive rash. With early

diagnosis and treatment most people make a full recovery.

WHAT TO DO

Seek urgent medical advice

if you notice any of the signs

of meningitis; for example,

shielding eyes from the light. Do

not wait for all the symptoms

and signs to appear because

they may not all develop. Treat

the fever (p.219).

Check the casualty for signs

of a rash. On dark skin,

check on lighter parts of the

body; for example, the inner

eyelids or fingertips. If you see

any signs, call 999/112 for

emergency help.

1 2

MENINGITIS

■■ If a casualty’s condition is

deteriorating, and you suspect

meningitis, call 999/112 for

emergency help even if she has

already seen a doctor.

While waiting for help

to arrive, reassure the

casualty and keep her cool.

Monitor and record vital signs –

breathing, pulse and level of

response (pp.52–53).

3

Accompanying the later stage of

meningitis is a distinctive red or

purple rash that does not fade if

you press it. If you press the side

of a glass firmly against most

rashes they will fade; if a rash

does not fade, call 999/112 for

emergency help immediately.

IMPORTANT MENINGITIS RASH

SEE ALSO Fever p.219

CAUTION

221

MENINGITIS | FAINTING

SEE ALSO The unresponsive casualty pp.54–87

■■ Brief period of unresponsiveness

that causes the casualty to fall to

the ground

■■ A slow pulse

■■ Pale, cold skin and sweating

■■ To improve blood flow to the brain

■■ To reassure the casualty and make

him comfortable

A faint is a brief loss of responsiveness caused by a temporary

reduction of the blood flow to the brain. It may be a reaction to

pain, exhaustion, lack of food or emotional stress. Fainting is also

common after long periods of physical inactivity, such as

standing or sitting still, especially in a warm atmosphere. This

inactivity causes blood to pool in the legs, reducing the amount

of blood reaching the brain.

When a person faints, the pulse rate becomes very slow.

However, the rate soon picks up and returns to normal. A

casualty who has fainted usually makes a rapid and complete

recovery. Do not advise a person who feels faint to sit on a chair

with his head between his knees because if he faints he may

fall and injure himself. If the casualty is a woman in the late stage

of pregnancy, help her to lie down so that she is leaning towards

her left side to prevent the pregnant uterus restricting blood

flow back to her heart.

WHAT TO DO

When a casualty feels

faint, advise him to lie

down. Kneel down, raise his legs,

supporting his ankles on your

shoulders to improve blood flow

to the brain. Watch his face for

signs of recovery.

Make sure that the casualty

has plenty of fresh air; ask

someone to open a window if

you are indoors. In addition, ask

any bystanders to stand clear.

As the casualty recovers,

reassure him and help him

to sit up gradually. If he starts to

feel faint again, advise him to lie

down once again, and raise

and support his legs until he

recovers fully.

1 2 3

FAINTING

■■ If the casualty does not regain

responsiveness quickly, open

the airway and check breathing

(The unresponsive casualty,

pp.54–87).

CAUTION

RECOGNITION

YOUR AIMS

222

MEDICAL CONDITIONS

An allergy is an abnormal reaction of the body’s defence

system (immune response) to a normally harmless “trigger”

substance (or allergen). An allergy can present itself as a

mild itching, swelling, wheezing or digestive condition,

or can progress to full-blown anaphylaxis, or anaphylactic

shock (opposite), which can occur within seconds or

minutes of exposure to an offending allergen.

Common allergy triggers include pollen, dust, nuts,

shellfish, eggs, wasp and bee stings, latex and certain

medications. Skin changes can be subtle, absent or

variable in some cases.

ALLERGY

WHAT TO DO

Assess the casualty’s signs and symptoms. Ask if she has any

known allergy.

Remove the trigger if possible, or move the casualty from

the trigger. 2

1

SEE ALSO Anaphylactic shock opposite | Asthma p.102

Features of mild allergy vary

depending on the trigger. There

may be:

■■ Red, itchy rash or raised areas of skin

(weals)

■■ Red, itchy eyes

■■Wheezing and/or difficulty breathing

■■ Swelling of hands, feet and/or face

■■ Abdominal pain, vomiting and

diarrhoea

RECOGNITION

■■ Call 999/112 for emergency

help if the casualty does not

improve, she has difficulty in

breathing or is becoming

distressed. Monitor and record

vital signs (pp.52–53) while

waiting for help.

CAUTION

■■ To assess the severity of the allergic

reaction

■■ To seek medical advice if necessary

YOUR AIMS

Treat any symptoms. Allow the casualty to take her own

medication for a known allergy. 3

If you are at all concerned about the casualty’s condition, seek

medical advice. 4

223

ALLERGY | ANAPHYLACTIC SHOCK

ANAPHYLACTIC SHOCK

SEE ALSO Hypoxia p.92 | Shock pp.112–13 | The unresponsive casualty pp.54–87

WHAT TO DO

Call 999/112 for emergency

help. Tell ambulance control

that you suspect anaphylaxis.

If the casualty has an autoinjector

of adrenaline, help

her to use it. If she is unable to

administer it, and you have been

trained, give it to her. Pull off the

safety cap and, holding the autoinjector

with your fist, push the

tip firmly against the casualty’s

thigh until it clicks, releasing the

medication (it can be delivered

through clothing). Hold for

ten seconds, remove the

autoinjector, then massage the

injection site for ten seconds.

Help the casualty to sit up

in the position that best

relieves any breathing difficulty.

If she becomes pale with a weak

pulse, help her to lie down with

legs raised and treat for shock

(pp.112–13).

2

1 3

Features of allergy (opposite) may

be present:

■■ Red, itchy rash or raised areas of skin

(weals)

■■ Red itchy, watery eyes

■■ Swelling of hands, feet and/or face

■■ Abdominal pain, vomiting and

diarrhoea

There may also be:

■■ Difficulty breathing, ranging from

a tight chest to severe difficulty,

causing the casualty to wheeze

and gasp for air

■■ Pale or flushed skin

■■ Visible swelling of tongue and throat

with puffiness around the eyes

■■ Feeling of terror

■■ Confusion and agitation

■■ Signs of shock, leading to collapse

and unresponsiveness

RECOGNITION

This is a severe allergic reaction affecting the whole body. It

may develop within seconds or minutes of contact with a trigger

and is potentially fatal. In an anaphylactic reaction, chemicals

are released into the blood that widen (dilate) blood vessels.

This causes blood pressure to fall and air passages to narrow

(constrict), resulting in breathing difficulties. In addition, the

tongue and throat can swell, obstructing the airway. The amount

of oxygen reaching the vital organs can be severely reduced,

causing hypoxia (p.92). Common triggers include: nuts, shellfish,

eggs, wasp and bee stings, latex and certain medications.

A casualty with anaphylactic shock needs emergency

treatment with an injection of adrenaline.

■■ If a pregnant casualty needs to

lie down, lean her towards her

left side to prevent the pregnant

uterus restricting blood flow

back to the heart.

■■ If the person becomes

unresponsive, open the airway

and check breathing (The

unresponsive casualty

pp.54–87).

CAUTION

■■ To ease breathing

■■ Treat shock

■■ To arrange urgent removal to

hospital

YOUR AIMS

Monitor and record vital

signs – breathing, pulse

level of response (pp.52–53) –

while waiting for help to arrive.

Repeated doses of adrenaline

can be given at five-minute

intervals if there is no

improvement or the

symptoms return.

4

224

MEDICAL CONDITIONS

■■ To relieve the pain

■■ To obtain medical advice if necessary

YOUR AIMS

A headache may accompany any illness, particularly a feverish

ailment such as flu. It may develop for no reason, but can often

be traced to tiredness, tension, stress or undue heat or cold.

Mild “poisoning” caused by a stuffy or fume-filled atmosphere,

or by excess alcohol or any other drug, can also induce a

headache. However, a headache may also be the most

prominent symptom of meningitis or a stroke.

WHAT TO DO

HEADACHE

■■ Do not give aspirin to anyone

under 16 years of age or who

you know is allergic to it.

Seek urgent medical advice if:

■■ Pain develops very suddenly

■■ Pain is severe and incapacitating

■■ Pain is accompanied by fever or

vomiting

■■ Pain is recurrent or persistent

■■ Pain is accompanied by loss of

strength or sensation, or by

impaired level of response

■■ Pain is accompanied by a stiff

neck and sensitivity to light

■■ Pain follows a head injury

CAUTION

WHAT TO DO

Help the casualty to sit or

lie down in a quiet place.

Give him a cold compress to

hold against his head (p.241).

An adult may take the

recommended dose of

paracetamol tablets or his own

painkillers. A child may have

the recommended dose of

paracetamol syrup (not aspirin).

2

1

Migraine attacks are severe, “sickening” headaches and can

be triggered by a variety of causes, such as allergy, stress or

tiredness. Other triggers include lack of sleep, missed meals,

alcohol and some foods – for example, cheese or chocolate.

Migraine sufferers usually know how to recognise and deal with

attacks and may carry their own medication.

■■ Before the attack there may be

disturbance of vision in the form of

flickering lights and/or a “blind patch”

■■ Intense throbbing headache, which

may be on just one side of the head

■■ Abdominal pain, nausea and vomiting

■■ Inability to tolerate bright light or

loud noise

RECOGNITION

■■ Do not give aspirin to anyone

under 16 years of age or who

you know is allergic to it.

CAUTION

Advise the casualty to lie

down or sleep for a few

hours in a quiet, dark room.

Provide him with some towels

and a container in case he

vomits.

Help the casualty to take 2

any medication that he may

have for migraine attacks.

1

If this is the first attack,

advise the casualty to seek

medical advice.

3

SEE ALSO Head injury pp.144–45 | Meningitis p.220 | Stroke pp.212–13

MIGRAINE

■■ To relieve the pain

■■ To obtain medical advice if necessary

YOUR AIMS

225

HEADACHE | MIGRAINE | SORE THROAT | EARACHE AND TOOTHACHE

EARACHE AND TOOTHACHE

WHAT TO DO

WHAT TO DO

An adult may take the

recommended dose of

paracetamol tablets or her own

painkillers. A child may have

the recommended dose of

paracetamol syrup (not aspirin).

Give her a source of heat,

such as a hot-water bottle

wrapped in a towel, to hold

against the affected side.

In addition for toothache,

you can soak a plug of

cotton wool in oil of cloves to

hold against the affected tooth.

2

1 3

■■ To relieve the pain

■■ To obtain medical or dental advice

if necessary

YOUR AIMS

Earache can result from inflammation of the outer, middle or

inner ear, and is often caused by an infection associated with a

cold, tonsillitis or flu. It can also be caused by a boil, an object

stuck in the ear canal or transmitted pain from a tooth abscess.

There may also be temporary hearing loss. Earache often occurs

when flying as a result of the changes in air pressure during

ascent and descent. Infection can cause pus to collect in the

middle ear and the eardrum may rupture, allowing the pus to

drain, which temporarily eases the pain.

Toothache can develop when pulp inside a tooth becomes

inflamed due to dental decay. If untreated, the pulp becomes

infected, leading to an abscess, which causes a throbbing pain.

Infection may cause swelling around the tooth or jaw.

■■ Do not give aspirin to anyone

under 16 years of age or who

you know is allergic to it.

■■ If there is a discharge from an

ear, fever or hearing loss, obtain

medical help.

CAUTION

Advise a casualty to seek

medical advice if you are

concerned, particularly if the

casualty is a child. If a casualty

has toothache, advise her to see

her dentist.

4

The most common sore throat is a “raw” feeling caused by

inflammation, which is often the first sign of a cough or cold.

Tonsillitis occurs when the tonsils at the back of the throat are

infected. The tonsils become red and swollen and white spots of

pus may be seen. Swallowing may be difficult and the glands at

the angle of the jaw may be enlarged and sore.

■■ To relieve the pain

■■ To obtain medical advice if necessary

YOUR AIMS

■■ Do not give aspirin to anyone

under 16 years of age or who

you know is allergic to it.

■■ If you suspect tonsillitis or

glandular fever, tell the casualty

to seek medical advice.

CAUTION

An adult may take the

recommended dose of paracetamol

tablets or his own painkillers. A child may

have the recommended dose of

paracetamol syrup (not aspirin).

2 Give the casualty

plenty of fluids to

help ease the pain and

stop the throat from

becoming dry.

1

SEE ALSO Foreign object in the ear p.197

SORE THROAT

226

MEDICAL CONDITIONS

■■ To relieve pain and discomfort

■■ To obtain medical help if necessary

YOUR AIMS

Pain in the abdomen often has a relatively minor cause, such as

food poisoning. The pain of a stitch usually occurs during

exercise and is sharp. Distension (widening) or obstruction of the

intestine causes colic – pain that comes and goes in waves –

which often makes the casualty double up in agony and may be

accompanied by vomiting.

Occasionally abdominal pain is a sign of a serious disorder

affecting the organs and other structures in the abdomen. If the

appendix bursts, or the intestine is damaged, the contents of

the intestine can leak into the abdominal cavity, causing

inflammation of the cavity lining. This life-threatening condition,

called peritonitis, causes intense pain, which is made worse

by movement or pressure on the abdomen, and will lead to

shock (pp.112–13).

An inflamed appendix (appendicitis) is especially common in

children. Symptoms include pain (often starting in the centre of

the abdomen and moving to the lower right-hand side), loss of

appetite, nausea, vomiting, bad breath and fever. If the appendix

bursts, peritonitis will develop. The treatment is urgent surgical

removal of the appendix.

ABDOMINAL PAIN

■■ If the pain is severe, or occurs

with fever and vomiting, call

999/112 for emergency help.

Treat the casualty for shock

(pp.112–13). Do not give her

medicine or allow her to

eat or drink, because an

anaesthetic may be needed.

CAUTION

WHAT TO DO

Reassure the casualty and make her comfortable. Prop her

up if she finds breathing difficult. Give her a container to use

if she is vomiting.

Give the casualty a hot-water bottle wrapped in a towel to hold

against her abdomen. If in doubt about her condition, seek

medical advice.

2

1

SEE ALSO Shock pp.112–13

This common condition is a form of

cramp, usually associated with

exercise, which occurs in the trunk

or the sides of the chest. The most

likely cause is a build-up in the

muscles of chemical waste

products, such as lactic acid, during

physical exertion. Help the casualty

to sit down and reassure him. The

pain will usually ease quickly. If it

does not disappear within a few

minutes, or if you are concerned

about the casualty’s condition, seek

medical advice.

SPECIAL CASE STITCH

227

ABDOMINAL PAIN | VOMITING AND DIARRHOEA

VOMITING AND DIARRHOEA

SEE ALSO Drug poisoning p.201 | Swallowed poisons p.200

WHAT TO DO

Reassure the casualty if she is vomiting and

give her a warm damp cloth to wipe her face.

Help her to sit down and, when the vomiting

stops, give her water or unsweetened fruit

juice to sip slowly and often.

When the casualty is hungry again, advise

her to eat easily digested foods such as pasta,

bread or potatoes for the first 24 hours.

2

1

3

There may be:

■■ Nausea

■■ Vomiting and later diarrhoea

■■ Stomach pains

■■ Fever

RECOGNITION

These problems are usually due to irritation of the digestive

system. Diarrhoea and vomiting can be caused by a number of

different organisms, including viruses, bacteria and parasites.

They usually result from eating contaminated food or drinking

contaminated water, but infection can be passed directly from

person to person. Cleanliness and good hand hygiene (p.17) help

prevent the spread of infectious diarrhoea.

Vomiting and diarrhoea may occur either separately or together.

Both conditions can cause the body to lose vital fluids and salts,

resulting in dehydration. When they occur together, the risk of

dehydration is increased and can be serious, especially in infants,

young children and elderly people.

The aim of treatment is to prevent dehydration by giving

frequent sips of water or unsweetened fruit juice, even if the

casualty is vomiting. Rehydration powder, which is added to

water, provides the correct balance of water and salt to replace

those lost through the vomiting and diarrhoea.

■■ Do not give anti-diarrhoea

medicines.

■■ If you are concerned about a

casualty’s condition, particularly

if the vomiting or diarrhoea is

persistent, or the casualty is a

young child or an older person,

seek medical advice.

CAUTION

■■ To reassure the casualty

■■ To restore lost fluids and salts

YOUR AIMS

228

MEDICAL CONDITIONS

■■ To obtain medical help or arrange for

the woman to be taken to hospital

■■ To ensure privacy, reassure the

woman and make her comfortable

■■ To prevent infection in the mother,

baby and yourself

■■ To care for the baby during and

after delivery

YOUR AIMS Childbirth is a natural and often lengthy process that normally

occurs at about the 40th week of pregnancy. There is usually

plenty of time to get a woman to hospital, or get help to her,

before the baby arrives. Most pregnant women are aware of

what happens during childbirth, but a woman who goes into

labour unexpectedly or early may be very anxious. You will need

to reassure her and make her comfortable. Miscarriage, however,

is potentially serious because there is a risk of severe bleeding.

A woman who is miscarrying needs urgent medical help (p.128).

There are three distinct stages to childbirth. In the first stage,

the baby gets into position for the birth. The baby is born in the

second stage, and in the third stage, the afterbirth (placenta and

umbilical cord) is delivered.

First stage

In this stage, a woman’s body begins

to experience contractions, which,

together with the pressure of the

baby’s head, cause the cervix (neck

of the uterus/womb) to open. The

contractions become stronger and

more frequent until the cervix is

fully dilated (open) – about 10cm

(4in) – and ready for the baby to be

born. During this first stage, the

mucus plug that protects the uterus

from infection is expelled and the

amniotic fluid surrounding the baby

leaks out from the vagina. This stage

can take several hours for a first

baby, but is normally shorter in any

subsequent pregnancies.

Second stage

Once the cervix is fully dilated, the

baby’s head will press down on the

mother’s pelvic floor, triggering a

strong urge to push. The birth canal

(vagina) stretches as the baby

travels through it. The baby’s head

normally emerges first, and the

body is delivered soon afterwards.

This stage of labour normally lasts

about an hour.

Third stage

About 10–30 minutes after the baby

is born, the placenta (the organ that

nourishes the unborn baby) and the

umbilical cord will be expelled from

the uterus. The uterus begins to

contract again, pushing the placenta

out, then it closes down the area

where it was attached; this reduces

the bleeding.

CHILDBIRTH

Placenta detaches from

wall of uterus

Baby’s head

presses against

cervix

Baby

emerges

Uterus contracts

to push baby

down

Birth canal

fully dilated

Umbilical cord

229

CHILDBIRTH | EMERGENCY CHILDBIRTH

EMERGENCY CHILDBIRTH

SEE ALSO Shock pp.112–13 | Vaginal bleeding p.128

■■ Do not give the mother anything to eat because there is a risk

that she may vomit. If she is thirsty give her sips of water.

■■ Do not pull on the baby’s head or shoulders during delivery.

■■ If the umbilical cord is wrapped around the baby’s neck as he is

born, check that it is loose, and then very carefully ease it over

the head to protect the baby from strangulation.

■■ If a newborn baby does not cry, open the airway and check

breathing (Unresponsive infant, pp.80–83). Do not smack a baby.

■■ Do not pull or cut the umbilical cord, even when the placenta

has been delivered.

WHAT TO DO

Call 999/112 for emergency help. Give the

ambulance control details of the stage that the

mother has reached, the length of each contraction

and the intervals between them. Call the mother’s

midwife too if she requests it.

As the baby is born, handle him carefully, as

newborn babies are very slippery. Give him to

the mother; lay him on her stomach or wrap him in

a clean cloth, towel or blanket.

As the third stage begins, reassure the

mother. Support her as she delivers the

afterbirth; do not cut the cord. Keep the placenta

and the umbilical cord intact as the midwife,

doctor or ambulance crew need to check that it

is complete. If bleeding or pain is severe, treat for

shock (pp.112–13). Help the mother to lie down

and raise her legs.

When the second stage starts, the mother

will want to push. Make sure the surroundings

are as clean as possible to reduce the risk of

infection. The mother should remove any items

of clothing that could interfere with the birth. Put

clean sheets or towels under the woman; she may

also want to be covered. Encourage her to stay as

upright as possible.

During the first stage, help her sit or kneel

on the floor in a comfortable position. Support

her with cushions or let her move around. Stay

calm, and encourage her to breathe deeply during

her contractions.

Massage her lower back gently using the heel

of your hand. She may find having her face and

hands wiped soothing, or you can spray her face

with cool water and give her ice cubes to suck.

4

5

6

2

1

3

In the rare event of a baby arriving

quickly, you should not try to “deliver”

the baby; the birth will happen

naturally without intervention. Your

role is to comfort and listen to the

wishes of the mother and care for her

and her baby.

CAUTION

This chapter outlines the techniques

and procedures that underpin first aid,

including moving a casualty and applying

dressings and bandages. Usually, a first

aider is not expected to move an injured

person, but in some circumstances – such

as when a casualty is in immediate danger –

it may be necessary. The key principles for

moving casualties are described here.

Information is also given on making an

assessment of the risks involved in moving

a casualty or assisting a casualty to safety.

A guide to the equipment and materials

commonly found in a first aid kit is given,

with information on how and when to use

them. Applying dressings and bandages

effectively is an essential part of first aid:

wounds usually require a dressing, and

almost all injuries benefit from the support

that bandages can give.

■■ To assess the casualty’s condition

■■ To comfort and reassure the casualty

■■ To maintain a casualty’s privacy and dignity

■■ To use a first aid technique relevant to the injury

■■ To use dressings and bandages as needed

■■ To apply good handling techniques if moving

a casualty

■■ To obtain appropriate help: call 999/112 for

emergency help if you suspect serious injury

or illness

AIMS AND OBJECTIVES

TECHNIQUES

AND EQUIPMENT

232

REMOVING CLOTHING

To make a thorough examination of a casualty,

obtain an accurate diagnosis or give treatment,

you may have to remove some of his clothing.

This should be done with the minimum of

disturbance to the casualty and with his

agreement if possible. Remove as little clothing

as possible and do not damage clothing unless it

is necessary. If you need to cut a garment, try to

cut along the seams, keeping the clothing clear

of the casualty’s injury. Maintain the casualty’s

privacy and prevent exposure to cold. Stop if

removing clothing increases the casualty’s

discomfort or pain.

REMOVING CLOTHING IN LOWER BODY INJURIES

REMOVING CLOTHING IN UPPER BODY INJURIES

Shoes

Untie any laces, support the ankle

and carefully pull the shoe off by

the heel. To remove long boots,

you may need to cut them down

the back seam.

Socks

Remove socks by pulling them

off gently. If this is not possible,

lift each sock away from the leg

and cut the fabric with a pair

of scissors.

Trousers

Gently pull up the trouser leg

to expose the calf and knee or pull

down from the waist. If you need

to cut clothing, lift it clear of the

casualty’s injury.

Jackets

Support the injured arm. Undo any fastenings on the

jacket and gently pull the garment off the casualty’s

shoulders. Remove the arm on the uninjured side from

its sleeve. Pull the garment round to the injured side

of the body and ease it off the injured arm.

Sweaters and sweatshirts

With clothing that cannot be unfastened, begin by

easing the arm on the uninjured side out of its sleeve.

Next, roll up the garment and stretch it over the

casualty’s head. Finally, slip off the other sleeve of the

garment, taking care not to disturb her arm on the

injured side.

TECHNIQUES AND EQUIPMENT

233

Protective headgear, such as a riding hat or a motorcyclist’s

crash helmet, is best left on; it should be removed only if

absolutely necessary, for example, if you cannot maintain an

open airway. If the item does need to be removed, the casualty

should do this herself if possible; otherwise, you and a helper

should remove it. Take care to support the head and neck at all

times and keep the head aligned with the spine.

REMOVING CLOTHING | REMOVING HEADGEAR

SEE ALSO Spinal injury pp.157–59

Ask a helper to grip the

sides of the helmet and pull

them apart to take pressure off

the head, then lift the helmet

upwards and backwards.

Undo or cut the straps. Working from the base

of the helmet, ease your fingers underneath

the rim. Support the back of the neck with one

hand and hold the lower jaw firmly. Ask a helper to

hold the helmet with both hands.

Maintain support on the head and neck. Ask your helper to tilt

the helmet forwards slightly so that it will pass over the base of

the skull, and then to lift it straight off the casualty’s head.

Continue to support the casualty’s neck and

lower jaw. Ask your helper, working from

above, to tilt the helmet backwards (without

moving the head) and gently lift the front of the

helmet clear of the casualty’s chin.

2

1

3

2

Do not remove a helmet unless

absolutely necessary.

CAUTION

REMOVING AN OPEN-FACE OR RIDING HELMET

REMOVING A FULL-FACE HELMET

Undo or cut through the

chinstrap. Support the

casualty’s head and neck,

keeping them aligned with the

spine. Hold the lower jaw with

one hand and support the neck

with the other hand.

1

REMOVING HEADGEAR

234

CASUALTY HANDLING

■■ Do not approach a casualty

if doing so puts your own life in

danger.

■■ Do not move a casualty unless

there is an emergency situation

that demands you take

immediate action.

When giving first aid you should leave a casualty in the position

in which you find him until medical help arrives. Only move him

if he is in imminent danger, and even then only if it is safe for you

to approach and you have the training and equipment to carry

out the move. A casualty should be moved quickly if he is in

imminent danger from:

■■Drowning (p.100)

■■Fire or he is in an area that is filling with smoke (pp.32–33)

■■Explosion or gunfire

■■A collapsing building or other structure

CAUTION

If it is necessary to move a casualty, consider

the following before you start.

■■Is the task necessary? Usually, the casualty

can be assessed and treated in the position in

which you find him.

■■What are his injuries or conditions, and will a

move make them worse?

■■Can the casualty move himself? Ask the

casualty if he feels able to move.

■■The weight and size of the casualty.

■■Can anyone help? If so, are you and any

helpers trained and physically fit?

■■Will you need protective equipment to enter

the area, and do you have it?

■■Is there any equipment available to assist

with moving the casualty and are you trained

to use it?

■■Is there enough space around the casualty

to move him safely?

■■What sort of ground will you be crossing?

If you need to move a casualty, take the

following steps to ensure safety.

■■Select a method relevant to the situation,

the casualty’s condition and the help and

equipment that is available.

■■Use a team. Appoint one person to

coordinate the move and make sure that the

team understands exactly what to do.

■■Plan your move carefully and make sure that

everyone is prepared.

■■Prepare any equipment and make sure that

the team and equipment are in position.

■■Use the correct technique to avoid injuring

the casualty, yourself or any helpers.

■■Ensure the safety and comfort of the casualty,

yourself and any helpers.

■■Always explain to the casualty what is

happening, and encourage him to cooperate

as much as possible.

■■Position yourself as close as possible

to the casualty’s body.

■■Adopt a stable base, with your feet shoulderwidth

apart, so that you remain well balanced

and maintain good posture at all times during

the procedure.

■■Use the strongest muscles in your legs and

arms to power the move. Bend your knees.

ASSESSING THE RISK OF MOVING A CASUALTY

ASSISTING A CASUALTY SAFELY

TECHNIQUES AND EQUIPMENT

235

FIRST AID MATERIALS

All workplaces, leisure centres, homes and cars

should have first aid kits. The kits for workplaces

or public places must conform to legal

requirements and be clearly marked in a green

box with a white cross and easily accessible. For

home or the car, you can either buy a kit or put

together first aid items yourself and keep them

in a clean, waterproof container. Any first aid kit

must be kept in a dry place, and checked and

replenished regularly.

The items on these pages form the basis of a

first aid kit for the home. You may wish to add

pain-relief tablets such as paracetamol.

STERILE DRESSINGS

CASUALTY HANDLING | FIRST AID MATERIALS

Wound dressings

The most useful dressings

consist of a dressing pad

attached to a roller

bandage, and are sealed in

protective wrapping. They

are easy to apply, so are

ideal in an emergency.

Various sizes are available.

Individual sterile dressing

pads are also available that

can be secured with tape

or bandages. Dressings

with a non-stick surface

are useful.

Adhesive dressings or plasters

These are applied to small cuts

and grazes and are made of fabric

or waterproof plastic. Use

hypoallergenic plasters for anyone

who is allergic to the adhesive in

regular ones. People who work

with food are required to use blue

plasters. Special gel plasters can

protect blisters.

STERILE EYE PAD

STERILE WOUND DRESSING STERILE PAD

FABRIC PLASTERS WATERPROOF PLASTERS

CLEAR PLASTERS BLUE CATERING PLASTERS

NOVELTY PLASTERS FOR CHILDREN

GEL BLISTER PLASTER »

236

FIRST AID MATERIALS

PROTECTIVE ITEMS

BANDAGES

Roller bandages

These items are used to give

support to injured joints, secure

dressings in place, maintain

pressure on wounds and

limit swelling.

Triangular bandages

Made of cloth, these items can be used folded

as bandages or slings. If they are sterile and

individually wrapped, they may also be used

as dressings for large wounds and burns.

Disposable gloves

Wear gloves, if available, whenever you dress

wounds or when you handle body fluids or other

waste materials. Use latex-free gloves because

some people are allergic to latex.

Tubular bandages

Gauze tubular bandage is used to secure dressings

on fingers and toes and is put over the injury using

a special applicator. Elasticated tubular bandages

are sometimes used to support injured joints such

as the knee or elbow.

Protection from infection

You can use a plastic face shield or a pocket mask

to protect you and the casualty from cross infection

when giving rescue breaths.

TECHNIQUES AND EQUIPMENT

FACE SHIELD POCKET MASK

GAUZE TUBULAR BANDAGE AND APPLICATOR

SUPPPORT

ROLLER BANDAGE

CONFORMING

ROLLER BANDAGE

OPEN-WEAVE

ROLLER BANDAGE

SELF-ADHESIVE

BANDAGE

FOLDED TRIANGULAR BANDAGE

«

237

BASIC MATERIALS FOR A FIRST AID KIT

ADDITIONAL ITEMS

FIRST AID MATERIALS

Cleansing wipes

Alcohol-free wipes can be used

to clean skin around wounds.

Useful extras

Kitchen film or clean plastic bags can be used to dress

burns and scalds. Keep a bottle of alcohol gel to clean

your hands when no water is available.

Scissors, shears and tweezers

Choose items that ideally are blunt-ended so that they

will not cause injuries. Use shears to cut clothing.

Pins and clips

Use these to secure the ends of bandages.

Gauze pads

Use these pads as dressings, as

padding, or as swabs to clean

around wounds.

Adhesive tape

Use tape to secure dressings

or the loose ends of bandages.

If the casualty is allergic to the

adhesive on the tape, use a

hypoallergenic tape.

For use outdoors

A blanket can protect a casualty from cold. Survival

bags are very compact and will keep a person warm

and dry in an emergency. A torch helps visibility, and

a whistle can be used to summon help.

■■ Easily identifiable watertight box

■■ 20 adhesive dressings (plasters) in

assorted sizes

■■ Six medium sterile dressings

■■ Two large sterile dressings

■■ One sterile eye pad

■■ Six triangular bandages

■■ Six safety pins

■■ Disposable gloves

■■ Two roller bandages

■■ Scissors

■■ Tweezers

■■ Alcohol-free wound cleansing wipes

■■ Adhesive tape

■■ Plastic face shield or pocket mask

■■ Notepad and pencil

■■ Alcohol gel

Other useful items:

■■ Blanket, survival bag, torch, whistle

■■Warning triangle and high visibility

jacket to keep in the car

238

DRESSINGS

You should always cover a wound with a

dressing because this helps to prevent infection.

With severe bleeding, dressings are used to help

the blood-clotting process by exerting pressure

on the wound. Use a pre-packed sterile wound

dressing with a bandage attached (opposite)

whenever possible. If no such dressing is

available, use a sterile pad. Alternatively,

any clean, non-fluffy material can be used

to improvise a dressing (p.240). Protect small

cuts with an adhesive dressing (p.241).

When handling or applying a dressing, there

are a number of rules to follow. These enable

you to apply dressings correctly; they also

protect the casualty and yourself from

cross infection.

■■Always put on disposable gloves, if these are

available, before handling any dressing.

■■Cover the wound with a dressing that extends

beyond the wound’s edges.

■■Hold the edge of the dressing, keeping your

fingers well away from the area that will be in

contact with the wound.

■■Place the dressing directly on top of the

wound; do not slide it on from the side.

■■Remove and replace any dressing that slips

out of position.

■■If you only have one sterile dressing, use it

to cover the wound, and put other clean

materials on top of it.

■■If blood seeps through the dressing, do not

remove it; instead, place another dressing

over the top. If blood seeps through the

second dressing, remove both dressings

completely and then apply a fresh dressing,

making sure that you put pressure on the

bleeding point.

■■After treating a wound, dispose of gloves,

used dressings and soiled items in a suitable

plastic bag, ideally a clinical waste bag

(below). Keep disposable gloves on until you

have finished handling any materials that may

be contaminated, then put them in the waste

bag as well.

RULES FOR USING DRESSINGS

TECHNIQUES AND EQUIPMENT

WEAR DISPOSABLE GLOVES USE DRESSING LARGER THAN WOUND DISPOSE OF WASTE

SEE ALSO Cuts and grazes p.119 | First aid materials pp.235–37 | Severe external bleeding pp.114–15

239

HOW TO APPLY A STERILE WOUND DRESSING

DRESSINGS

■■ If the dressing slips out of place,

remove it and apply a new

dressing.

■■ Take care not to impair the

circulation beyond the

bandage (p.243).

WHAT TO DO

Break the seal and remove the wrapping.

Unwind some of the bandage, taking care not

to drop the roll or touch the dressing pad.

Wind the other end (head) of the bandage

around the limb to cover the whole pad. Leave

the short end of the bandage hanging free.

To secure the bandage, tie the ends in a reef

knot (p.250). Tie the knot directly over the pad

to maintain firm pressure on the wound.

Once you have secured the bandage, check

the circulation in the limb beyond it (p.243).

Loosen the bandage if it is too tight, then reapply.

Recheck every ten minutes.

Unfold the dressing pad, and lay it directly on

the wound. Hold the bandage on each side of

the pad as you place it over the wound.

Wind the short end of the bandage once

around the limb and the pad to secure

the dressing.

4

5

6

2

1

3

This type of dressing consists of a dressing pad attached to

a roller bandage. The pad is a piece of gauze backed with a layer

of cotton wool or padding.

Sterile dressings are available individually wrapped in various

sizes. They are sealed in protective wrappings to keep them

sterile. Once the seal on this type of dressing has been broken,

the dressing is no longer sterile.

CAUTION

»

240

DRESSINGS

If there is no sterile wound dressing with bandage available,

use a sterile pad or make a pad out of pieces of gauze. Make sure

the pad is large enough to extend well beyond the edges of the

wound. Hold the dressing face down; never touch the part of

the dressing that will be in contact with a wound. Secure the

dressing with tape. If you need to maintain pressure to control

bleeding, use a bandage.

If you have no suitable dressings, any clean

non-fluffy material can be used in an emergency.

If using a piece of folded cloth, hold it by its

edges, unfold it, then refold it so that the clean

inner side can be placed against the wound.

IMPROVISED DRESSINGS

STERILE PAD AND GAUZE DRESSINGS

TECHNIQUES AND EQUIPMENT

WHAT TO DO

WHAT TO DO

■■ Never apply adhesive tape all

the way around a limb or digit

since this can impair circulation.

■■ Check that the casualty is not

allergic to the adhesive before

using adhesive tape; if there is

any allergy, use a pad and

bandage instead.

CAUTION

Secure the pad with a

bandage or a clean strip

of cloth, such as a scarf. Tie

the ends in a reef knot (p.250).

Place the cloth pad

directly on to the wound. If

necessary, cover the pad with

more material.

Secure the pad with adhesive tape or a roller

bandage.

Hold the material by the

edges. Open it out and

refold it so that the inner surface

faces outwards.

Holding the dressing or pad by the edges,

place it directly on to the wound.

2 3

2

1

1

«

241

DRESSINGS | COLD COMPRESSES

Plasters, or adhesive dressings, are useful for covering small

cuts and grazes. They consist of a gauze or cellulose pad with an

adhesive backing, and are wrapped singly in sterile packs. There

are several sizes available, as well as special shapes for use on

fingertips, heels and elbows; some types are waterproof. Blister

plasters have an oval cushioned pad. People who work with food

must cover any wounds with visible, blue, waterproof plasters.

Cooling an injury such as a bruise or sprain can reduce swelling

and pain. There are two types of compress: cold pads, which are

made from material dampened with cold water, and ice packs. An

ice pack can be made using ice cubes (or packs of frozen peas or

other small vegetables) wrapped in a dry cloth.

ADHESIVE DRESSINGS

WHAT TO DO

Clean and dry the skin around the wound. Unwrap the plaster

and hold it by the protective strips over the backing, with the pad

side facing downwards.

Peel back the strips to

expose the pad, but do not

remove them. Without touching

the surface of the pad, place the

pad on the wound.

Soak a clean flannel or

towel in cold water. Wring it

out lightly and fold it into a pad.

Hold it firmly against the injured

area (right).

Partly fill a plastic bag with

small ice cubes or crushed

ice, or use a pack of frozen

vegetables. Wrap the bag in a

dry cloth.

Carefully pull away the

protective strips, then press

the edges of the plaster down.

Re-soak the pad in cold

water every few minutes to

keep it cold. Cool the injury for

no more than ten minutes.

Hold the pack firmly on the

area (left). Cool the injury

for no more than ten minutes,

topping up the ice as needed.

1

3

2

2

1

2

1

■■ Check that the casualty

is not allergic to the adhesive

dressings. If he is, use

hypoallergenic tape or

a pad and bandage.

■■ To prevent cold injuries, always

wrap an ice pack in a cloth. Do

not leave it on the skin for more

than ten minutes at a time.

CAUTION

CAUTION

COLD PAD ICE PACK

USING A COLD COMPRESS

COLD COMPRESSES

242

PRINCIPLES OF BANDAGING

There are a number of different first aid uses

for bandages: they can be used to secure

dressings, control bleeding, support and

immobilise limbs and reduce swelling in an

injured limb. There are three main types of

bandage. Roller bandages secure dressings and

support injured limbs. Tubular bandages hold

dressings on fingers or toes, or support injured

joints. Triangular bandages can be used as large

dressings, as slings to secure dressings or folded

to immobilise limbs. If you have no bandage

available, you can improvise from everyday

items; for example, you can fold a square of

fabric, such as a headscarf, diagonally to make

a triangular bandage (p.249).

■■Reassure the casualty before applying a

bandage and explain clearly what you are

going to do.

■■Help the casualty to sit or lie down in a

comfortable position.

■■Support the injured part of the body while

you are working on it. Ask the casualty or a

helper to assist.

■■Work from the front of the casualty, and from

the injured side where possible.

■■Pass the bandages through the body’s natural

hollows at the ankles, knees, waist and neck,

then slide them into position by easing them

back and forth under the body.

■■Apply bandages firmly, but not so tightly that

they interfere with circulation to the area

beyond the bandage (opposite).

■■Fingers or toes should be left exposed, if

possible, so that you can check the circulation

afterwards.

■■Use reef knots to tie bandages (p.250).

Ensure that the knots do not cause

discomfort, and do not tie the knot over a

bony area. Tuck loose ends under a knot if

possible, to provide additional padding.

■■Check the circulation in the area beyond the

bandage (opposite) every ten minutes once

it is secure. If necessary, unroll the bandage

until the blood supply returns, and reapply

it more loosely.

RULES FOR APPLYING A BANDAGE

TECHNIQUES AND EQUIPMENT

SEE ALSO Roller bandages pp.244–47 | Triangular bandages p.249 | Tubular gauze bandages p.248

243

If circulation is impaired there

may be:

■■ A swollen and congested limb

■■ Blue skin with prominent veins

■■ A feeling that the skin is painfully

distended

Later there may be:

■■ Pale skin

■■ Skin cold to touch

■■ Numbness and tingling followed

by severe pain

■■ Inability to move affected fingers

or toes

RECOGNITION

When applying bandages to immobilise

a limb you also need to use soft, bulky material,

such as towels or clothing, as padding. Place the

padding between the legs, or between an arm

and the body, so that the bandaging does not

displace broken bones or press bony areas

against each other. Use folded triangular

bandages and tie them at intervals along the

limb, avoiding the injury site. Secure with reef

knots (p.250) tied on the uninjured side. If both

sides of the body are injured, tie knots in the

middle or where there is least chance of causing

further damage.

When bandaging a limb or applying a sling, you must check the

circulation in the hand or foot immediately after you have

finished bandaging, and every ten minutes thereafter. These

checks are essential because limbs can swell after an injury,

and a bandage can rapidly become too tight and restrict blood

circulation to the area beyond it. If this occurs, you need to undo

the bandage and reapply it more loosely.

IMMOBILISING A LIMB

CHECKING CIRCULATION AFTER BANDAGING

TIE KNOTS ON THE UNINJURED SIDE

PRINCIPLES OF BANDAGING

Press one of the nails or the

skin beyond the bandage,

for five seconds until it turns

pale, then release the pressure.

If the colour does not return

within two seconds, the bandage

is too tight.

Loosen a tight bandage by

unrolling enough turns for

warmth and colour to return to

the skin. The casualty may feel

a tingling sensation. If necessary

loosen and reapply the bandage.

Recheck every ten minutes.

1 2

WHAT TO DO

244

ROLLER BANDAGES

This type of bandage can be made of cotton,

gauze, elasticated fabric or linen and is

wrapped around the injured part of the body

in spiral turns. There are three main types of

roller bandage.

■■Open-weave bandages are used to hold

dressings in place. Because of their loose

weave they allow good ventilation, but they

cannot be used to exert direct pressure on

the wound to control bleeding or to provide

support to joints.

■■ Self-adhesive support bandages are used to

support muscle (and joint) injuries and do not

need pins or clips.

■■Crêpe bandages are used to give firm, even

support to injured joints.

There are several ways to fasten the end

of a roller bandage. Safety pins or adhesive tape

are usually included in first aid kits. Some

bandage packs may contain bandage clips. If you

do not have any of these, a simple tuck should

keep the bandage end in place.

Before applying a roller bandage, check that it

is tightly rolled and of a suitable width for the

injured area. Small areas such as fingers require

narrow bandages of approximately 2.5cm (1in)

wide, while wider bandages of 10–15cm (4–6in)

are more suitable for large areas such as legs.

It is better for a roller bandage to be too wide

than too narrow. Smaller sizes may be needed

for a child.

SECURING ROLLER BANDAGES

CHOOSING THE CORRECT SIZE OF BANDAGE

TECHNIQUES AND EQUIPMENT

Adhesive tape

The ends of bandages can be

folded under and then stuck down

with small strips of adhesive tape.

Safety pin

These pins can secure all types of

roller bandage. Fold the end of the

bandage under, then put your

finger under the previous layer of

bandage to prevent injury as you

insert the pin (right). Make sure

that, once fastened, the pin lies flat

(far right).

Bandage clip

Metal clips are sometimes supplied

with crêpe roller bandages for

securing the ends.

Tucking in the end

If you have no fastening, secure the

bandage by passing the end around

the limb once and tucking it in.

245

Follow the general rules below when applying a roller bandage

to an injury.

■■Keep the rolled part of the bandage (the “head”) uppermost

as you work. (The unrolled short end is called the “tail”.)

■■Position yourself in front of the casualty, on the injured side.

■■Support the injured part while you apply the bandage.

APPLYING A ROLLER BANDAGE

ROLLER BANDAGES

WHAT TO DO

Place the tail of the bandage below the injury.

Working from the inside of the limb outwards,

make two straight turns with the bandage to

anchor the tail in place.

Finish with one straight turn. If the bandage is

too short, apply another one in the same way

so that the injured area is covered.

Secure the end of the bandage, then check

the circulation beyond the bandage (p.243).

If necessary, unroll the bandage until the blood

supply returns, and reapply it more loosely.

Recheck every ten minutes.

Wind the bandage in spiralling turns working

from the inner to the outer side of the limb,

and work up the limb. Cover one half to twothirds

of the previous layer of bandage with

each new turn.

3

2 4

1

■■Once you have applied the

bandage, check the circulation

in the limb beyond it (p.243).

This is especially important if

you are applying an elasticated

or crêpe bandage since these

mould to the shape of the limb

and may become tighter if the

limb swells.

CAUTION

»

246

ROLLER BANDAGES

ELBOW AND KNEE BANDAGES

TECHNIQUES AND EQUIPMENT

WHAT TO DO

Pass the bandage to the

inner side of the limb, just

above the joint. Make a turn

around the limb, covering the

upper half of the bandage from

the first turn.

To finish bandaging the

joint, make two straight

turns around the limb, then

secure the end of the bandage

(p.244). Check the circulation

beyond the bandage as soon as

you have finished, then recheck

every ten minutes (p.243). If

necessary unroll the bandage

and reapply more loosely.

Support the injured limb in

a comfortable position for

the casualty, with the joint

partially flexed. Place the tail of

the bandage on the inner side of

the joint. Pass the bandage over

and around to the outside of the

joint. Make one-and-a-half turns,

so that the tail end of the bandage

is fixed and the joint is covered.

Continue to bandage

diagonally above and below

the joint in a figure-of-eight.

Increase the bandaged area by

covering about two-thirds of the

previous turn with each new

layer of bandage.

Pass the bandage from the

inner side of the upper limb

to just below the joint. Make one

diagonal turn below the elbow

joint to cover the lower half of

the bandaging from the first

straight turn.

2

5

1

3 4

■■ If the dressing slips out of place,

remove it and apply a new one.

■■ Take care not to impair the

circulation beyond the

bandage (p.243).

CAUTION

Roller bandages can be used on elbows and knees to support soft

tissue injuries such as strains or sprains. To ensure that there is

effective support, flex the joint slightly, then apply the bandage

in figure-of-eight turns rather than the standard spiralling turns

(p.245). Work from the inside to the outside of the upper surface

of the joint. Extend the bandaging far enough on either side of the

joint to exert an even pressure.

«

247

A roller bandage may be applied to hold

dressings in place on a hand, or to support a

wrist in soft tissue injuries. A support bandage

should extend well beyond the injury site

to provide pressure over the whole of the

injured area.

HAND BANDAGES

ROLLER BANDAGES

WHAT TO DO

Repeat the sequence of figure-of-eight turns.

Extend the bandaging by covering about twothirds

of the bandage from the previous turn with

each new layer. When the hand is completely

covered, finish with two straight turns around the

casualty’s wrist.

Secure the end (p.244). As soon as you have

finished, check the circulation beyond the

bandage (p.243), then recheck every ten minutes.

If necessary, unroll the bandage until the blood

supply returns and reapply it more loosely.

Pass the bandage diagonally

across the back of the hand

to the outer side of the wrist.

Take the bandage under the

wrist. Then repeat the diagonal

over the back of the hand.

Working from the inner side

of the wrist, pass the

bandage diagonally across the

back of the hand to the nail of

the little finger, and across the

front of the casualty’s fingers.

Place the tail of the bandage

on the inner side of the

wrist, below the base of the

thumb. Make two straight turns

around the wrist.

1 2 3

4

5

248

TUBULAR GAUZE BANDAGES

These bandages are rolls of seamless, tubular fabric. The tubular

gauze bandage is used with an applicator that is supplied with the

bandage. It is suitable for holding dressings in place on a finger or

toe, but not to control bleeding. Use hypoallergenic tape to secure

the bandage if the casualty has an allergy to adhesive tape.

TECHNIQUES AND EQUIPMENT

4

1 3

2

Cut a piece of tubular gauze about two-and-ahalf

times the length of the casualty’s injured

finger. Push the whole length of the tubular gauze

on to the applicator, then gently slide the

applicator over the finger and dressing.

While still holding the gauze at the base of

the finger, gently push the applicator back

over the finger to apply a second layer of gauze.

Once the gauze has been applied, remove the

applicator from the finger.

Holding the end of the gauze on the finger,

pull the applicator slightly beyond the

fingertip, leaving a layer of gauze bandage on

the finger. Twist the applicator twice to seal the

bandage over the end of the finger.

Secure the gauze at the base of the finger with

adhesive tape, that does not encircle the

finger. Check the circulation to the finger (p.243),

then again every ten minutes. Ask the casualty

if the finger feels cold or tingly. If necessary,

remove the gauze and apply it more loosely.

■■ Do not encircle the finger

completely with tape because

this may impair circulation.

APPLYING A TUBULAR GAUZE BANDAGE

CAUTION

249

This type of bandage may be supplied in a

sterile pack as part of a first aid kit. You can also

make one by cutting or folding a square metre

of sturdy fabric (such as linen or calico)

diagonally in half. The bandage can be used in

the following three ways.

■■Folded as a broad-fold bandage or narrowfold

bandage (below) to immobilise and

support a limb or to secure a splint or

bulky dressing.

■■Opened to form a sling, or to hold a hand,

foot or scalp dressing in place.

■■If from a sterile pack, folded into a pad and

used as a sterile dressing.

Keep triangular bandages in

their packs so that they remain

sterile until you need them.

Alternatively, fold them as

shown (right) so that they are

ready-folded for use as a pad

or bandage, or can be shaken

open for use as a sling.

STORING A TRIANGULAR BANDAGE

MAKING A BROAD-FOLD

BANDAGE

MAKING A NARROW-FOLD

BANDAGE

TUBULAR GAUZE BANDAGES | TRIANGULAR BANDAGES

Open out a triangular bandage and lay it

flat on a clean surface. Fold the bandage

in half horizontally, so that the point of the triangle

touches the centre of the base.

Start by folding the triangle

into a narrow-fold bandage

(above right). Bring the two ends

of the bandage into the centre.

Fold a triangular bandage to make a broad-fold

bandage (above).

Continue folding the ends

into the centre until the

bandage is a convenient size for

storing. Keep the bandage in a

dry place.

Fold the bandage in half again in the

same direction, so that the first folded

edge touches the base. The bandage should now

form a broad strip of fabric.

Fold the bandage horizontally in half again.

It should form a long, narrow, thick strip

of material.

2

2

1

1

1

2

Point

End

OPEN TRIANGULAR BANDAGE Base

TRIANGULAR BANDAGES

250

REEF KNOTS

HAND AND FOOT COVER BANDAGE

When securing a triangular bandage, always

use a reef knot. It is secure and will not slip, it is

easy to untie and it lies flat, so it is more

comfortable for the casualty. Avoid tying the

knot around or directly over the injury, since

this may cause discomfort.

Pass the left end of

the bandage (dark)

over and under the

right end (light).

Lift both ends

of the bandage

above the rest of

the material.

Lay the bandage

flat. Place the

casualty’s hand on the

bandage, fingers

towards the point. Fold

the point down over

the hand.

Pass the end in

your right hand

(dark) over and under

the left end (light).

Cross the ends

over the hand,

then pass the ends

around the wrist in

opposite directions. Tie

the ends in a reef knot

(above) at the wrist.

Pull the ends to

tighten the knot,

then tuck them under

the bandage.

Pull the point

gently to tighten

the bandage. Fold the

point up over the knot

and tuck it in.

1 2

1

3

2

4

3

TYING AND UNTYING A REEF KNOT

Untying a reef knot

Pull one end and one piece of bandage

from the same side of the knot firmly so

that the piece of bandage straightens.

Hold the knot and pull the straightened

end through it.

An open triangular

bandage can be used

to hold a dressing in

place on a hand or

foot, but it will not

provide enough

pressure to control

bleeding. The method

for covering a hand

(right) can also be

used for a foot, with

the bandage ends tied

at the ankle.

TECHNIQUES AND EQUIPMENT

251

ARM SLING

WHAT TO DO

Ensure that the injured arm

is supported with the hand

slightly higher than the elbow.

Fold the base of the bandage

under to form a hem. Place the

bandage with the base parallel

to the casualty’s body and level

with his little finger nail. Slide

the upper end under the injured

arm and pull it around the neck

to the opposite shoulder.

Tie a reef knot (opposite)

on the injured side, at the

hollow above the casualty’s

collar bone. Tuck both free ends

of the bandage under the knot

to pad it. Adjust the sling so that

the front edge supports the

hand – it should extend to the

top of the casualty’s little finger.

Fold the lower end of

the bandage up over the

forearm and bring it to meet

the upper end at the shoulder.

Hold the point of the

bandage beyond the elbow

and twist it until the fabric fits

the elbow snugly, then tuck it in

(inset). Alternatively, if you have

a safety pin, fold the fabric and

fasten it to the front.

As soon as you have

finished, check the

circulation in the fingers (p.243).

Recheck every ten minutes. If

necessary, loosen and reapply

the bandages and sling.

1

3

2

4 5

An arm sling holds the forearm in a slightly

raised or horizontal position. It provides support

for an injured upper arm, wrist or forearm, on a

casualty whose elbow can be bent, or to

immobilise the arm for a rib fracture (p.154).

An elevation sling (p.252) is used to keep the

forearm and hand raised in a higher position.

REEF KNOTS | HAND AND FOOT COVER BANDAGE | ARM SLING

252

ELEVATION SLING

This form of sling supports the forearm and

hand in a raised position, with the fingertips

touching the casualty’s shoulder. In this way, an

elevation sling helps to control bleeding from

wounds in the forearm or hand, to minimise

swelling. An elevation sling is also used to

support the arm in the case of an injured hand.

WHAT TO DO

TECHNIQUES AND EQUIPMENT

Ask the casualty to support

his injured arm across his

chest, with his fingers resting on

the opposite shoulder.

Bring the lower end of the

bandage up diagonally

across his back, to meet the

other end at his shoulder.

Place the bandage over his

body, with one end over the

shoulder on the uninjured side.

Hold the point of the bandage

just beyond his elbow.

Tie the ends in a reef knot

(p.250) at the hollow above

the bone. Tuck the ends under

the knot to pad it.

Ask the casualty to let go

of his injured arm while

you tuck the base of the

bandage under his hand,

forearm and elbow.

Twist the point until the

bandage fits closely around

the casualty’s elbow (inset). Tuck

the point in just above his elbow

to secure it. If you have a safety

pin, fold the fabric over the

elbow and fasten the point at

the corner. Check the circulation

in the thumb every ten minutes

(p.243); loosen and reapply

if necessary.

1

4

2

5

3

6

253

ELEVATION SLING | IMPROVISED SLINGS

IMPROVISED SLINGS

If you suspect that the forearm

is broken, use a cloth sling or

a jacket corner to provide

support. Do not use any other

improvised sling: it will not

provide enough support.

If you need to support a casualty’s injured arm but do not have

a triangular bandage available, you can make a sling by using a

square metre (just over one square yard) of any strong cloth

(p.249). You can also improvise by using an item of the casualty’s

clothing (below). Check circulation after applying support (p.243)

and recheck every ten minutes.

CAUTION

Jacket corner

Undo the casualty’s

jacket. Fold the lower

edge on the injured side

up over his arm. Secure

the corner of the hem to

the jacket breast with a

large safety pin. Tuck and

pin the excess material

closely around the elbow.

Button-up jacket

Undo one button of

a jacket or coat (or

waistcoat). Place the

hand of the injured arm

inside the garment at

the gap formed by the

unfastened button.

Advise the casualty to rest

his wrist on the button

just beneath the gap.

Belt or thin garment

Use a belt, a tie or a pair

of braces or tights to

make a “collar-and-cuff”

support. Fasten the item

to form a loop. Place it

over the casualty’s head,

then twist it once to form

a smaller loop at the

front. Place the casualty’s

hand into the loop.

Long-sleeved shirt

Place the injured arm

across the casualty’s

chest. Pin the cuff of the

sleeve to the breast of

the shirt. To improvise an

elevation sling (opposite),

pin the sleeve at the

casualty’s opposite

shoulder, to keep her

arm raised.

This chapter is designed as a userfriendly

quick-reference guide to

first aid treatment for casualties with

serious illnesses or injuries. It begins

with an action plan to help you assess a

casualty and identify first aid priorities,

using the primary survey (pp.44–45)

followed by the secondary survey

(pp.46–48) where appropriate.

The chapter goes on to show how to

treat unresponsive casualties, whose care

always takes priority over that of less

seriously injured casualties. In addition,

there is step-by-step essential first aid for

potentially life-threatening illnesses and

injuries that benefit from immediate first

aid. These include asthma, stroke, severe

bleeding, shock, heart attack, burns, broken

bones and spinal injuries. Each condition is

described in more detail in the main part of

the book and cross-referenced here so that

the entry can easily be found if you need

further advice and background information.

■■ To protect yourself from danger and make the

area safe

■■ To assess the situation quickly and calmly and

summon appropriate help

■■ To assist casualties and provide necessary treatment

with the help of bystanders

■■ To call 999/112 for emergency help if you suspect

a serious illness or injury

■■ To be aware of your own needs

AIMS AND OBJECTIVES

EMERGENCY

FIRST AID

256

EMERGENCY FIRST AID

ACTION IN AN EMERGENCY

UNRESPONSIVE

CASUALTY

Use the primary survey (pp.44–45) to identify

the most serious injury, and treat injuries in

order of priority. Once these are managed

carry out a secondary survey (pp.46–48).

AIRWAY

Is the casualty’s airway open

and clear?

Open the airway

Tilt the head and lift the chin

to open the airway.

BREATHING

Is the casualty

breathing normally?

Check breathing

Look along the chest,

and listen and feel

for breaths.

CIRCULATION

Check for and treat life-threatening conditions, such

as severe bleeding.

Call 999/112 for emergency help.

Maintain an open airway. Place the casualty on

his side in the recovery position.

DANGER

Make sure the area is safe before you

approach. Is anyone in danger?

RESPONSE

Is the casualty responding?

Try to initiate a response by asking

questions and gently shaking his

shoulders.

Is there a response?

CPR/CIRCULATION

Ask someone to call 999/112 for

emergency help and bring an AED

if possible. Begin cardiopulmonary

resuscitation/CPR (adult p.258,

child p.260, infant p.260).

Are you on your own?

CPR/CIRCULATION

If the casualty is a child or infant, give

FIVE initial rescue breaths and

cardiopulmonary resuscitation/CPR for

one minute (child p.260, infant p.260).

Call 999/112 for emergency help, then

continue CPR. Take a child or infant to

the phone if necessary.

If the casualty is an adult, call 999/112

for emergency help first, then begin

CPR (p.258).

Do not leave any casualty (adult or child)

alone to search for an AED.

START

CHEST-COMPRESSION-ONLY CPR

If you have not had training in CPR or

you are unwilling or unable to give

rescue breaths you can give chest

compressions only. The emergency

services will give instructions for

chest-compression-only CPR.

NO

NO

NO

NO

YES

YES

YES

YES

257

ACTION IN AN EMERGENCY

Anaphylactic shock p.268

Asthma p.268

Broken bones p.274

Burns and scalds p.274

Choking adult p.264

Choking child p.264

Choking infant p.266

Head injury p.272

Heart attack p.262

Hypoglycaemia p.278

Meningitis p.266

Seizures in adults p.276

Seizures in children p.276

Severe external bleeding p.270

Shock p.270

Spinal injury p.272

Stroke p.262

Swallowed poisons p.278

RESPONSIVE

CASUALTY

If it is not safe, do not approach.

Call 999/112 for emergency help.

AIRWAY AND

BREATHING

If a person is alert and

talking to you, it follows

that her airway is open

and clear and she is

breathing. Her breathing

may be fast, slow, easy

or difficult. Assess and

treat any problem found.

CIRCULATION

Are there life-threatening conditions, such as

severe bleeding or heart attack?

CARRY OUT A SECONDARY SURVEY

Assess the level of response using the AVPU scale (p.52) and

carry out a head-to-toe survey to check for signs of illness or injury.

Call for appropriate help. Call 999/112 for emergency help if you suspect

serious injury or illness. Monitor and record a casualty's vital signs – breathing,

pulse and level of response (pp.52–53) – while waiting for help to arrive.

TREAT LIFE-THREATENING

INJURIES OR ILLNESSES

Call 999/112 for emergency help.

Monitor and record a casualty's vital

signs – breathing, pulse and level of

response (pp.52–53) – while waiting for

help to arrive.

A–Z OF EMERGENCIES

NO

YES

258

EMERGENCY FIRST AID

CPR FOR AN ADULT

CHEST-COMPRESSION-ONLY CPR

Place one hand on the centre

of the casualty’s chest. Place the

heel of your other hand on top of

the first and interlock your fingers,

but keep your fingers off the

casualty’s ribs.

Check for a response. Gently

shake the casualty’s shoulders,

and talk to him. If there is no

response, go to the next step.

Lean directly over the casualty’s

chest and press down vertically

about 5–6cm (2–2½in). Release

the pressure, but do not remove

your hands. Give 30 compressions

at a rate of 100–120 per minute.

Open the casualty’s airway. Place

one hand on the forehead and

gently tilt the head – the mouth

should fall open. Place the

fingertips of your other hand on

the chin and lift it.

Tilt the casualty’s head with one

hand and lift the chin with two

fingers of your other hand. Pinch

the nostrils closed, and allow his

mouth to fall open. Take a breath,

seal your lips over the casualty’s

mouth, and blow steadily until the

chest rises.

Check breathing: put your ear as

near to the casualty’s mouth and

nose as you can and look along his

chest. Look, listen and feel for

breathing for no more than

10 seconds. If he is not breathing

call 999/112 for emergency help,

then begin chest compressions.

POSITION HANDS

ON CHEST

CHECK FOR

RESPONSE

GIVE 30 CHEST

COMPRESSIONS

OPEN THE

AIRWAY

OPEN AIRWAY,

BEGIN RESCUE

BREATHS

CHECK

BREATHING

3

3

2

2

1

1

259

■■ If you have not had training in

CPR, or you are unwilling or

unable to give rescue breaths

you can give chest compressions

only, see below. The emergency

services will give instructions for

chest-compression-only CPR.

■■ If the casualty vomits during

CPR, roll him away from you

onto his side, with his head

turned towards the floor to

allow vomit to drain. Clear his

mouth, then immediately roll

him onto his back again and

restart CPR.

■■ If there is more than one

rescuer, change over every

1–2 minutes, with minimal

interruption to CPR.

■■ Ask a helper to fetch an AED.

■■ Chest-compression-only CPR is

given only if you have not had

training in CPR, or you are

unwilling or unable to give

rescue breaths. The emergency

services will give instructions for

chest-compression-only CPR.

■■ If the casualty vomits during

CPR, roll him away from you

onto his side, ensuring that his

head is turned towards the floor

to allow vomit to drain. Clear his

mouth, then immediately roll

him onto his back again and

restart chest compressions.

■■ If there is more than one

rescuer, change over every

1–2 minutes, with minimal

interruption to chest

compressions.

■■ Ask a helper to fetch an AED.

Maintaining the open airway,

take your mouth away from the

casualty’s. Look along the chest

and watch it fall. Repeat to give

TWO rescue breaths; each full

breath should take one second.

Repeat 30 chest compressions

followed by TWO rescue breaths.

Kneel level with the casualty's

chest. Place one hand on the

centre of the chest. Put the heel

of your other hand on top of the

first and interlock your fingers.

Press down on his breastbone, to

depress the chest 5–6cm (2–2½in),

then release the pressure.

Continue CPR (30:2) until:

emergency help arrives; the

casualty shows signs of becoming

responsive – such as coughing,

opening his eyes, speaking or

moving purposefully – and starts

breathing normally; or you are too

exhausted to continue.

Give compressions at a rate of

100–120 per minute until: help

arrives; the casualty shows signs of

becoming responsive (coughing,

opening his eyes, speaking or

moving purposefully) and starts

breathing normally; or you are too

exhausted to continue.

WATCH CHEST

FALL

BEGIN CHEST

COMPRESSIONS

CONTINUE CPR

CONTINUE CHEST

COMPRESSIONS

FIND OUT MORE pp.66–69

FIND OUT MORE pp.70–71

5

5

4

4

CAUTION

CAUTION

CPR FOR AN ADULT | CHEST-COMPRESSION-ONLY CPR

260

EMERGENCY FIRST AID

CPR FOR A CHILD ONE YEAR TO PUBERTY

CPR FOR AN INFANT UNDER ONE YEAR

Tilt the child’s head with one hand

and lift the chin with two fingers

of the other hand to ensure the

airway is open.

Place the infant on a firm surface

or on the floor. Gently tilt the

head with one hand and lift the

chin with one finger of the other

hand to ensure the airway is open.

Pinch the nose to close the

nostrils. Allow the mouth to fall

open. Take a breath and seal your

lips over the child’s mouth. Blow

steadily until the chest rises, then

watch it fall; a rescue breath

should take one second. Give

FIVE rescue breaths.

Take a breath and place your lips

over the infant’s mouth and nose.

Blow gently and steadily into the

mouth and nose until the chest

rises, then watch it fall. Each full

breath should take about one

second. Give FIVE rescue breaths.

Place the heel of one hand on the

centre of the chest. Lean directly

over the child’s chest and press

down to at least one third of its

depth, then release the pressure,

but do not remove your hand.

Give 30 compressions at a rate

of 100–120 per minute.

Place the tips of your index and

middle finger on the centre of

the chest. Lean over the infant’s

chest and press down vertically

to at least one third of its depth.

Release the pressure but not your

fingers. Give 30 compressions at a

rate of 100–120 per minute.

CHECK THAT

AIRWAY IS OPEN

CHECK THAT

AIRWAY IS OPEN

GIVE FIVE INITIAL

RESCUE BREATHS

GIVE FIVE INITIAL

RESCUE BREATHS

GIVE 30 CHEST

COMPRESSIONS

GIVE 30 CHEST

COMPRESSIONS

3

3

2

2

1

1

261

■■ If you have not had training in

CPR, or you are unwilling or

unable to give rescue breaths

you can give chest compressions

only. The emergency services

will give instructions for chestcompression-

only CPR.

■■ If the child vomits, roll her away

from you onto her side, with her

head turned towards the floor

to allow vomit to drain. Clear

her mouth, then immediately

roll her onto her back again and

restart CPR.

■■ If there is more than one

rescuer, change over every

1–2 minutes, with minimal

interruption to CPR.

■■ Ask a helper to fetch an AED,

ideally with paediatric pads.

■■ If you have not had training in

CPR or you are unwilling or

unable to give rescue breaths

you can give chest compressions

only. The emergency services

will give instructions for chestcompression-

only CPR.

■■ If the infant vomits during CPR,

roll her away from you onto her

side, with her head turned

towards the floor to allow vomit

to drain. Clear her mouth, roll

her onto her back again

immediately and restart CPR.

■■ If there is more than one

rescuer, change over every

1–2 minutes, with minimal

interruption to CPR.

■■ Do not use AED on an infant.

Return to the head and give TWO

rescue breaths. Repeat 30 chest

compressions followed by TWO

rescue breaths (30:2) for one

minute. Call 999/112 for

emergency help if this has not

already been done. Take the child

to the phone with you if necessary.

Return to the head and give

TWO more rescue breaths. Repeat

30 chest compressions followed

by TWO rescue breaths (30:2) for

one minute. Call 999/112 for

emergency help if this has not

already been done. Take the infant

to the phone if necessary.

Continue CPR (30:2) until:

emergency help arrives; the child

shows signs of becoming

responsive – such as coughing,

opening her eyes, speaking or

moving purposefully – and starts

breathing normally; or you are too

exhausted to continue.

Continue CPR (30:2) until:

emergency help arrives; the infant

shows signs of becoming

responsive – such as coughing,

opening her eyes, speaking or

moving purposefully – and starts

breathing normally; or you are

too exhausted to continue.

GIVE TWO

RESCUE BREATHS

GIVE TWO

RESCUE BREATHS

CONTINUE CPR

CONTINUE CPR

FIND OUT MORE pp.76–79

FIND OUT MORE pp.82–83

5

5

4

4

CAUTION

CAUTION

CPR FOR A CHILD | CPR FOR AN INFANT

262

EMERGENCY FIRST AID

HEART ATTACK

STROKE

Call 999/112 for emergency help.

Tell ambulance control that you

suspect a heart attack.

Keep the casualty comfortable.

Ask him to smile. If he has had a

stroke, he may only be able to

smile on one side – the other side

of his face may droop.

Help the casualty into a

comfortable position; a half-sitting

position is often best. Support his

head and shoulders and place

cushions under his knees.

Reassure the casualty.

Ask the casualty to raise his arms.

If he has had a stroke, he may only

be able to lift one arm.

CALL FOR

EMERGENCY HELP

CHECK

CASUALTY'S

FACE

MAKE CASUALTY

COMFORTABLE

CHECK

CASUALTY'S

ARMS

2

2

1

1

There may be:

■■ Vice-like chest pain, spreading to one

or both arms or jaw that does not

ease with rest

■■ Breathlessness

■■ Discomfort, like indigestion, in upper

abdomen

■■ Collapse, with no warning

■■ Sudden dizziness or faintness

■■ Casualty may have sense of

impending doom

■■ “Ashen” skin and blueness of lips

■■ Rapid, weak or irregular pulse

■■ Profuse sweating

■■ Extreme gasping for air (air hunger)

Use the FAST (Face – Arms –

Speech – Time) guide (p.212) to

assess the casualty.

■■ Facial weakness – casualty is unable

to smile evenly

■■ Arm weakness – casualty may only

be able to move his arm on one side

of his body

■■ Speech problems

There may also be:

■■ Sudden weakness or numbness

along one side or both sides of body

■■ Sudden blurring or loss of vision

■■ Sudden difficulty understanding the

spoken word

■■ Sudden confusion

■■ Sudden severe headache with no

apparent cause

■■ Dizziness, unsteadiness or a

sudden fall

RECOGNITION

RECOGNITION

263

■■ Be aware of the possibility of

collapse without warning.

■■ Do not give the casualty aspirin

if you know that he is allergic

to it, or if he is under 16 years

of age.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–59).

■■ Do not give the casualty

anything to eat or drink; he

will probably find it difficult

to swallow.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–59).

Assist the casualty to take one

full dose aspirin tablet (300mg

in total); advise him to chew it

slowly. If the casualty has tablets

or a spray for angina, allow him to

take it. Help him if necessary.

Ask the casualty some questions.

Can he speak and/or understand

what you are saying?

Encourage the casualty to rest.

Keep any bystanders away.

Monitor and record the casualty’s

vital signs – breathing, pulse and

level of response – while waiting

for help to arrive.

Call 999/112 for emergency help.

Tell ambulance control that you

suspect a stroke. Reassure the

casualty and monitor and record

his vital signs – breathing, pulse

and level of response – while

waiting for help to arrive.

GIVE CASUALTY

MEDICATION

CHECK

CASUALTY'S

SPEECH

MONITOR

CASUALTY

CALL FOR

EMERGENCY

HELP

FIND OUT MORE p.211

FIND OUT MORE pp.212–13

4

4

3

3

CAUTION

CAUTION

HEART ATTACK | STROKE

264

EMERGENCY FIRST AID

CHOKING ADULT

CHOKING CHILD ONE YEAR TO PUBERTY

If the casualty is breathing,

encourage her to cough to try to

remove the obstruction herself.

If this fails, go to step 2.

If the child is breathing,

encourage her to cough to try to

remove the obstruction herself. If

this fails, go to step 2.

If the casualty cannot speak,

cough or breathe, bend her

forward. Give up to five sharp

blows between the shoulder

blades with the heel of your hand.

Check her mouth. If choking

persists, proceed to step 3.

If the child cannot speak, cough

or breathe, bend her forward.

Give up to five sharp blows

between the shoulder blades with

the heel of your hand. Check her

mouth. If choking persists,

proceed to step 3.

ENCOURAGE

CASUALTY TO

COUGH

ENCOURAGE

CHILD TO COUGH

GIVE UP TO FIVE

BACK BLOWS

GIVE UP TO FIVE

BACK BLOWS

2

2

1

1

Ask the casualty: “Are you

choking?”

For mild obstruction:

■■ Difficulty in speaking, coughing and

breathing

For severe obstruction:

■■ Inability to speak, cough or breathe

■■ Eventually casualty will become

unresponsive

Ask the child: “Are you choking?”

For mild obstruction:

■■ Difficulty in speaking, coughing and

breathing

For severe obstruction:

■■ Inability to speak, cough or breathe

■■ Eventually child will become

unresponsive

RECOGNITION

RECOGNITION

265

Stand behind the casualty. Put

both arms around her, and put one

fist between her navel and the

bottom of her breastbone. Grasp

your fist with your other hand, and

pull sharply inwards and upwards

up to five times. Recheck the

casualty’s mouth.

Stand behind the child. Put both

your arms around her, and put

one fist between her navel and

the bottom of her breastbone.

Grasp your fist with your other

hand, and pull sharply inwards and

upwards up to five times. Recheck

the child’s mouth.

If the obstruction has not cleared,

call 999/112 for emergency help.

Repeat steps 2 and 3 – rechecking

the mouth after each step – until

emergency help arrives, the

obstruction is cleared or the

casualty becomes unresponsive.

If the obstruction has not cleared,

call 999/112 for emergency help.

Repeat steps 2 and 3 – rechecking

the mouth after each step – until

emergency help arrives, the

obstruction is cleared or the child

becomes unresponsive.

GIVE UP TO FIVE

ABDOMINAL

THRUSTS

GIVE UP TO FIVE

ABDOMINAL

THRUSTS

CALL FOR

EMERGENCY HELP

THEN CONTINUE

CALL FOR

EMERGENCY HELP

THEN CONTINUE

FIND OUT MORE p.94

FIND OUT MORE p.95

4

4

3

3

CHOKING ADULT | CHOKING CHILD

■■ Do not do a finger sweep when

checking the mouth.

■■ If the child becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.260–61).

■■ Do not do a finger sweep when

checking the mouth.

■■ If the casualty becomes

unresponsive, open the

airway and check breathing

(p.256). Be prepared to give

CPR (pp.258–59).

CAUTION

CAUTION

266

EMERGENCY FIRST AID

CHOKING INFANT UNDER ONE YEAR

MENINGITIS

If the infant is unable to cough or

breathe, lay her face down along

your forearm and thigh, and

support her head. Give up to five

back blows between the shoulder

blades with the heel of your hand.

If you notice any signs of

meningitis, such as the casualty

shielding her eyes from light or

a stiff neck, seek urgent medical

advice.

Turn the infant over so that she is

face up along your other leg and

check her mouth. Check the

mouth – do not sweep the mouth

with your finger. Pick out any

obvious obstructions. If choking

persists, proceed to step 3.

Keep the casualty cool and give

plenty of water to replace fluids

lost through sweating. An adult

may take the recommended dose

of paracetamol tablets; a child

may have the recommended dose

of paracetamol syrup.

GIVE UP TO FIVE

BACK BLOWS

SEEK MEDICAL

ADVICE

CHECK INFANT’S

MOUTH

TREAT FEVER

2

2

1

1

Mild obstruction:

■■ Able to cough but difficulty in

breathing or making any noise

Severe obstruction:

■■ Inability to cough, make any noise

or breathe

■■ Eventually infant will become

unresponsive

Some, but not all, of these signs

and symptoms may be present:

■■ Flu-like illness with a high

temperature

■■ Cold hands and feet

■■ Joint and/or limb pain

■■Mottled or very pale skin

As infection develops:

■■ Severe headache

■■ Neck stiffness

■■ Eyes become sensitive to light

■■ Drowsiness

■■ A distinctive rash of red or purple

spots that look like bruises and do

not fade when pressed

■■ In infants, a high-pitched moaning or

whimpering cry, floppiness and a

tense or bulging fontanelle (soft part

of the skull)

RECOGNITION

RECOGNITION

267

With the infant lying on your leg,

place two fingertips on the lower

half of her breastbone, a finger’s

breadth below the nipples. Give

up to five sharp downward thrusts,

similar to chest compressions

(p.260), but sharper and slower.

Recheck the infant’s mouth.

If the obstruction is still not clear,

call 999/112 for emergency help.

Take the infant with you to make

the call if necessary. Repeat steps

1 to 3 until emergency help arrives,

the obstruction is cleared or the

infant becomes unresponsive (see

caution, above right).

Call 999/112 for emergency help

if you see signs of the rash, or if

medical help is delayed. Reassure

the casualty. Keep her cool and

monitor her vital signs –

breathing, pulse and level of

response – until help arrives.

Check the casualty for signs

of the meningitis rash: press

against the rash with the side of a

glass. Most rashes will fade when

pressed; if you can still see the

rash through the glass, it is

possibly meningitis.

GIVE UP TO FIVE

CHEST THRUSTS

CHECK FOR SIGNS

OF A RASH

CALL FOR

EMERGENCY HELP

THEN CONTINUE

CALL FOR

EMERGENCY

HELP

FIND OUT MORE p.96

FIND OUT MORE p.220

4

4

3

3

CHOKING INFANT | MENINGITIS

■■ Do not do a finger sweep when

checking the mouth.

■■ Do not use abdominal thrusts on

an infant.

■■ If the infant becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.260–61).

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

CAUTION

CAUTION

268

EMERGENCY FIRST AID

ASTHMA

ANAPHYLACTIC SHOCK

Keep calm and reassure the

casualty. Help her to find her

reliever inhaler (it is usually blue)

and take her usual dose; use a

spacer device if she has one. The

reliever inhaler should take effect

within minutes.

Call 999/112 for emergency help.

Ideally, ask someone to make the

call while you treat the casualty.

Tell ambulance control that you

suspect anaphylaxis.

Help the casualty into a

comfortable position. Tell her to

breathe slowly and deeply. A mild

attack should ease within a few

minutes. If it does not ease, the

casualty may take one to two

puffs from her inhaler every two

minutes, up to ten puffs.

If she has an adrenaline autoinjector,

help her to use it. If you

are trained, give it to her. Hold the

injector in your fist, pull off the

safety cap and push the tip against

her thigh until it clicks. Hold it

for ten seconds, remove it and

massage the site for ten seconds.

HELP CASUALTY

USE INHALER

CALL FOR

EMERGENCY

HELP

ENCOURAGE

SLOW BREATHS

HELP CASUALTY

WITH

MEDICATION

2

2

1

1

■■ Difficulty in breathing

■■Wheezing

■■ Coughing

■■ Distress and anxiety

■■ Difficulty in speaking

■■ Grey-blue colouring in skin, lips,

earlobes and nailbeds

In a severe attack:

■■ Exhaustion and casualty may

become unresponsive

■■ Anxiety

■■ Red, blotchy skin, itchy rash and red,

itchy, watery eyes

■■ Swelling of hands, feet and face

■■ Puffiness around the eyes;

■■ Abdominal pain, vomiting and

diarrhoea

■■ Difficulty breathing, ranging from

tight chest to severe difficulty, which

causes wheezing and gasping for air

■■ Swelling of tongue and throat

■■ A feeling of terror

■■ Confusion and agitation

■■ Signs of shock (p.270) leading to

casualty becoming unresponsive

RECOGNITION

RECOGNITION

269

Call 999/112 for emergency help

if the attack is severe and one of

the following occurs: the inhaler

has no effect; breathlessness

makes talking difficult; the

casualty is becoming exhausted.

Reassure the casualty and help

her to sit in a position that eases

any breathing difficulties. If she

becomes very pale with a weak

pulse, lay her down with legs

raised as for shock (pp.270–71).

Monitor and record the casualty’s

vital signs – breathing, pulse and

level of response – until she

recovers or help arrives. Help her

to reuse her inhaler as required.

Advise the casualty to seek

medical advice if she is concerned

about the attack.

Monitor and record vital signs –

breathing, pulse and level of

response – while waiting for help

to arrive. Repeat the adrenaline

dose every five minutes if there is

no improvement or the casualty’s

symptoms return.

CALL FOR

EMERGENCY HELP

MAKE CASUALTY

COMFORTABLE

MONITOR

CASUALTY

MONITOR

CASUALTY

FIND OUT MORE p.102

FIND OUT MORE p.223

4

4

3

3

ASTHMA | ANAPHYLACTIC SHOCK

■■ Do not leave the casualty alone

since the attack may quickly

worsen.

■■ If this is a first attack and she

has no medication, call 999/112

for emergency help

immediately.

■■ If the attack worsens, the

casualty may become

unresponsive. If this happens

open the airway and check

breathing (p.256). Be prepared

to begin CPR (pp.258–61).

■■ An adrenaline autoinjector can

be delivered through clothing.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

■■ If a pregnant casualty needs to

lie down, lean her towards her

left side to prevent the pregnant

uterus restricting blood flow

back to the heart.

CAUTION

CAUTION

270

EMERGENCY FIRST AID

SEVERE EXTERNAL BLEEDING

SHOCK

Apply direct pressure over the

wound with your fingers or the

palm of your hand using a sterile

dressing or clean, non-fluffy pad. If

you do not have a dressing, ask

the casualty to apply direct

pressure himself. Remove or cut

any clothing if necessary.

Press either side of the embedded

object to control bleeding. Do

not press directly on the object

and do not make any attempt to

remove it.

Treat any cause of shock, such as

bleeding (above) or burns

(pp.274–75). Help the casualty to

lie down, ideally on a blanket.

Raise and support his legs above

the level of his heart.

Call 999/112 for emergency help

– ideally ask a helper to to do this.

Give the ambulance control

details of the injury and extent

of the bleeding.

Call 999/112 for emergency help

– ideally ask a helper to do this.

Tell ambulance control that you

suspect shock.

APPLY DIRECT

PRESSURE TO

WOUND

IF THERE IS AN

OBJECT IN THE

WOUND

HELP CASUALTY

TO LIE DOWN

CALL FOR

EMERGENCY

HELP

CALL FOR

EMERGENCY

HELP

3

2

2

1

1

■■ Rapid pulse

■■ Pale, cold, clammy skin

■■ Sweating

As shock develops:

■■ Rapid, shallow breathing

■■Weak, “thready” pulse

■■ Grey-blue skin, especially inside lips

■■Weakness and giddiness

■■ Nausea and vomiting

■■ Thirst

As the brain’s oxygen supply

weakens:

■■ Restlessness and aggressive

behaviour

■■ Gasping for air

■■ Casualty will become unresponsive

RECOGNITION

271

Monitor and record vital signs –

breathing, pulse and level of

response – while waiting for

emergency help to arrive.

Loosen any tight clothing to

reduce constriction at the neck,

chest and waist.

Secure a pad over the wound with

a bandage. Check the circulation

beyond the bandage every ten

minutes. Loosen and reapply the

bandage if necessary. Treat

casualty for shock, see below.

Cover the casualty with a blanket

to keep him warm. Advise the

casualty not to move. Monitor

and record vital signs – breathing,

pulse and level of response – while

waiting for help to arrive.

MONITOR

CASUALTY

LOOSEN TIGHT

CLOTHING

APPLY BANDAGE

AND TREAT

FOR SHOCK

KEEP CASUALTY

WARM

FIND OUT MORE pp.114–115

FIND OUT MORE pp.112–13

4

4

5

3

SEVERE EXTERNAL BLEEDING | SHOCK

■■ Do not apply a tourniquet.

■■ If there is an object in the

wound, apply pressure on either

side of the wound to control

bleeding.

■■ If blood seeps through the

bandage, place another pad on

top. If blood seeps through the

second pad, remove all dressings

and apply a fresh one, ensuring

that it exerts pressure on the

bleeding area.

■■ Do not give the casualty

anything to eat or drink as an

anaesthetic may be needed.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

■■ Do not give the casualty

anything to eat or drink because

an anaesthetic may be needed.

■■ Do not leave the casualty

unattended, unless you have to

call for emergency help.

■■ Do not let the casualty move.

■■ Do not try to warm the casualty

with a hot-water bottle or any

other form of direct heat.

■■ If the casualty is in the late

stages of pregnancy, lean her

towards her left side so the

pregnant uterus does not

restrict blood flow to the heart.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

CAUTION

CAUTION

272

EMERGENCY FIRST AID

HEAD INJURY

SPINAL INJURY

Replace any displaced skin flaps

over the wound. Put a sterile

dressing or a clean, non-fluffy pad

over the wound. Apply firm, direct

pressure with your hand to control

the bleeding.

Sit or kneel behind the casualty’s

head and, resting your arms on

the ground. Grasp either side of

the casualty’s head and hold it

still. Do not cover her ears.

Secure the dressing over the

wound with a roller bandage to

help maintain direct pressure on

the injury.

Tell the casualty not to move. Call

999/112 for emergency help. If

possible, ask a helper to make the

call while you support the head

and neck. Tell ambulance control

that a spinal injury is suspected.

APPLY DIRECT

PRESSURE TO ANY

WOUND

STEADY AND

SUPPORT HEAD

SECURE

DRESSING WITH

BANDAGE

CALL FOR

EMERGENCY

HELP 1

1 2

2

■■ Can occur after a fall from a height

onto the back, head or feet

There may be:

■■ Pain in neck or back

■■ Step, irregularity or twist in the

normal curve of the spine

■■ Tenderness in the skin over the spine

■■Weakness or loss of movement in the

limbs

■■ Loss of sensation, or abnormal

sensation

■■ Loss of bladder and/or bowel control

■■ Difficulty breathing

There may be:

■■ Level of response may be impaired

for a brief period

■■ Possible scalp wound

■■ Dizziness and/or nausea

■■ Loss of memory of events at the time

of, or immediately before, the injury

■■Mild headache

■■ Confusion

For severe injury:

■■ History of severe blow to the head

■■ Deteriorating level of response

■■ Casualty may become unresponsive

■■ Leakage of blood or bloodstained

watery fluid from the ear or nose

■■ Unequal pupil size

RECOGNITION

RECOGNITION

273

Continue to hold her head. Ask

a helper to place rolled towels,

or other padding, on either side

of the casualty’s head for extra

support.

Help the casualty to lie down,

ideally on a blanket. Ensure that

his head and shoulders are slightly

raised. Make him as comfortable

as possible.

Monitor and record the casualty’s

vital signs – breathing, pulse and

level of response. Call 999/112 for

emergency help if there are any

signs of severe head injury.

Monitor and record the casualty’s

vital signs – breathing, pulse and

level of response – while waiting

for help to arrive.

PLACE EXTRA

SUPPORT

AROUND HEAD

HELP CASUALTY

TO LIE DOWN

MONITOR

CASUALTY

MONITOR

CASUALTY

FIND OUT MORE pp.144–45

FIND OUT MORE pp.157–59

4

4

3

3

HEAD INJURY | SPINAL INJURY

Seek medical advice if after the

injury you notice signs of

worsening head injury such as:

■■ Increasing drowsiness

■■ Persistent headache

■■ Confusion, dizziness, loss of

balance and/or loss of memory

■■ Difficulty speaking

■■ Difficulty walking

■■ Vomiting episodes

■■ Double vision

■■ Seizure

■■ Do not move the casualty unless

she is in danger.

■■ If the casualty is unresponsive,

open the airway by gently lifting

the jaw, but do not tilt the head,

then check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

■■ If you need to place the casualty

into the recovery position use

the log-roll technique (p.159).

CAUTION

CAUTION

274

EMERGENCY FIRST AID

BROKEN BONES

BURNS AND SCALDS

Help the casualty to support the

affected part at the joints above

and below the injury, in the most

comfortable position.

Immediately flood the injury

with cold water; cool for at least

ten minutes or until pain is

relieved. Make the casualty

comfortable by helping him to

sit or lie down and protect the

injured area from contact with

the ground.

Place padding, such as towels or

cushions, around the affected

part, and support it in a

comfortable position.

Call 999/112 for emergency help

if necessary. Tell ambulance

control that the injury is a burn

and explain what caused it, and

the estimated size and depth.

SUPPORT

INJURED PART

START TO COOL

BURN

PROTECT INJURY

WITH PADDING

CALL FOR

EMERGENCY

HELP

2

2

1

1

■■ Deformity, swelling and bruising

at the injury site

■■ Pain and difficulty in moving the

injured part

There may be:

■■ Bending, twisting or shortening of

a limb

■■ A wound, possibly with bone ends

protruding

There may be:

■■ Possible areas of superficial, partialthickness

and/or full-thickness burns

■■ Pain in the area of the burn

■■ Breathing difficulties if the airway

is affected

■■ Swelling and blistering of the skin

■■ Signs of shock

RECOGNITION

RECOGNITION

275

For extra support or if help is

delayed, secure the injured part to

an uninjured part of the body. For

upper body injuries, use a sling;

for lower limb injuries, use broadand

narrow-fold bandages. Tie

knots on the uninjured side.

While you are cooling the burn,

carefully remove any clothing or

jewellery from the area before it

starts to swell; a helper can do this

for you. Do not remove anything

that is sticking to the burn.

A casualty with an arm injury

could be taken by car if not in

shock; a leg injury should go by

ambulance, so call 999/112 for

emergency help. Treat for shock.

Monitor and record the casualty’s

breathing, pulse and level of

response while waiting for help.

When cooled cover the burn with

kitchen film placed lengthways

over the injury, or use a plastic

bag. Alternatively, use a sterile

dressing or clean, non-fluffy pad.

Monitor and record the casualty’s

vital signs while waiting for help

to arrive.

SUPPORT WITH

SLINGS OR

BANDAGES

REMOVE ANY

CONSTRICTIONS

TAKE OR SEND

CASUALTY TO

HOSPITAL

COVER BURN

FIND OUT MORE pp.136–38

FIND OUT MORE pp.174–75

4

4

3

3

BROKEN BONES | BURNS AND SCALDS

■■ Do not attempt to move an injured

limb unnecessarily, or if it causes

further pain.

■■ If there is an open wound, cover

it with a sterile dressing or a

clean, non-fluffy pad and bandage

it in place.

■■ Do not give the casualty anything

to eat or drink as an anaesthetic

may be needed.

■■ Do not raise a broken leg when

treating a casualty for shock.

■■ Do not apply lotions, ointment or

fat to a burn; specialised burn

dressings are also not

recommended.

■■ Do not use adhesive dressings.

■■ Do not touch the burn or burst

any blisters.

■■ If the burn is severe, treat the

casualty for shock (pp.270–71).

■■ If the burn is on the face, do not

cover it. Keep cooling with water

until help arrives.

■■ If the burn is caused by contact

with chemicals, wear protective

gloves and cool for at least

20 minutes.

■■Watch the casualty for signs of

smoke inhalation, such as difficulty

breathing.

CAUTION

CAUTION

276

EMERGENCY FIRST AID

SEIZURES IN ADULTS

SEIZURES IN CHILDREN

Try to ease the casualty’s fall. Talk

to him calmly and reassuringly.

Clear away any potentially

dangerous objects to prevent

injury to the casualty. Ask

bystanders to keep clear. Make a

note of when the seizure began.

Clear away any nearby objects

and surround the child with soft

padding, such as pillows or rolled

towels, so that even violent

movement will not result in injury.

If possible, cushion the casualty’s

head with soft material until the

seizure ceases. Place padding

around him to protect him from

objects that cannot be moved.

Loosen any tight clothing around

the casualty’s neck.

Remove bedding and clothing,

such as a vest or pyjama top; you

may have to wait until the seizure

stops to do this. Ensure a good

supply of cool air, but do not let

the child become too cold.

PROTECT

CASUALTY

PROTECT CHILD

FROM INJURY

PROTECT HEAD

AND LOOSEN

TIGHT CLOTHING

HELP THE CHILD

COOL DOWN

2

2

1

1

Seizures often follow a pattern:

■■ Sudden loss of responsiveness

■■ Rigidity and arching of the back

■■ Breathing may be noisy and become

become difficult. The lips may show

a grey-blue tinge (cyanosis)

■■ Convulsive movements begin

■■ Saliva (bloodstained if he has bitten

his lip or tongue) may appear at

the mouth

■■ Possible loss of bladder or bowel

control

■■Muscles relax and breathing

becomes normal again

■■ After the seizure the casualty

may be dazed and unaware of

what has happened

■■ Casualty may fall into a deep sleep

■■ Loss of or impaired response

■■ Vigorous shaking with clenched fists

and arched back

There may also be:

■■ Signs of fever, such as hot, flushed

skin

■■ A twitching face and squinting, fixed

or upturned eyes

■■ Breath-holding, with red, puffy face

and neck

■■ Drooling at the mouth

■■ Possible vomiting

■■ Loss of bladder or bowel control

RECOGNITION

RECOGNITION

277

Once the seizure has stopped the

casualty may fall into a deep sleep.

Open the casualty's airway and

check breathing (p.256). If he is

breathing, place him in the

recovery position.

Once the seizure has stopped,

open the airway and check

breathing (p.256). If the child

is breathing, place him in the

recovery position.

Monitor and record vital signs –

breathing, pulse and level of

response – until he recovers. Note

the duration of the seizure.

Call 999/112 for emergency help.

Reassure the parents or carer, if

necessary. Monitor and record

the child’s vital signs – breathing,

pulse, level of response and

temperature – while waiting for

help to arrive.

PLACE CASUALTY

IN RECOVERY

POSITION

PLACE CHILD IN

RECOVERY

POSITION

MONITOR

CASUALTY'S

RECOVERY

CALL FOR

EMERGENCY

HELP

FIND OUT MORE pp.216–17

FIND OUT MORE p.218

4

4

3

3

SEIZURES IN ADULTS | SEIZURES IN CHILDREN

■■ Do not attempt to restrain the

casualty.

■■ Do not put anything in the

casualty's mouth during a

seizure.

Call 999/112 for emergency

help if the casualty:

■■ Is having repeated seizures

■■ Has a seizure that lasts more

than five minutes

■■ Is having his first seizure

■■ Remains unresponsive for more

than ten minutes after the

seizure has stopped

■■ Has sustained an injury

■■ Do not let the child get too cold.

■■ Do not sponge a child to cool

him as there is a risk of over

cooling.

■■ If the child becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.260–61).

CAUTION

CAUTION

278

EMERGENCY FIRST AID

SWALLOWED POISONS

HYPOGLYCAEMIA

Reassure the casualty. If she

is responsive, ask her what she has

swallowed and if possible how

much and when. Look for clues

such as poisonous leaves or

berries, containers or pill bottles.

Help the casualty to sit down. If

he has his own emergency sugar

remedy, help him to take it. If not

give him the equivalent of 15–20g

of glucose – a 150ml glass of fruit

juice or non-diet fizzy drink, three

teaspoons (or lumps) of sugar or

three sweets such as jelly babies.

Call 999/112 for emergency help.

Give ambulance control as much

information as possible. This will

help the medical team to give the

casualty the correct treatment.

If the casualty responds quickly,

give him more food or drink and

let him rest until he feels better.

Help him to find his glucose

testing kit so that he can check

his glucose levels.

IDENTIFY THE

POISON

GIVE CASUALTY

SUGAR

CALL FOR

EMERGENCY HELP

GIVE MORE

SUGARY FOOD

2

2

1

1

■■ A history of ingestion/exposure to

poison; evidence of poison nearby

Depending on what the casualty

has taken, there may be:

■■ Vomit that may be bloodstained, and

later diarrhoea

■■ Cramping abdominal pains

■■ Pain or burning sensation

■■ Empty containers near the casualty

■■ Impaired level of response

■■ Seizures

There may be:

■■ A history of diabetes – the casualty

may recognise the onset of a

hypoglycaemic (low blood sugar)

episode

■■Weakness, faintness or hunger

■■ Confusion and irrational behaviour

■■ Sweating with cold, clammy skin

■■ Rapid pulse

■■ Palpitations and muscle tremors

■■ Deteriorating level of response

■■ Diabetes medical warning bracelet

or necklace

■■ Emergency sugar remedy such as

glucose gel or sweets with the

person

■■ Glucose testing kit and medication

such as insulin pen or tablets

RECOGNITION

RECOGNITION

279

Monitor and record the casualty's

vital signs – breathing, pulse and

level of response – while waiting

for help to arrive. Keep samples of

vomited material and any other

clues and give them to the

ambulance crew.

Monitor and record the casualty’s

vital signs – breathing, pulse and

level of response – until he is fully

recovered.

If the casualty has swallowed a

substance that has burnt her lips,

give her frequent sips of cool milk

or water.

If the casualty’s condition

does not improve, look for other

causes of his condition. Call

999/112 for emergency help.

Continue to monitor his vital

signs – breathing, pulse and level

of response – while waiting for

help to arrive.

MONITOR

CASUALTY

MONITOR

CASUALTY

IF CASUALTY'S

LIPS ARE BURNT

CALL FOR

EMERGENCY HELP

FIND OUT MORE p.200

FIND OUT MORE p.215

4

4

3

3

SWALLOWED POISONS | HYPOGLYCAEMIA

■■ Do not attempt to induce

vomiting.

■■ If the casualty is contaminated

with chemicals, wear protective

equipment such as disposable

gloves, a mask and goggles.

■■ If the casualty becomes

unresponsive, make sure that

there is no vomit or other matter

in the mouth. Open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–60).

■■ If there are chemicals on the

casualty’s mouth, protect

yourself by using a face shield

or pocket mask when giving

rescue breaths.

■■ If the operson is not fully

responsive do not give him

anything to eat or drink.

■■ If the casualty becomes

unresponsive, open the airway

and check breathing (p.256).

Be prepared to begin CPR

(pp.258–61).

CAUTION

CAUTION

280

APPENDIX

FIRST AID REGULATIONS

First aid may be practised in any situation

where injuries or illnesses occur. In many

cases, the first person on the scene is a

volunteer who wants to help, rather than

someone who is medically trained. However,

in certain circumstances the provision of first

aid, and first aid responsibilities, is defined by

statutes. In the UK, these regulations apply to

incidents occurring in the workplace and at

mass gatherings.

FIRST AID AT WORK

The Health and Safety (First Aid) Regulations

1981 (as amended) place a duty on employers

to make first aid provision for employees. The

practical aspects of this statutory duty for

employers and for the self-employed are set

out in the Guidance on Regulations, which was

amended on 1 October 2013. In order to meet

their regulatory requirements, employers have

a responsibility to carry out an assessment of

their first aid needs based on hazards and risks

involved in their work, select a suitable training

provider and undertake due diligence on that

provider.

The Voluntary Aid Societies are cited in the

Guidance on Regulations as the standard setters

for currently accepted first aid at work. The

training provided by the Voluntary Aid Societies

meets the requirements of employers identified

in the needs assessment.

The Guidance on Regulations encourages all

employers to assess their organisation’s ability

to meet certain first aid standards. The number

of first aiders required in a specific workplace is

dependent on your needs assessment, which

should be carried out by your Health and Safety

Representative. The checklist opposite will

assist in determining the number and type of

first aid personnel required in a workplace.

Comprehensive advice can also be found at

www.hse.gov.uk/firstaid/

ACCIDENT BOOK

An employer has the overall responsibility for

an accident book, but it is the responsibility of

the first aider or appointed person to look after

and note details of incidents in the book.

If an employee is involved in an incident

in the workplace, the following details should

be recorded in the accident book:

■■ Date, time and place of incident

■■ Name and job of the injured or ill person

■■ Details of the injury/illness and what first aid

was given

■■ What happened to the person immediately

afterwards (for example, went home or taken

to hospital)

■■ Name and signature of the first aider

or person dealing with the incident

REPORTING OF INJURIES, DISEASES

AND DANGEROUS OCCURRENCES

In the event of injury or ill health at work, an

employer has a legal obligation to report the

incident. The Reporting of Injuries, Diseases

and Dangerous Occurrences Regulations

1995 (RIDDOR) requires an employer to

report the following:

■■Deaths

■■Major injuries

■■Injuries lasting more than seven days –

where an employee or self-employed person

is away from work or unable to perform their

normal work duties for more than seven

consecutive days

■■ Injuries to members of the public or people

not at work, where they are taken from the

scene of an accident to hospital

■■ Some work-related diseases

■■ Some dangerous occurrences such as a

near miss, where something happened that

although no injury occurred could have

resulted in an injury

281

FIRST AID REGULATIONS

FACTORS TO CONSIDER

Is your workplace low risk (for

example, shops, offices and

libraries)?

Is your workplace higher risk (for

example, light engineering and

assembly work, food processing,

warehousing, extensive work with

dangerous machinery or sharp

instruments, construction or

chemical manufacture). Do your

work activities involve special

hazards, such as hydrofluoric acid

or confined spaces?

Are there inexperienced workers on

site, or employees with disabilities

or special health problems?

What is your record of accidents

and ill health? What injuries and

illness have occurred and where?

Do you have employees who travel

a lot, work remotely or work alone?

Do any of your employees work

shifts or work out of hours?

Are the premises spread out; for

example, are there several buildings

on the site or multi-floor buildings?

Is your workplace remote from

emergency medical services?

Do any of your employees work at

sites occupied by other employers?

Do you have sufficient provision

to cover absences of first aiders

or appointed persons?

Do members of the public visit

your premises (for example,

schools, places of entertainment,

fairgrounds, shops)?

The minimum provision is: An appointed person to take charge of first aid

arrangements ■ A suitably stocked first aid box. As there is a possibility of an

accident or sudden illness consider providing a qualified first aider

First aider requirements: For fewer than 25 employees, one appointed

person ■ For 25–50 employees, at least one first aider trained in Emergency

First Aid at Work (EFAW) ■ For over 50 employees, one First Aid at Work

(FAW) trained first aider for every 100 employees (or part thereof)

Where there are large numbers of employees consider: Additional first aid

equipment ■ A first aid room

The minimum provision is: An appointed person to take charge of first aid

arrangements ■ A suitably stocked first aid box

First aider requirements: For fewer than five employees, one appointed

person; for 5–50 employees, at least one first aider trained in Emergency First

Aid at Work (EFAW) or First Aid at Work (FAW) dependng on the type of

injuries that could occur; for over 50 employees, at least one First Aid at Work

(FAW) trained first aider for every 50 employees (or part thereof)

Consider: Additional training for first aiders to deal with injuries resulting from

special hazards ■ Additional first aid equipment ■ Precise siting of first aid

equipment ■ Providing a first aid room ■ Informing the emergency services

if there are chemicals on site.

Consider: Additional training for first aiders ■ Additional first aid equipment

■ Local siting of first-aid equipment

Your first aid provision should cover any work-experience trainees

Ensure your first aid provision caters for the type of injury and illness that

might occur in your workplace. Monitor accidents and ill health and review

your first aid provision as appropriate

Consider: Personal first aid kits ■ Personal communicators or mobile phones

for remote or lone workers

Ensure there is adequate first aid provision at all times while people

are at work

Consider: First aid provision in each building or on each floor

Consider: Special arrangements with the emergency services ■ Informing the

emergency services of your location

Make arrangements with other site occupiers to ensure adequate provision of

first aid. A written agreement between employers is strongly recommended

Consider what cover is needed for: Annual leave and other planned absences

■ Unplanned and exceptional absences

Under the regulations, there is no legal obligation to provide first aid for

non-employees, but the Health and Safety Executive (HSE), strongly

recommends that you consider the members of the public when planning

your first aid provision

CHECKLIST FOR ASSESSMENT OF FIRST AID NEEDS

282

INDEX

INDEX

ABC check 45

Abdomen

examining for injury 51

pain 226

stitch 226

wound 128

Abrasions 20, 111

Absence seizures 216

Aches

abdominal pain 226

earache 225

headache 224

toothache 225

Adhesive dressings 235

applying 241

Adhesive tape 237

securing roller bandages 244

Adrenaline autoinjector 48

anaphylactic shock 223, 268–69

Afterbirth, delivery of 228, 229

Agonal breathing 59

Aids

HIV infection 16

human bites 203

Air travel, earache 225

Airway

breathing difficulties 88–105

burns 177

checking 44

croup 103

hanging and strangulation 97

inhalation of fumes 98–99

obstruction 92–95

opening 59

adults 63

children 73

infants 80

jaw thrust method 159

respiratory system 90–91

unresponsive casualty 93

Alcohol poisoning 202

Allergy 222

anaphylactic shock 223

asthma 102

Alveoli 56, 90

Ambulances, telephoning for

help 21–22

Amphetamines, overdose 201

Amputation 117

Anaesthetic, poisoning 201

Anaphylactic shock 223

emergency first aid 268–69

Angina pectoris 210

drugs 48

Animal bites 203

Ankles

bandaging 160

fractures 163

sprains 140–41

Anus, bleeding from 116

Approved Code of Practice

(ACOP) 280

Arms

bandaging 245

slings 251

examining for injury 50

immobilising 243

injuries 149–55

elbow 151

forearm and wrist 152

hand and fingers 153

upper arm 150

muscles 134

wounds

amputation 117

bleeding at elbow crease 127

fingers 126

Arteries

bleeding from 110

circulatory system 108

pulse 53

severe bleeding 114–15

Artificial ventilation

see Rescue breathing

Aspirin

heart attack and 211, 263

overdose 201

Assessing casualties 39–53, 256–57

examining casualty 49–51

primary survey 41, 44–45

secondary survey 41, 46–48

symptoms and signs 50–51

unresponsive casualties:

adults 62

children 72

infants 80

Assessing a situation 28

Asthma 102

emergency first aid 268–69

inhalers 48

Auto-injectors 48

using, 223, 268

Automated external defibrillators

(AED) 54, 57, 84–87

for children 87

Autonomic nerves 143

AVPU code, checking level of response

52, 144

B

Babies see Infants

Back injuries 157–59

emergency first aid 272–73

examining for 51

pain 156

recovery position 65, 75

treatment 158–59

Bacteria, food poisoning 199

Bandages 236, 242–49

checking circulation 243

choosing correct size 244

elbow and knee 246

first aid kit 236–37

general rules 242–43

hand and wrist 247

Bandages continued

immobilising limb 243

roller bandages 236, 244–47

triangular bandages 236, 249–52

tubular bandages 236, 248

Barbiturates, overdose 201

Bee stings 204

allergy to 222

Benzodiazepines, overdose 201

Biohazard bags 18

Birth 228–29

Bites and stings 190, 203–07

anaphylactic shock 223

animal bites 190, 203

human bites 190, 203

insect stings 190, 204–05

marine creatures 190, 207

rabies 203

snake bites 206

tetanus 203

ticks 205

Bleeding

bruising 119

checking for 49–51

childbirth 229

emergency first aid 270–71

from ear 123

from mouth 125

internal bleeding 116

miscarriage 228

nosebleeds 124

severe bleeding 114–15

shock 112–13

types of 110

types of wound 111

vaginal 128

varicose veins 129

see also Wounds

Blisters 120

burns 183

Blood

circulatory system 56, 88, 108–09

clotting 110

composition 109

see also Bleeding

Blood pressure 108

Body temperature 171

fever 219

frostbite 189

heat exhaustion 184

heatstroke 185

hypothermia 186–88

taking 53

Bones

joints 135

skeleton 132–33

structure 134

see also Fractures

Bracelets, medical warning 48

Brachial pulse 53

Brain

absence seizures 216

cerebral compression 144

concussion 144

A

283

INDEX

Brain continued

head injury 144–45

heatstroke 185

meningitis 220, 266–67

nervous system 142–43

oxygen deprivation 54, 59

seizures 216–17

skull fracture 144

stroke 212–13

see also Unresponsive casualty

Breathing

agonal 59

airway obstruction 93

asthma 102, 268–69

checking 44, 52

unresponsive adult 63

unresponsive child 73

unresponsive infant 81

circulatory system 56

croup 103

examining for injury 49, 50

fume inhalation 98–99

hyperventilation 101

opening airway 59

adults 63

children 73

infants 80

rescue breathing 59

adults 68–69

children 76–77

infants 82–83

respiratory system 91

Broad-fold bandages 249

Bruises 111

cold compresses 241

treatment 119

Bullet wounds 111

Burns 172–81

airway 177

assessing 172–73

chemical 179–80

depth 173

dressing 176

electrical 172, 178

emergency first aid 274–75

flash burns to eye 181

minor burns and scalds 176

severe burns and scalds 174–75

sunburn 183

swallowed poisons 200

Bystanders 29–31

C

Capillaries

bleeding 110

circulatory system 90, 108

Car accidents

see Traffic accidents

Carbon dioxide

hyperventilation 101

inhalation of 98

respiratory system 90

Carbon monoxide 33

inhalation of 98

Cardiac arrest 84

in water 36

Cardiopulmonary resuscitation

see CPR

Carotid pulse 53

Cartilage 135

Casualties

assessing 31, 39–53, 256–57

unresponsive 62, 70, 78

dealing with 19–21

examining 49–51

handling 234

monitoring vital signs 52–53

moving 234

multiple 31

passing on information 23

removing clothing 232

resisting help 20

unresponsive 54–87

see also Emergencies

Central nervous system 143

Cerebral compression 144

Cerebrospinal fluid 143

Cheekbone fractures 147

Chemicals

burns 172, 179–80

CS spray 181

Hazchem symbols 31

in eye 180, 199

inhaled gases 199

pepper spray 181

on skin 199

swallowed poisons 200

Chest, “flail-chest” injury 154

Chest compressions 57

adults 66–67, 70–71, 258–59

chest-compression-only CPR 70–71,

children 78

children 77–78, 261

infants 83, 261

pregnant casualties 68

Chest injuries

penetrating wounds 104–05

ribcage fractures 154

Chest pain 104, 210, 211

Childbirth 228–29

miscarriage 208, 228

stages 228

Children

chest compressions 77–78, 259

choking 95, 264–65

croup 103

dealing with 19

dehydration 182

nosebleeds 124

recovery positions 74–75

rescue breathing 76–77, 260–61

resuscitation 61, 72–79, 260–61

seizures 218, 276–77

see also Infants

Choking 94–96

adults 94

children 95

emergency first aid 264–67

infants 96

Circulatory system 56, 90, 108–09

checking circulation after bandaging

243

CPR, adults 66–71, 258–59

Circulatory system continued

children 76–79, 260–61,

infants 82–83, 260–61

problems 112–13, 212

anaphylactic shock 223

fainting 221

heart disorders 210–11

internal bleeding 116

shock 112–13

pulse 53

Cleansing wipes 237

Clips 237

securing roller bandages 244

Closed fractures 136

treatment 137

Clothing

on fire 33

improvised slings 253

removing 233

Clotting, blood 110

Cocaine, overdose 201

Cold

burns 172

frostbite 189

hypothermia 186–88

temperature control 171

Cold compresses 241

Collar bone, fractures 148

Colles’ fracture 152

Coma see Unresponsive casualty

Compresses, cold 241

Concussion 144

Consciousness see Response, levels of,

and Unresponsive casualty

Contusions 111

Convulsions

see Seizures

Coral stings 207

Cornea, flash burns 181

Coronary arteries 210–11

CPR 57

adults 66–71, 258–9

chest-compression-only 70–71,

258–59

in children 78

children 76–79, 260–61

infants 82–83, 260–61

Cramp 167

stitch 226

Crash helmets, removing 233

Cross infection, preventing 16–18

Croup 103

Crush injuries 118

CS spray injury 181

Cuts 119

D

Defibrillators 54, 84–87

Dehydration 182

vomiting and diarrhoea 227

Delayed reactions 25

Delivery, childbirth 228–29

Diabetes, insulin pen for 48

Diabetes mellitus 214, 214–15

hyperglycaemia 214

hypoglycaemia 208, 215, 278–79

284

INDEX

Diarrhoea 227

Digestive system

diarrhoea 227

food poisoning 199

vomiting 227

Dislocated joints 139

shoulder 149

Dressings 235, 238–41

adhesive 241

applying 239–41

burns 175

first aid kit 235

gauze 240

improvised 240

non-sterile 240

sterile 235

applying 239–40

Drowning 100

Drugs

administering 24

assessing a casualty 48

poisoning 199

Drunkenness 202

E Ears 193

bleeding from 124

earache 225

examining for injury 49

foreign objects 197

internal bleeding 116

Ecstasy

heat exhaustion 184

heatstroke 201

overdose 199

Elbows

bandaging 246

bleeding from joint crease 127

injuries 151

Elderly people

hypothermia 188

Electrical injuries 34–35

burns 168, 178

high voltage 34

lightning 35

low-voltage 35

Elevation slings 252

Emergencies, action at 19–37

assessing casualty 39–53, 256–57

assessing situation 28

controlling bystanders 29

electrical injuries 34–35

emergency first aid 254–79

fires 32–33

major incidents 37

moving casualties 234

multiple casualties 31

telephoning for help 22

traffic incidents 30–31

triage 37

water rescue 36

Emotions, after an incident 24–25

Epiglottitis 90

Epilepsy 216–17

drugs 48

Epinephrine see Adrenaline

Eyes 192

chemical burn 179–80

examining for injury 49

flash burns 181

foreign objects 196

incapacitant spray injury 181

sterile eye pads 235

wounds 123

F Face

burns 175, 177

examining for injury 50

fractures 146–47

FAST test 212, 262

Face shields and masks 236

for rescue breathing 69, 79

Fainting 221

Febrile convulsions 218

Feet

bandaging: triangular bandages 250

checking circulation 243

cramp 167

examining for injury 51

fractures 166

frostbite 189

Femur 132

fractures 160–61

Fever 219

febrile convulsions 218

Fibroblast cells 110

Fibula 132

fractures 162–63

“Fight or flight response” 15

Fingers

fractures 153

frostbite 189

wounds 126

tubular bandages 248

see also Hands

Fires 32–33

burns 172

smoke inhalation 98–99

First aid 11–37

being a first aider 14–15

emergency first aid 254–79

giving care with confidence 15

looking after yourself 16–18

materials 235–53

priorities 14

regulations and legislation 280

First aid courses 11

First aid kit 235–37

Fish-hooks, embedded 195

Fits 216–18

“Flail-chest” injury 154

Food poisoning 199

Foot see Feet

Forearm, injuries 152

Foreign objects 190–97

in ear 197

in eye 196

in nose 197

Foreign objects continued

swallowed 195

in wounds 115, 121

Fractures 136–38

closed fractures 136

treatment 137

emergency first aid 274–75

open fractures 136

treatment 138

protruding bone 138

stable fractures 136

type of

ankle 162–63

arm 150–52

collar bone 148

facial 146–47

foot 166

hand 153

hip 160–61

leg 160–63

pelvis 155

ribcage 154

skull 144

spine 157–59

unstable fractures 136

Frostbite 189

Fuels, inhalation of 98

Fumes 33

inhalation of 98–99

G

Gases, inhaled 199

Gauze pads 237

Germs, cross infection 16–18

Gloves, disposable 236

Glue, poisoning 199

Grazes 111

treatment 119

Gunshot wounds 111

H

Haemorrhage see Bleeding

Hallucinogens, overdose 199

Handling and moving casualties 234

Hands

bandaging

roller bandages 247

slings 252

triangular bandages 250

bones 132

checking circulation 243

injuries 153

palm wounds 127

see also Fingers

Hanging 97

Hazchem symbols 31

Head injuries 144

cerebral compression 144

concussion 144

emergency first aid 272–73

examining for 49

scalp wounds 122

skull fracture 144

wounds 122

Headache 224

Headgear, removing 233

Health and Safety (First Aid)

Regulations (1981) 280

285

INDEX

Heart

cardiac arrest 84

circulatory system 56, 90–91, 108–09

disorders 210–11

angina 210

heart attack 211

emergency first aid 262–63

heartbeat 108

restoring rhythm 59

defibrillators 59, 84–85

see also Resuscitation

Heat

body temperature 171

heat exhaustion 184

heatstroke 185

sunburn 183

Helicopter rescue 29

Helmets, removing 233

Help, requesting 22–23

Hepatitis

B 16

C 16

human bites 203

Heroin, overdose 201

High-voltage electricity 35

Hip fractures 160–61

HIV 16

human bites 203

Hooks, fish 195

Hormones, “fight or flight response” 15

Hornet stings 204

Human bites 190, 203

Humerus 132

Hygiene

childbirth 229

preventing cross infection 16–18

Hyperglycaemia 214

Hyperventilation 101

Hypoglycaemia 208, 215

emergency first aid 278–79

Hypothermia 186–88

Hypoxia 92

I Ice packs 241

Immunisation 16

Impalement 117

Improvised dressings 240

Improvised slings 253

Incapacitant spray exposure 181

Incised wounds 111

Industrial chemicals 199

Infants

assessing casualties 80

childbirth 228–29

choking 96, 266–67

dehydration 182

hypothermia 188

pulse 53

recovery position 81

rescue breaths 82, 260–61

resuscitation 61, 82–83,

260–61

Infection

childbirth 229

cross infection 16–18

Infection continued

in wounds 120

Information, passing on 23

Inhalation

fumes 98–99

gases 199

respiratory system 91

Inhalers, asthma 48, 102

Injuries, mechanisms of 42–43

Insects

in ears 197

stings 190, 204–05

Insulin

diabetes mellitus 214

pen for diabetes 48

Internal bleeding 116

Intervertebral discs 133, 155

J Jaw thrust 159

Jaws

dislocation 147

fractures 147

Jellyfish stings 207

Joints 135

injuries

dislocation 139

elbows 151

fingers 153

knees 164

shoulders 149

sprains 140–41

wrists 152

wounds in creases 127

K Ketamine, overdose 201

Kidney failure, “crush syndrome” 118

Knees

bandaging 246

injuries 164

Knots, bandages 250

L

Labour, childbirth 228–29

Lacerations 111

Legislation 280

Legs

bandaging 243

cramp 167

examining for injury 51

hip and thigh 160–61

knee 164

lower leg 162–63

varicose veins 129

immobilising 243

injuries

amputation 117

ankle sprain 140–41, 165

Level of response

impaired 144

monitoring 52

Ligaments 135

shoulder injuries 149

Ligaments continued

sprains 140–41

Lighter fuel, poisoning 201

Lightning 35

Limbs see Arms; Legs

Lips, burned 200

“Log-roll”, moving casualties 159

Low-voltage electricity 35

LSD, overdose 201

Lungs 90

airway obstruction 93

asthma 102

penetrating wounds 104–05

respiratory system 90–91

M

Major incidents 37

Marine stings 190, 207

Masks, in rescue breathing 69, 79

Mass gatherings 280

Mechanisms of injuries 43

Medical warning jewellery 48

Medication see Drugs

Meningitis 220, 266–67

Menstrual bleeding 128

Migraine 224

Miscarriage 128, 208, 228

Monitoring vital signs 52–53

Morphine, overdose 201

Mosquitoes 205

Mouth 198

bleeding from 125

burned lips 200

examining for injury 50

insect stings 204, 205

internal bleeding 116

knocked-out tooth 125

sore throat 225

toothache 225

Mouth-to-mouth breathing

see Rescue breathing

Mouth-to-nose rescue breathing 69, 79

Mouth-to-stoma rescue breathing 69

Moving casualties 234

hip and thigh injuries 160–61

lower leg injuries 162–63

“log-roll” 159

splints 160

Multiple casualties 31

Muscles 134

ruptures 140

stitch 226

strains 140–41

tears 140

N

Nails, checking circulation 243

Narcotics, overdose 201

Narrow-fold bandages 249

Neck

back pain 156

examining for injury 50–51

spinal injury 157–59

whiplash injury 42

Needles, sharps containers 18

286

INDEX

Nervous system 142–43

seizures 216–17

children 218

spinal injury 157–59

stroke 212–13

structure 142–43, 155

see also Brain; Unresponsive casualty

Nose 193

examining for injury 50

foreign object in 197

fractures 147

internal bleeding 116

mouth-to-nose rescue breaths

69, 79

Nosebleed 124, 147

O

Open fractures 136

treatment 138

Orifices, bleeding from

ear 123

mouth 125

nose 124

vagina 128

Over-breathing,

hyperventilation 101

Overdose, drug 201

Oxygen

breathing 56

circulatory system 56, 90

hypoxia 92

respiratory system 90–91

P Painkillers, overdose 201

Palm wounds 127

Panic attacks, hyperventilation 101

Paracetamol, overdose 201

Pelvis

examining for injury 51

fractures 155

Pepper spray injury 181

Peripheral nerves 143

Personal belongings 21

Pins 237

Placenta, delivery of 228, 229

Plants, poisonous 199

Plasters 235

applying 241

Platelets 109–10

Pneumothorax 104

Poisoning 190, 198–202

alcohol 202

chemicals on skin 199

drugs 201

emergency first aid 278–79

food 199

in eye 199

inhaled gases 199

injected poisons 199

plants 199

swallowed poisons 199, 200,

278–79

types of poison 199

Portuguese man-of-war

stings 207

Pregnancy

childbirth 208, 228–29

miscarriage 228

Pulse, checking 53

Puncture wounds 111

animal bites 203

marine stings 207

snake bites 206

R Rabies 203

Radial pulse 53

Radiation burns 172

Radius 132

fractures 152

Reactions, delayed 25

Recovery position

adults 64–65

children 74–75

infants 81

spinal injuries 65, 75

Red blood cells 109

Reef knots 250

Regulations, first aid 280

Rescue breathing 59

adults 66–69

with chest compressions 66–69

children 76–79

with chest compressions 76–77

face shields 69, 79

infants 82–83

with chest compressions 83

mouth-to-nose 69, 79

mouth-to-stoma 69

pocket masks 69, 79

Respiratory system 88–105

airway obstruction 93

asthma 102, 268–69

breathing 91

choking 94–96

croup 103

disorders 92–105

drowning 100

hanging and strangulation 97

hyperventilation 101

hypoxia 92

inhalation of fumes 98–99

inhaled gases 199

penetrating chest wounds 104–05

Response, levels of 52

AVPU 52, 144

checking level of response 52

impaired response 144

See also Unresponsive casualty

Resuscitation

adults 62–71

chest compressions 66–71, 258–59

chest-compression-only CPR 70–71

CPR 66–71, 258–59

rescue breathing 68–69, 259

sequence chart 60

children 72–79

chest compressions 77–79, 261

CPR 76–77, 260–61

rescue breathing 76–77, 79,

260–61

sequence chart 61

Resuscitation continued

choking 94–96

defibrillators 84–86

infants 61, 80–83

chest compressions 83, 261

CPR 80–81, 260–61

rescue breathing 80–81, 260–61

sequence chart 61

priorities 57–8

recovery position 64–65, 74–75, 81

Ribcage, fractures 154

“RICE” procedure, strains and sprains

140, 141

Road accidents

see Traffic incidents

Roller bandages 236

applying 245–47

choosing correct size 244

elbow and knee 246

securing 244

Ruptured muscles 140

S

Safety

emergencies 28, 30

fires 32

moving casualties 234

personal 14

traffic incidents 30

Safety pins

securing roller bandages 244

Scalds 172

minor burns and scalds 176

severe burns and scalds 174–75

Scalp

examining for injury 50

wounds 122

Sciatica 156

Scissors 237

Scorpion sting 205

Sea anemone stings 207

Sea creatures, stings 207

Sea urchin spines 207

Seizures

absence seizures 216

in adults 216–17

in children 218

emergency first aid 276–77

Sensory organs 192–93

Serum 110

Sexual assault 128

Sharps containers 18

Shock 112–13

anaphylactic shock 223, 268–69

burns and 172

emergency first aid 274–75

Shoulders

dislocation 139

injuries 149

Signs, assessing a casualty 51

Skeleton 132–33 see also Bones

Skin

allergies 222

bites and stings 203–07

burns and scalds 172–81

chemical burns 179, 199

embedded fish-hooks 195

287

INDEX

examining for injury 50

splinters 194

structure 170

sunburn 183

temperature control 171

Skull 133

examining for injury 50

fractures 144

see also Head injuries

Slings 251–53

elevation 252

improvised 253

Smoke 33

inhalation of 98–99

Snake bites 206

Soft tissue injuries 140–41

Solvents

inhalation of 98

poisoning 201

Sore throat 225

Spider bites 205

Spinal cord

injuries 157

nervous system 142–43

protection 142, 155

Spine 142

back pain 156

examining for injury 50–51

spinal injury 157–59

emergency first aid 272–73

moving casualty 159

recovery position 65

Splinters 194

Splints 160

Sprains 140–41

ankle 140–41, 165

cold compresses 141, 241

finger 153

shoulder 149

Stab wounds 111

Sterile dressings 235

applying 239–40

Stimulants, overdose 201

Stings

allergy to 222

anaphylactic shock 223

insects 204–05

marine creatures 190, 207

Stitch 226

Stoma, mouth-to-stoma rescue breaths 69

Strains, muscles 140–41

Strangulation 97

Stress, looking after yourself 24

Stroke 212–13

emergency first aid 262–63

Sunburn 183

Surveying casualties

primary 44–45

secondary 46–48

Survival bags 237

Swallowed poisons 200, 201

emergency first aid 278–79

Symptoms, assess a casualty 51

T Teeth

knocked out 125

Teeth continued

sockets, bleeding 125

toothache 225

Telephoning for help 22–23

Temperature, body 171

fever 219

frostbite 189

heat exhaustion 184

Temperature continued

heatstroke 185

hypothermia 186–88

taking 53

Tendons 135

shoulder injuries 149

Tetanus 119, 203

Thermometers 53

Thighs, fractures 160–61

Throat

insect stings 204, 205

sore 225

see also Airways

Tibia 132

fractures 162–63

Tick bites 205

Toes see Feet

Tooth sockets, bleeding 125

Toothache 225

Traffic incidents 30–31

safety 28, 30

Tranquillisers

overdose 201

Transient ischaemic attack

(TIA) 212

Transporting casualties see Moving

casualties

Travel, air travel 225

Triangular bandages 236, 249–53

folding 249

hand and foot cover 250

reef knots 250

slings 251–52

storing 249

Tubular bandages 236

applying 248

Tweezers 237

U Ulna 132

fractures 152

Ultraviolet light, flash burns

to eye 181

Umbilical cord, childbirth 229

Unconsciousness see Unresponsive

casualty

Unresponsive casualty

cerebral compression 144

checking response 44, 62, 72, 80

choking 94–96

concussion 144

diabetes mellitus 214, 215

emergency first aid 256, 258–61

examining 49–51

impaired level of response 144

penetrating chest wound 105

recovery position

adult 64–65

child 74–75

Unresponsive casualty continued

infant 81

seizures in adults 216–17

seizures in children 218

skull fracture 144

spinal injury 157–59

stroke 212–13

see also Resuscitation

Urethra, internal bleeding 116

V Vaginal bleeding 116, 128

childbirth 229

miscarriage 228

Varicose veins, bleeding 129

Veins 104

bleeding 110

varicose veins 129

Vertebrae 133

injuries 157

Vital signs, monitoring 52–53

Vomiting 227

W Wasp stings 204

allergy to 222

Waste material 18

Water

drowning 100

electrical injuries 35

hypothermia 186

rescue from 36

Weever fish spines 207

Whiplash injury 42

White blood cells 109

“Wind chill factor” 186

Windpipe see Airway

Work, first aid at 280–81

Wounds

abdominal 128

amputation 117

animal bites 203

at joint creases 127

blood clotting 110

chest 104–05

cross infection 16–18

crush injuries 118

cuts and grazes 119

dressing and bandaging 238–50

emergency first aid 270–71

eyes 123

fingers 126

foreign objects 115, 121

head injury 144–45

healing 110

impalement 117

infection 120

palm 127

scalp and head 122

severe bleeding 114–15

types of 111

Wrist

bandages 247

injuries 152

ACKNOWLEDGMENTS

288

AUTHORS OF REVISED 10TH EDITION

St John Ambulance

Dr Margaret Austin dstj lrcpi lrsci lm

Chief Medical Adviser

St Andrew’s First Aid

Mr Rudy Crawford mbe bsc (hons) mb chb frcs

(glasg) frcem

Chairman of the Board

British Red Cross

Dr Barry Klaassen bsc (hons) mb chb frcs (edin)

frcem

Chief Medical Adviser

Dr Vivien J. Armstrong mbbs drcog frca pgce (fe)

CONTRIBUTORS TO THE REVISED 10TH EDITION

Dr Meng Aw-Yong bsc mbbs dfms dfmb

Medical Adviser, St John Ambulance

Jim Dorman

Operations and Policy Director, St Andrew's First Aid

Joe Mulligan

Head of First Aid Education, British Red Cross

TRIPARTITE COMMERCIAL COMMITTEE

St John Ambulance

Andrew New

Head of Training

Richard Fernandez

Head of of Public Affairs

Deji Soetan

Marketing Manager

St Andrew’s First Aid

Grant MacKintosh

National Sales Manager

Laura Dennett

Marketing and Fundraising Executive

Jim Dorman

Operations and Policy Director

British Red Cross

Patrick Gollop

Head of Training

Paul Stoddart

Marketing Manager

AUTHORS’ ACKNOWLEDGMENTS

The authors would like to extend special thanks to: St John Ambulance Clinical Directorate – Sarah Flynn Project Assistance;

St Andrew's First Aid – Stewart Simpson Training Manager; British Red Cross – Christine Boase Product Development Manager, Marenka

Vossen Project Assistance First Aid Education, Tracey Taylor First Aid Education Development Manager.

PUBLISHERS’ ACKNOWLEDGMENTS

Dorling Kindersley would like to thank: Alex Lloyd for design assistance; Daniel Stewart for organising locations for photography; Bev

Speight and Nigel Wright of XAB Design for art direction of the original photography shoots.

Dorling Kindersley would also like to thank the following people who appear as models:

Lyndon Allen, Gillian Andrews, Kayko Andrieux, Mags Ashcroft, Nicholas Austin, Neil Bamford, Jay Benedict, Dunstan Bentley, Joseph

Bevan, Bob Bridle, Gerard Brown, Helen Brown, Jennifer Brown, Val Brown, Michelle Burke, Tamlyn Calitz, Tyler Chambers, Evie Clark, Tim

Clark, Junior Cole, Sue Cooper, Linda Dare, Julia Davies, Simon Davis, Tom Defrates, Louise Dick, Jemima Dunne, Maria Elia, Phil Fitzgerald,

Alex Gayer, John Goldsmid, Nicholas Hayne, Stephen Hines, Nicola Hodgson, Spencer Holbrook, Jennifer Irving, Dan James, Megan Jones,

Dallas Kidman, Carol King, Ashwin Khurana, Andrea Kofi-Opata, Andrews Kofi-Opata, Edna Kofi-Opata, Joslyn Kofi-Opata, Tim Lane, Libby

Lawson, Wren Lawson-Foley, Daniel Lee, Crispin Lord, Danny Lord, Harriet Lord, Phil Lord, Gareth Lowe, Mulkina Mackay, Ethan Mackay-

Wardle, Ben Marcus, Catherine McCormick, Fiona McDonald, Alfie McMeeking, Cath McMeeking, Archie Midgley, David Midgley, Eve Mills,

Erica Mills, Gary Moore, Sandra Newman, Matt Robbins, Dean Morris, Eva Mulligan, Priscilla Nelson-Cole, Rachel NG, Emma Noppers, Phil

Ormerod, Julie Oughton, Rebekah Parsons-King, Stefan Podohorodecki, Tom Raettig, Andrew Roff, Ian Rowland, Phil Sergeant, Vicky Short,

Lucy Sims, Gregory Small, Andrew Smith, Emily Smith, Sophie Smith, Bev Speight, Silke Spingies, Michael Stanfield, Alex Stewart, Adam

Stoneham, David Swinson, Hannah Swinson, Laura Swinson, Becky Tennant, Laura Tester, Pip Tinsley, Daniel Toorie, Helen Thewlis, Fiona

Vance, Adam Walker, Jonathan Ward, David Wardle, Dion Wardle, Francesca Wardell, Angela Wilkes, Liz Wheeler, Jenny Woodcock, Nigel

Wright, Nan Zhang.

Picture credits Dorling Kindersley would like to thank the following for their kind permission to reproduce their photographs: Getty

Images: Andrew Boyd 168–69.

All other images © Dorling Kindersley. For further information see www.dkimages.com

ACKNOWLEDGMENTS

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