STUDY MATERIALS

PH 225: BASIC FIRST AID

PURE AND APPLED SCIENCE

BY
ABDALLA BENARD
EMAIL: [email protected]
Tel:0925186123

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 An introduction to first aid

Imagine: Whilst feeding your child, they start to gag and appear unable to breathe. You
have tried slapping them on the back, with no success. They seem close to losing
consciousness, their lips are turning a definite shade of blue.

People rarely give first aid a thought, until the day they need it. The above scenario is the sort
of everyday occurrence that can so easily lead to tragedy.

However, with the correct first aid training anyone could, in the short term (until the arrival of
the emergency services) save a life.

These notes have been designed to aid you with your first aid training. It is, however, not
a substitute for hands on training from a professional first aid trainer, but a reference for
you to look back on when you need to.

We hope the training you undertake with us will give you the knowledge and confidence
to, if the worst happens, help keep someone alive.

FIRST AID
First aid is the first assistance or treatment given to a casualty or a sick person for any
injury or sudden illness before the arrival of an ambulance, the arrival of a qualified
paramedical or medical person or before arriving at a facility that can provide
professional medical care.
The Aims of first aid
Preserve life (keep safe from danger or harm)

This doesn’t just refer to the injured party, but yourself and anyone helping you. Far too
often, a helper will inadvertently put themselves in danger and subsequently be
54another casualty for the emergency services to deal with. Please take a moment to
assess the situation, and make sure there are no threats to you before you step in.

Prevent the situation from getting worse

If you are in no danger yourself, try to stop the situation from becoming worse by
removing any obvious dangers (such as stopping traffic, clearing people away from the
casualty, opening a window to clear any fumes, etc.). Also, act as quickly as you can to
stop the casualty’s condition from worsening.

Promote recovery
Your role as a first aider is, after ensuring that the situation cannot get worse, helping the
casualty to recover from their injury or illness, or stop their condition from getting worse. If the
injury is severe, then the best you can do is try to keep them alive until the emergency services
arrive.
The priorities of treatment

This is the course of action you should try to follow, providing the situation allows.

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Primary survey (Airway → Breathing):

A. Make sure the casualty’s airway is clear. Do this by gently tipping their head back so
that the front of the throat is extended.

B. Check if they are breathing normally. You can do this by placing the back of your
hand near their nose and mouth. You are looking for about two breaths every ten seconds. If
the casualty is breathing, then their heart is working, which means blood is being circulated
around their body.

Secondary survey (Breathing → Bleeding → Bones):

Once you are satisfied that the casualty is breathing normally, the second thing to do is
make sure to treat any bleeding. This is to stem any blood loss and to ensure there is a steady
supply of oxygenated blood to the casualty’s vital organs. If there is no bleeding, or you have
dealt with any cuts, the next priority is broken bones.

An emergency action plan is important to have in place should you be faced with a
situation requiring first aid.

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1. REMOVE DANGER: Make the scene safe, do not take risks.
2. DANGER: Look for any further danger. If yes, go back a step, if no go to step 3.
3. RESPONSE: Shout and gently shake or tap the casualty. If the casualty responds, find out what
happened. Check their signs and symptoms (how does the casualty feel or look? Try to work out
what’s wrong) and determine a treatment (remember - if you are unsure, always seek medical
advice). If there is no response, shout for help but don’t leave the casualty just yet and go to step
4.
4. AIRWAY: Open the casualty’s airway by lifting their chin and tilting their head back.
5. BREATHING NORMAL: Look, listen and feel for two breaths in a maximum of ten seconds.
If you can clearly determine the casualty is breathing, perform a secondary survey (check for
bleeding, injuries and clues). Put the casualty into the recovery position, dial 999 if not already
done, monitor airway and breathing and keep the casualty warm. If you cannot determine if the
casualty is breathing, go to step 6.
6. DIAL 999 FOR AN AMBULANCE NOW IF YOU HAVEN’T DONE SO ALREADY.
7. RESUSCITATION: Give 30 chest compressions followed by 2 rescue breaths, continue giving
cycles of 30 compressions to 2 breaths. If there is more than one first aider on hand, change over
every 2 minutes to prevent fatigue. Continue until the ambulance arrives.
Resuscitation (the act of bringing someone back to life or waking them)

To maintain life, we need our hearts to pump oxygenated blood to our vital organs. To achieve
this, we need to be breathing and our hearts need to be pumping. Should either of these
functions stop, our brain and other vital organs will start to deteriorate (brain cells usually die
within 3-4 minutes due to lack of oxygen) which will eventually lead to death.

‘Ventricular fibrillation’ is the most common result of cardiac arrest, caused by heart attack.
When this happens, the best chance of survival for the patient is to have their heart ‘restarted’
with a defibrillator. These are carried on all ambulances and can also be found in some public
places (shopping centers, etc.). These days’ defibrillators are very sophisticated, and will talk
you through the process, but you should be trained in the use of them before attempting to use
one. However, even if you are trained to use one, you must call an ambulance first, as this
will give the casualty the best chance of survival.

Even so, we need to keep the heart and brain oxygenated as best we can while help is on
the way; this is when we start Cardio Pulmonary Resuscitation (CPR).

Cardio Pulmonary Resuscitation (CPR) – Primary Survey:

D Danger – ensure the area is safe and find out what has happened
• Make sure that it is safe for you to approach the casualty. Do not put yourself in any danger,
because if you get injured you won’t be able to help the casualty.
• Remove any danger from the casualty, or if that is not possible, and it is safe to do so, try to
move the casualty away from the danger area.
• Try to find out what happened, making sure that you are safe doing so.

DO NOT PUT YOURSELF IN ANY DANGER.

• How many casualties are there? Can you cope with the situation?

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R Response – is the casualty conscious?
• Try to get a response from the casualty. Gently shake their shoulders, shout and clap your
hands in front of them, pinch their underarm or fingernail to get a pain response.
• If they do not respond, immediately shout for help, or call 999 if you have a mobile fphone
on you. Whatever you do, do not leave the casualty alone.

A Airway – clear the airway

 Clear the airway by placing your fingertips under the casualty’s chin and lifting, so the
front of the neck is extended. Simultaneously placing your other hand on their forehead
to gently tilt the head back.

B Breathing – is the casualty breathing normally?

• When their airway is cleared, check if they are breathing normally. You are looking for two breaths
in ten seconds. Take no longer than this to assess their breathing, as every second counts.
• Check whether their chest and abdomen are rising and falling.
• Listen for breath (more than a sporadic gasp).
• Use the back of your hand (lick the back of your hand if that will help) or your cheek to feel for
any breath from the casualty.
This will all determine if the casualty is breathing normally. If they are, you will need to
place them in the recovery position, which will be covered later in the notes.

If the casualty is not breathing normally:

The first thing to do in this situation is call 999 for an ambulance. If someone is with you,
get them to do this so you don’t have to leave the casualty. If you are alone, and do not have
a mobile with you, you may need to leave the casualty to do this. However, it is vital that an
ambulance is called, as the casualty will stand a much better chance of survival with help on
the way. Once the ambulance is called, start CPR:

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• Place the heel of one hand in the centre of the casualty’s chest. Place the other hand on top and
interlink your fingers.
• Take a position next to the casualty’s chest, kneeling at whichever side feels more comfortable for
you.
• Press down firmly on the casualty’s breastbone current guidelines suggest pushing down to a depth
of 6cm) then release the pressure, but try not to lose contact with the casualty. This is known as a
chest compression. When applying pressure, avoid doing so on the ribs, upper abdomen or the end
of the casualty’s breastbone.
• Each compression should take the same amount of time.
• Carry out 30 chest compressions at a speed of 100-120 compressions per minute.
• After 30 chest compressions, you must administer two rescue breaths (see images
below).

In an ideal situation, the casualty will be on a flat hard surface to be able to administer CPR.
However, this isn’t always the case, and you may find that you

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need to perform CPR on a casualty who is, for example, in bed. If this situation arises, try to get
the casualty onto the floor without hurting yourself or the casualty. If it is not possible, remove
any pillows or cushions so the casualty is lying flat and attempt CPR. This is still better than
doing nothing.

Combining chest compressions with rescue breaths:

• After chest compressions, make sure the casualty’s airway is clear by tilting their head back.
• Pinch the casualty’s nose closed; this will make sure the breath you give them does not escape.
• Take a breath and place your mouth over the casualty’s, forming a seal.
• Steadily blow into the casualty’s mouth, making sure their head is tilted back and the airway is open.
Keep your eyes down on the casualty’s chest to make sure it rises (this should take about a second).
This is known as a rescue breath.
• Remove your mouth from the casualty’s and leave enough room for you to take a fresh breath of air.
Keep the casualty’s airway open and watch for the chest deflating, as the air is expelled.
• Place your mouth over the casualty’s forming the seal again and give another rescue breath. You need
to do this twice.
• Replace your hands on the casualty’s chest immediately and perform another
30 chest compressions, followed by 2 more rescue breaths.

Continue swapping between 30 chest compressions and 2 rescue breaths.

Should your rescue breaths not be effective, follow the steps below:
• Give a further 30 chest compressions.
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• Remove any visible obstructions in the casualty’s mouth.
• Make certain their airway is clear by tilting their head back and lifting the chin. If the airway is not
clear, the breath you give will not fill their lungs.

Do not give the casualty more than two rescue breaths before continuing with chest
compressions.

If you have someone with you, take it in turns to administer chest compressions. Every 1-2
minutes, change over so one person administers chest compressions while the other gives the
rescue breaths. Ensure there is as little delay in swapping as possible, so the casualty is constantly
receiving CPR.

Continue CPR until:

The emergency services arrive to take over. You
become too fatigued to continue.

Resuscitation f or babies and children :

Understandably, some people are reluctant to perform CPR on a child or baby for fear of
causing further harm to them. However, a child in this state is likely to suffer far worse
consequences if CPR is not administered. Please keep that in mind should the situation ever
arise.

CPR on a child is very similar to CPR on an adult. There are only a few minor modifications
to the process, which are detailed below:

• Give the child 5 rescue breaths before starting CPR, then switch back to 30 chest compressions to
2 rescue breaths.
• If you are alone, perform CPR for about a minute before going for help.

Chest compressions on a child should be about one-third of the depth of the chest. For a baby
under 1 year old, only use two fingers to administer CPR. For a child over 1 year use either
one or two hands to compress the chest, again one third of the depth of the chest

Full details on child CPR is covered later in the notes.

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 Resuscitation with chest compressions only
An adult cardiac arrest casualty will probably still have oxygen in their blood stream. If there
is any reason you cannot give the casualty rescue breaths, you can still help the casualty by
giving them ‘chest compression only’ resuscitation. Although not ideal, it will still circulate the
residual oxygen in their blood to their vital organs, so it is better than no CPR.

If you are only giving chest compressions, the continuous rate should be 100-
120 compressions per minute.

If you have someone with you, take it in turns to administer chest compressions. Every 1-2
minutes, change over so one person administers chest compressions while the other rests
and maintains the casualty’s airway. Ensure there is as little delay in swapping as possible,
so the casualty is constantly receiving chest
compressions.

Vomiting during CPR:

It is not uncommon for an unconscious casualty who has stopped breathing to vomit. This is an
autonomic reaction from the unconscious casualty which you may not notice until you come to
give a rescue breath, or their breath comes out with a gurgling noise.
• If this happens, turn their head to the side and allow the vomit to drain.
• Before continuing resuscitation, clean the casualty’s face, and if you have a face shield
handy use it.

Points of hygiene during resuscitation :

• Use a cloth, or whatever you have to hand to wipe the casualty’s mouth clean.
• Face shields are useful to have on you, as they protect you from any serious infections such as
TB, Hepatitis, etc. Always use one if you have it with you.
• If you do not have a face shield to hand, a piece of plastic with a hole cut or torn into it will
suffice, as will a handkerchief or any piece of material which will help to prevent direct
contact.
• If you are in any doubt about the safety of giving rescue breaths, you can perform ‘chest
compression only’ resuscitation as a last means (this is described above).
• If you have protective gloves, use these. Always wash your hands afterwards to prevent any
contamination.

Main causes of un consciousness i n a casualty:

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Unconsciousness is an interruption to normal brain activity. Unconsciousness disrupts the
body’s autonomic reflexes such as coughing. The worst position for an unconscious casualty is
lying on their back, as they may ‘swallow’ their tongue (the tongue slides back in the throat
blocking the airway) which will suffocate them, or they may asphyxiate on their vomit.

If a casualty is unconscious, you need to take immediate action: clear the airway, call for an
ambulance by dialling 999 and if you can, treat the cause of their condition.

To help you remember the main causes of unconsciousness in a casualty, try to remember
FISH SHAPED. These points are dealt with more fully elsewhere in these notes.

F Fainting, (sudden temporary S Stroke(damage to the brain due to loss

of consciousness from interruption in blood supply as result
sudden decrease of blood of blood clot) flow to the brain)
I Imbalance of heat(un usual H Heart attack(occurs when an artery sensitivity to heat)
that sends blood and oxygen to the
heart is blocked)

S Shock,( a critical condition A Asphyxia (choking) as a result sudden drop

in Lack of oxygen or excess of CO2 in blood flow) the body

H Head injury (injury to brain, P Poisoning

skull, bruises, or cut on
head)
E Epilepsy (is a central nervous
system(neurological)disorder in wc
brain activity becomes abnormal
causing seizure)
D Diabetes (chronic disease that occur
when the pancreas does not produce
enough insulin ) insulin are hormones
that regulates blood glucose

Responses in casualties :
To correctly ascertain the level of consciousness in a casualty, you can use the
AVPU scale:

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A) Alert
The casualty is fully alert
The casualty is awake and fully aware of their surroundings (they will usually know the
answer to general questions like the date, their name, where they are, etc.)

V) Voice
Confused
The casualty may not be fully aware of their surroundings, but will ask and answer
questions.

Inappropriate words
This refers to casualties who are conscious, but may not be able to string a coherent
sentence together. Words may be in the wrong place or missing altogether from responses.
Making sounds
The casualty is not able to respond verbally, but may make grunts or moans in response to
painful stimuli.

No sounds
In this case the casualty will make no vocal sounds.

P) Pain
Locating pain
The casualty will be able to locate painful stimuli, and tell you where it is being applied
(pinch on the underside of the arm, pressing firmly on a finger nail,
etc.).

Pain response (but not able to locate the pain)

The casualty will respond to painful stimuli, but not be able to locate where the pain is.

U) Unresponsive
The casualty is not able to respond to pain or vocal stimuli. They will remain
unresponsive.

You can perform primary and secondary surveys of the casualty, which will help you to
decide in which order to treat the casualty, the most urgent first. You can then go on to assess
the casualty further, which may help with diagnosis and treatment. The more information you
can give the ambulance crew the better.

Primary survey:
When you perform the DRAB check, this is usually the primary survey. This has been
covered previously (page 4). Primary surveys are to assess whether the casualty is
breathing. Once you have established this, you can move onto the secondary survey.

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 Secondary survey:
If a casualty is unconscious, but breathing, you must protect the airway. As detailed
bPeafgoer |e, risks are swallowing the tongue, vomiting, etc. Place the
casualty in the recovery position immediately, as described here (see page 12).
The secondary survey needs to be done quickly in the following order of importance:

Bleeding
• Check the casualty from head to toe for bleeding.

• Make sure to check any covered areas, such as the back.

• Stop or control any bleeding you find (see page 36).

Head and neck

• Check for any signs of bruising, swelling or bleeding, particularly from the ears.
• Make sure to examine the whole of the head and face.
• Feel the back of the neck, as this is a hidden area.
• Try to ascertain if the casualty has been in an accident that is likely to damage the neck (for
spinal injuries, see page 55).

Shoulders and chest

• Check both shoulders by placing your hands on them to see if there are any irregularities.
• Run your fingers across the collarbones to check for any damage.
• Run your hands over the ribcage, squeezing and rocking gently, to make sure there are no
breaks, as a broken rib could easily puncture a lung.

Abdomen and pelvis

• Press the abdomen gently with the palm of your hand to see if there are any irregularities or
pain response.
• Gently put pressure on the pelvis to check for any fractures.
• Check if the casualty is bleeding or is incontinent.

Legs and arms

• Run your hands down the legs gently, checking for any fractures or breaks.
• Repeat the action with the arms.
• Check the casualty for any clues to their condition (medic alert jewellery, needle marks,
smell of alcohol, etc.).

Check the pockets

• Check there is nothing in the pockets that will injure the casualty further when you roll
them into the recovery position.
• Try to have a witness present if you need to remove any items from the casualty who can
vouch for you.
• Be wary, there may be sharp objects in the casualty’s pockets such as needles or a knife.
• Be sure to loosen any restrictive clothing, such as ties and belts.

Recovery
• Gently place the casualty in the recovery position (see page 12).
P aIf gey |o 11u have any suspicion that the casualty may have an injured neck, try to get
someone to hold the head in line with the body while you turn the casualty (see spinal
injuries, page 55) to lessen the risk of further damage.
• Be careful not to cause further injury to the casualty or exacerbate suspected injuries.
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Mechanics of injury

Before attempting to move a casualty, it is important to think about the

‘mechanics of injury’. This is the process of figuring out what has happened, and what
injuries are likely to have been sustained by the casualty. If you suspect there is a neck injury
involved, you must try to get someone to help you by keeping the casualty’s head in line with
their body at all times, even when the casualty is lying still. Any movement can cause
serious, irreparable damage. See page 55 for how to do this, under treatment of spinal injury.

The recovery position

When an unconscious casualty is lying on their back, their breathing can be hampered by
them ‘swallowing their tongue’ (the tongue slides back in their throat, cutting off the airway).
Or, the person can vomit while unconscious, and are not able to reflexively heave or expel
the vomit, which can suffocate them. By placing the casualty on their side (the recovery
position), this ensures the airway is clear by stopping the tongue sliding back in the throat
and allowing vomit to drain from the mouth.

Try, if possible, to move the casualty onto their left, as this will keep any contents in the
stomach from escaping. However, always place breathing first, so if a casualty has any
damage to their right lung for example, place them on their right to protect the one working
lung.

Step 1
• Remove any dangers from the casualty (remove glasses, check pockets for anything that
will cause further injury) and straighten the legs.
• Preferably move the left arm out, with their elbow bent and palm face up.

Step 2
• Now bring the far side leg into a bent position, with the foot on the floor, tuck their foot
under the near side leg to keep it up.

Step 3
• Bring the far side arm across the chest, with the back of the hand against the casualty’s
cheek, and hold it there.
• Now using the bent knee as leverage and holding the back of the hand against the cheek,
pull the knee towards you, rolling the casualty onto their side.

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 Make sure their knee is touching the ground so that they don’t roll back.

Step 4
• Make sure that the upper leg is bent at both the hip and the knee, as though the casualty is in a
‘running’ position. Keep their hand under their cheek and tilt their head back to clear the airway.
• Check the casualty’s back for any hidden injuries, and if you have anything to hand, cover them for
warmth and their dignity.
• Call 999 and request an ambulance.
• Monitor the casualty’s breathing every 30 seconds while awaiting the ambulance. If the casualty stops
breathing, return them to their backs and commence CPR.

Things not to do:

• Never put anything into an unconscious casualty’s mouth.
• Never move a casualty without performing the checks mentioned first.
• Never place anything under the head of a casualty who is on their back. This could obstruct the airway.
• Never unnecessarily move a casualty as this could cause further injury.

Head injuries

Treat any suspected head injury with the utmost caution, as they have the potential to be very
serious. Head injuries often lead to unconsciousness and all the attendant problems. Also, head
injuries can cause permanent damage to the brain.

Head injuries may also be associated with neck and spinal injuries, so they must be
treated with the utmost caution (see spinal injuries, page 55).

The three main areas of concern with head injuries are concussion, compression and a
fractured skull.

Concussion
Concussion occurs when the brain is violently shaken. Our brains are cushioned within our
skulls by ‘cerebro-spinal fluid’ (CSF), so any blow to the head can cause the brain to bang
against the skull which disrupts its usual functions. A casualty may pass out briefly (no more
than 2-3 minutes), and when they come round their level of response should return to
normal. Concussion casualties should return to normal if no complications arise. However, a
concussed casualty should not be left on their own and should ideally be monitored for 24
hours. No sporting activity should be undertaken for at least three weeks after a concussion.
Compression
Compression injuries are very serious, as the brain is under extreme pressure which is caused
by bleeding or swelling in the cranial cavity. Compression can arise from a skull fracture or
head injury, but can also be brought on by illness (type of stroke, brain tumour, meningitis,
etc.).

Fractured skull

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Fractures to the skull are very serious as the broken bone of the skull can cause direct
damage to the brain which can cause bleeding and therefore compression. Treat any casualty
who has had a head injury, and whose response level is low, as having a fractured skull.

Possible signs and symptoms of head injury

Concussion Compression Fractured Skull

Casualty is unconscious for short Possible history of recent head Casualty may suffer from
period, after which trauma with recovery, followed concussion
response levels are back to by deterioration. or compression also, so
normal, recovery is usually symptoms of these may be
quick. present.
Short term memory loss, groggy, Response level deteriorates as the Bleeding, swelling or bruising of
confused irritable. condition develops. the head.

Mild headache. Severe headache. Soft, egg shell feeling of the scalp.(skin covering the
head)
Pale, clammy(sweaty skin) to the Flushed, dry skin.(due to Bruising apparent around the touch.
increased blood flow) eyes.
(light colour) ‘Panda eyes’(dark shade around
eyes).
Shallow to normal breathing. Deep, slow and noisy breathing Bruising or swelling behind
one (due to pressure on brain). or both ears.

Rapid, weak pulse.(number of Slow, strong pulse caused by Blood or fluid coming from an heartbeat
per minute) raised blood pressure. ear or the nose.

Pupils are normal and react to One or both pupils may dilate as Deformity or lack of
symmetry of light. pressure on the brain increases. the head.
Pupil( is hole located in the
center of the iris of the eye that
allows light to strike)
Nausea and vomiting can occur As condition worsens, fits may Blood visible in the white of the on
recovery. occur, with no recovery. eye.

Treatment of head injuries

Keep in mind that a casualty with any head injury may well be suffering from neck and
spine injuries also. Treat the casualty with the utmost care, and call for an ambulance
immediately.
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• If the casualty is or has been unconscious, you suspect a fractured skull, or their responses deteriorate
CALL AN AMBULANCE IMMEDIATELY.
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• Keep their airway clear and monitor their breathing.
• If the casualty is unconscious, and you don’t wish to move them as you suspect a neck injury, you can
use the jaw thrust method of keeping the airway clear (see page 58).
• If you are unable to use the jaw thrust method (manenuer), and you cannot keep the airway clear, put
the casualty in the recovery position but make sure the head, neck and body are in line as you turn
them to avoid any further damage to a neck or spinal injury.
• If the casualty is conscious, you can help them lie down, making sure to keep the head and neck in line
with the body. You can help stop any movement of their head by placing your hands on either side of
the head and keeping it still.
• If there is bleeding, help to control it by applying pressure directly to or around the wound. However,
if there is blood or fluid coming from an ear, do not try to stop the flow, as the fluid must be allowed to
drain.
• If there are any other injuries on the casualty, attempt to treat these. Some tips for treating head
injuries:
• Monitor the casualty’s breathing, pulse and response levels. If the casualty appears to recover, monitor
them closely as they may well deteriorate and their response levels drop.
• If a casualty has been concussed, try to make sure they are not left alone for the next 24 hours. Advise
them to seek medical help as soon as possible.
• If a casualty suffers any of the following in the few days after concussion, they should go to A&E
immediately: worsening headache, nausea or vomiting, drowsiness, weakness in a limb, problems
speaking, dizzy spells, blood or fluid from an ear or the nose, problems seeing, seizures or confusion.
• If the concussion is received playing sports, do not allow the concussed player to continue until they
have seen a doctor. Usually, concussed players are not allowed to participate for up to three weeks
after being concussed.

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 Stroke

Strokes must always be treated as a medical emergency, and an ambulance called

immediately. Any delay in the treatment of a stroke can have a dramatic effect on the
casualty’s recovery. If you suspect a stroke, CALL AN AMBULANCE IMMEDIATELY.

There are two types of stroke:

1. A blood clot blocks a blood vessel that supplies part of the brain. This is the most common.
2. A ruptured blood vessel in the brain. The build-up of blood ‘squashes’ an area of the
brain.

With either type of stroke the signs are similar, with the result that a part of the brain dies.
There is no age definition of a stroke casualty; anyone of any age can have a stroke.

Signs and symptoms of a stroke:

A stroke must be treated immediately. If you suspect a stroke, carry out the following FAST
test:

F Facial weakness
Can the casualty smile? Has their mouth or eye drooped?
A Arm weakness
Can the casualty raise both arms?
S Speech problems
Can the casualty speak clearly? Do they have problems understanding you?
T Time to call 999
If the casualty fails any of these tests, call 999 immediately as a stroke is a medical
emergency.

There may be other signs to look for, but the FAST check is the quickest and may save
time. However, please note the following may occur:

• One side of the face or body becomes suddenly numb.

• Loss of balance.
• Lack of co-ordination.
• Suddenly developing a severe headache.
• Sudden confusion.
• Problems seeing with one or both eyes.
• Pupil size becomes unequal

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Treatment of stroke:
• Clear the airway and maintain breathing.

• DIAL 999 FOR AN AMBULANCE IMMEDIATELY.

• If the casualty is unconscious, place in the recovery position.
• If conscious, lay the casualty down with their head and shoulders raised.
• Be sure to talk to and reassure the casualty. Just because they may not be able to speak, they still may
be able to understand and react to you.
• Monitor their breathing, pulse and response levels. Keep a record if possible for when the ambulance
arrives.

Hypoxia

Hypoxia means low oxygen in the blood stream. This condition has the potential to be fatal, so it
is vital for a first aider to recognise the signs and know how to treat the casualty.

There are five categories for the causes of hypoxia. These are:

External causes
There is not enough oxygen in the air surrounding the casualty, such as:
 Suffocation by smoke or gas.
• Drowning.
• Suffocation by earth, sand or a pillow/cushion, etc.
• High altitude (lower oxygen levels)

Airway causes
These can be swelling or narrowing of the airway caused by:
• Swallowing or swelling of the tongue.
• Vomit.
• Choking.
• Burns.
• Strangulation.
• Hanging.
• Anaphylactic shock.

Breathing causes
The lungs are unable to function properly, caused by:
• Crushing of the chest.
• A collapsed lung.
• Injury to the chest.
• Poisoning.
• Asthma attack.
• Disease or illness.

Circulation causes
Oxygenated blood is unable to circulate around the body, falling blood pressure, or oxygen is
not absorbed by the blood, caused by:
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• Heart attack.
• Cardiac arrest.
• Angina.
• Severe bleeding.
• Poisoning.
• Anaemia.

Control centre causes

The respiratory control centre in the brain, or the nerves connecting it to the lungs, fails,
caused by:
• Stroke.
• Head injury.
• Drug overdose.
• Poisoning.
• Spinal injury.
• Electric shock.

Signs and symptoms of hypoxia

• Skin appears pale and feels clammy to the touch. For dark skinned casualties, check the skin inside
the lips and eyelids.
• A bluish tinge to the casualty’s skin and lips (cyanosis).
• Increased pulse.
• Weakening pulse.
• Nausea or vomiting.
• An increase to the casualty’s breathing rate (caused by lack of oxygen).
• A decrease to the casualty’s breathing rate (check for control centre causes).
• Distressed breathing, or gasping.
• Confused or dizzy.
• Decreasing levels of consciousness.
• Look for clues from the cause of the hypoxia (bleeding, injury, chest pain, etc.).

Treatment of hypoxia
• Clear the airway and maintain breathing.
• Try to remove or treat the cause of hypoxia (stop bleeds, open windows to clear smoke or gas, etc.).
• Do not allow the casualty to eat, drink or smoke.

How the body responds to hypoxia

Adrenalin is released if the body detects that there are low levels of oxygen in the blood.
The effect this has on a body is:
• Increases the heart rate.
• Increases the strength of the heartbeat, and therefore blood pressure.
• Diverts blood away from the skin, stomach and intestines.
• Diverts the blood towards the brain, heart and lungs.
• Dilates the air passages (bronchioles) in the lungs.

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Adrenaline being released into the body has a dramatic effect on the signs and symptoms
that it is vital you as the first aider recognise.

The respiratory system

Air is taken in through the nose and mouth where it is warmed, filtered and moistened. It
then travels through the throat and past the epiglottis (the flap of

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skin at the back of the throat that closes over the airway when we swallow), where it enters
the larynx (the voice box or ‘Adam’s apple’). It then continues between the vocal cords in
the larynx and on into the trachea (windpipe). The trachea is protected by cartilage rings that
surround it and stop it from kinking. The trachea then splits into two ‘bronchi’, each
supplying oxygen to a lung.

The bronchi are divided into ‘bronchioles’, or smaller air passages. Right at the end of the
bronchioles are ‘alveoli’, microscopic air sacks. The walls of the alveoli are one cell thick,
which allows oxygen to pass through them and into the blood, which is carried in capillaries
around the alveoli. The waste gas from our body is carbon dioxide, which passes from the blood
through the alveoli and is breathed out.

The ‘thoracic cavity’ is in the chest, and is where the trachea, bronchi and lungs are all
situated. To enable us to draw air into the thoracic cavity, the diaphragm flattens and the chest
walls expand, which increases the size of the thoracic cavity creating a void which
draws in air.

Each lung is encased in a two layered membrane known as the ‘pleura’. Between these
two layers is a thin layer of fluid called ‘serous fluid’. This allows the chest walls to move
without friction.

The ribs curl around from the spine, connecting to the sternum (breast bone),

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 and protects the thoracic cavity.

‘Normal’ respiratory Breaths per minute

rates

Adult 12 -20

Child 20 40

Baby 30 60

Choking

Choking is a very common occurrence, and is probably one of the most useful skills you can
have as a first aider. Choking can lead to tragedy if not dealt with properly.

Signs and symptoms

• Casualty is unable to talk, breath or cough.
• They may be gasping and clutching their throat.
• They may appear distressed.
• They may become pale and show signs of cyanosis in later stages.
• Becoming unconscious.

Treatment o f an adult or child over 1 year:

Ask the casualty if they are choking firstly to establish this is the case. If they are not doing
so already, ask them to cough as this will usually dislodge minor obstructions. However, if
this doesn’t work, follow the steps below:

1 – Back slaps
• If there is no help around, shout for help. Do not leave the casualty alone.
• Bend the casualty forward at the waist so their head is lower than the chest. If the casualty is a
young child, you can place them over the knee to help with this.
• Find the hollow spot between the shoulder blades and administer five firm slaps with your open
hand. Make sure to check between blows if the obstruction has dislodged.
• If this does not work, go to step 2.

2 – Abdominal thrusts (Heimlich Manoeuvre)

• Stand (or kneel if it is a child) behind the casualty and place both your arms around their
waist.
• Make a fist and place it just below the casualty’s ribs with your thumb facing inwards (as if
you’re looking at a watch).
• Grasp your fist with your free hand and pull in sharply. Do this up to five times, making sure
you check between each thrust if the obstruction has dislodged.
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
• If this does not work, repeat step 1 and follow with step 2 until the obstruction
is dislodged.

• If the back slaps and abdominal thrusts do not appear to be working, shout for someone to
call 999 for an ambulance, but do not stop administering the treatment if the casualty is
conscious.

Choking in a bab y und er 1 year

The baby may attempt to cough on their own. If the choking is not serious, this will
clear the obstruction. The baby may cry which indicates they are now breathing
properly.

If the obstruction is not cleared by coughing, follow the steps below:

1 – Back slaps
• Shout for help immediately, but do not leave the baby alone.
• Lay the baby over your arm facing downwards with their legs either side of your elbow with their
head below their chest.
• Administer up to five slaps firmly between the shoulder blades with the palms of your fingers, not
your open hand.
• Check between each slap if the obstruction has dislodged.
• If this does not work go to step 2.

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2 – Chest thrusts
• Turn the baby over, so they are laying chest up on your other arm, keep their head below their
chest.
• Using two fingers on the baby’s chest give up to 5 chest thrusts. This is a similar manoeuvre to
chest compressions in CPR, but sharper and administered at a slower rate.
• Check between each thrust if the obstruction has dislodged.
• If this does not work, repeat step 1 and follow with step 2 until the obstruction is dislodged.

Never administer abdominal thrusts on a baby.

If the obstruction has still not dislodged repeat steps 1 and 2.

If the casualty becomes unconscious make sure they are laying on the ground (or on a
flat firm surface for a baby) and commence CPR. Make sure there is an ambulance on
the way. Continue CPR until help arrives or you become fatigued.

Anaphylactic shock

Anaphylaxis is an extreme allergic reaction which can be fatal. This is trigged by a massive
over reaction by the immune system. Severe anaphylactic reaction is a rare occurrence,
usually triggered by drugs such as penicillin, insect stings, nuts such as peanuts and shellfish
such as prawns, latex, dairy produce, etc.

When the body detects a ‘foreign protein’ the immune cells release histamine. Histamine
can have the following effects on the body if released in massive quantities:
• Dilates blood vessels.
• Constricts the bronchioles in lungs.
• Makes blood capillary walls weaken and leak, which causes severe swelling and shock.
• Weakens the heart’s contractions.
• Makes the skin itchy and come out in a rash.

Signs and symptoms

An allergic reaction can occur in seconds, so recognising the problem is essential:
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• Casualty’s face, tongue, neck, lips and eyes may suddenly swell up.
• Their voice may become hoarse, developing a ‘lump in the throat’ which may lead to loud, noisy
breathing which may stop altogether.
• Tightness in the chest, difficulty breathing, wheezing (the casualty may have
the equivalent of an asthma attack, with the addition of a swollen airway).
• Weak, rapid pulse.
• Nausea, stomach cramps, vomiting, diarrhoea.
• Itchy, red or blotchy skin.
• Anxiety, a feeling of impending doom.

Treatment of anaphylactic shock

• Dial 999 for an ambulance immediately.
• Lay the casualty in as comfortable position as possible. If the casualty is having problems breathing,
they may want to sit up to ease this.
• If the casualty is feeling faint, do not let them sit up. Keep them lying flat and raise their legs.
• If the casualty is aware of their condition, they may be carrying an adrenaline shot. This can save the
casualty’s life if administered promptly.
• The casualty can usually give themselves the adrenaline shot, but if they are unable you may have to
help them.
• If the casualty becomes unconscious, check their airway and breathing and resuscitate as
necessary.

• The adrenaline shot (epinephrine) can be given again if there is no improvement, or symptoms return
after five minutes.

Asthma

Asthma is a fairly common allergic reaction in the lungs, usually caused by pollution, dust,
pollen or traffic fumes. The muscles surrounding the bronchioles spasm and constrict which
makes it very difficult for the casualty to breathe. Asthma sufferers normally carry around
medication in the form of an inhaler which when breathed in dilates the bronchioles helping to
relieve the condition.

Asthma attacks can be very traumatic for the casualty, especially children, so be sure to
reassure them and keep them as calm as possible. This is best achieved by being calm yourself
and let them know you are a first aider. If the casualty is not calmed in a timely manner, their
attack may lead to ‘hyperventilation’ after the inhaler has been used and their breathing has
eased.

Signs and symptoms

• Difficulty in breathing.
• Wheezy breathing, originating in the lungs.
• Difficulty with speaking (needing breath in the middle of a sentence).
• Clammy, pale skin.
• Cyanosis, blue or greyish colour to the lips and skin.
• Use of muscles in the upper chest and neck help the casualty to breath.

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• If it is a severe attack, the casualty may become exhausted.
• If the attack is prolonged, the casualty may become unconscious and stop breathing.

Treatment of an asthma attack

• Sit the casualty upright, with their back to a wall, table or chair for support.
• Help the casualty to use their inhaler (usually a blue inhaler for an attack). This can be administered
every few minutes, if the attack does not abate.
• Keep talking to the casualty, reassuring them and keep them calm. Ask them simple questions; keep
their mind off the attack.
• Should the attack be severe, prolonged, appears to be getting worse or the casualty is becoming
exhausted dial 999 for an ambulance.
• Frigid, winter air can worsen an attack, so do not take the casualty outside for fresh air.
• Keep the casualty sitting upright while they are conscious, even if they become too weak to sit upright
on their own. Only ever lay a casualty having an asthma attack down if they become unconscious,
then place them in the recovery position and be prepared to carry out resuscitation.

Croup

This is a condition usually suffered by infants, where the larynx and trachea become
infected and swell. These attacks usually occur during the night and can be very alarming
but usually pass without any lasting harm being done to the child.

Signs and symptoms

• Distressed, difficult breathing
• A loud pitched or whistling sound as the casualty breathes.
• A short ‘barking’ cough.
• Clammy, pale skin.
• Cyanosis, blue or greyish colour to the lips and skin.
• Use of muscles in the upper chest and neck help the casualty to breath.

Treatment of croup
• Keep calm as panic will distress the child and worsen the attack.
• Sit the child upright and keep reassuring them.
• Call a doctor.
• If the attack is a severe one, does not ease or the child is running a temperature, dial 999 for an
ambulance.
Never try to put your fingers down the child’s throat as there is a small chance that the
condition could be ‘epiglottitis’. If it is then the epiglottis may swell even more and totally
block the child’s airway.

Hyperv entilation

Hyperventilation means ‘excessive breathing’. When we breathe in we take in a trace amount of

carbon dioxide and when we breathe out this rises to about 4% carbon dioxide.
Hyperventilation results in low levels of carbon dioxide in the blood which is what causes the
symptoms of this condition.
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Hyperventilation attacks can be brought on by anxiety, a panic attack or a sudden fright,
and can be confused with an asthma attack. Asthma sufferers may hyperventilate after
using their inhalers, once their airway has opened. The difference can be told by the large
amounts of air being taken in by the hyperventilating casualty compared to the tight,
wheezing breath of the asthma casualty.

Signs and symptoms

• Unnaturally fast deep breathing.
• Dizziness and faintness.
• Complaining of a ‘tight’ chest.
• Cramping in the hands and feet.
• Flush skin, and no signs of cyanosis.
• Pins and needles in the arms and hands.
• The casualty may feel they can’t breathe.
• A prolonged hyperventilation attack may result in the casualty passing out, and may stop breathing for
up to 30 seconds.

Treatment of hyperventilation
• Reassure the casualty, but be firm and stay calm.
• Move them to a quiet, preferably isolated area.
• Explain to the casualty that they are hyperventilating and need to calm down.
• Try to coach their breathing, slowing it and calming them.
• Ask the casualty to take tiny sips of water. This will reduce the amount of breaths they can take.
• Ask them to breathe through their nose, as this reduces the loss of carbon dioxide. They may need lots
of reassurance to do this.
• If the attack continues, or you are in any doubt, seek medical advice.

Drowning

It is a misconception that drowning victims breathe in a large amount of water.

In truth, 90% of drowning fatalities are caused by a relatively small amount of water in the
lungs which interferes with the oxygen exchange in the alveoli (known as wet drowning).
The other 10% are caused by spasms in the muscles near the epiglottis and larynx which
blocks the airway (known as dry drowning). The casualty will have swallowed a large
amount of water, which may be vomited during resuscitation.

Please remember that drowning can have many factors such as alcohol,
hypothermia or a medical condition such as heart attack or epilepsy.

Secondary Drowning:
When a small amount of water is taken into the lungs it causes irritation and fluid is
drawn from the blood into the alveoli. This reaction could happen several hours after a
near drowning, the casualty may relapse after appearing to have recovered fully and

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have difficulty breathing later on. This is why any drowning casualty who has been
resuscitated should be taken to hospital as a matter of urgency.

Treatment of drowning
Firstly, do not endanger yourself as you getting in trouble won’t help the casualty. Try not to enter
the water yourself unless you have been trained to do so. If possible, try to reach the casualty
with a stick, rope or a floating object (lifesavers or similar).
• Do not put yourself at risk. Try to reach the casualty with a rope, stick or float.
• Try to keep the casualty horizontal during the rescue as they may go into shock.
• Check their airway and breathing. Perform CPR if necessary.
• Dial 999 for an ambulance. Do this even if they appear to have fully recovered, as secondary
drowning may occur.

Collapsed lung / sucking chest w o und

The lungs are surrounded by two layers of membrane, known as the ‘pleura’. Between the
membranes is a ‘pleural cavity’ which contains a very thin layer of
‘serous fluid’. This fluid enables the layers to move against each other as we breathe.

A casualty with a penetrating chest injury will have had the outer layer of the pleura damaged.
This causes air to be sucked in from the outside of the chest into the pleural cavity which in
turn causes the lung to collapse (pneumothorax).

With any serious chest injury the inner layer of the pleura may become perforated,
which will cause air to be drawn from the lung into the pleural
cavity causing the lung to collapse. If air is continuously drawn into the pleural cavity, but is
unable to escape, pressure will build in the collapsed lung (tension pneumothorax). This pressure
may squeeze both the heart and uninjured lung preventing both from functioning
properly.

Signs and symptoms

• Severe difficulty breathing.
• Cyanosis of skin and lips (grey or bluish colouration).
• Painful breathing.
• Clammy, pale skin.
• Breathing is fast and shallow.
• Chest will not move symmetrically as the injured side may not rise.

If there is a sucking chest wound

• Sound of air being drawn into the wound along with bubbling blood.
• ‘Crackling’ feeling to the skin around the wound due to air entry.

Treatment of collapsed lung / sucking chest wound

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• Immediately cover the wound with either your, or the casualty’s hand (if they are conscious) to help
prevent air being sucked in.
• Dial 999 immediately for an ambulance. Ask someone to do this if you are not alone.
• Place a sterile pad over the wound and cover with plastic (cling film, kitchen foil or any other air tight
covering will do).
• Tape the plastic covering on three sides only, as you want to stop air getting in but not getting out.
• If the casualty loses consciousness, open the airway and check their breathing.
• Perform CPR if necessary. If they are breathing, place them in the recovery position with the injured
lung lowest, to help protect the uninjured lung.

Flail chest

This refers to a condition where the ribs surrounding the chest have been fractured in
several places creating a ‘floating’ section in the chest wall.

As the casualty draws breath the chest moves normally, but the flail section will move
inwards and outwards when the rest of the chest is moving outwards and inwards. These are
known as paradoxical chest movements.

Signs and symptoms

• Severe breathing difficulties.
• Painful,shallow breathing.
• Same signs and symptoms of a fracture.
• Paradoxical chest movement.

Treatment of flail chest

• Dial 999 immediately for an ambulance.
• Place the casualty in the most comfortable position for them, preferably sat up and inclined towards
the injury.
• Place large amounts of padding over the flail area.
• Put the arm of the injured side in an elevated sling, squeezing the arm gently against the padding to
help provide gentle, firm support to the injury.

The circulatory system

The circulatory system consists of a closed network of tubes (arteries, veins and capillaries)
which are all connected to a pump (the heart).

Arteries carry the blood away from the heart. They have strong, muscular, elastic walls which
expand as the blood from the heart surges through them. The largest artery is the ‘aorta’,
which connects directly to the heart.
Veins carry the blood towards the heart. Their walls are thinner than artery walls as the blood
they carry is under less pressure. They have one way valves to keep the blood flowing
towards the heart. The largest veins are the ‘vena cava’, which connect to the heart.

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 Capillaries are tiny blood vessels which float between the arteries and veins and carry oxygen,
carbon dioxide and nutrients in and out of the body’s cells.

The heart is basically a four chambered pump. The left and right sides are separate. The left
side of the heart takes oxygenated blood from the lungs and pumps it around the body,
whereas the right side of the heart takes blood from the body and pumps it to the lungs.

The two sides are separated into two chambers known as the ‘atria’ and the
‘ventricles’. The atria are the top chambers which collect blood as it returns from both the
lungs and the body, pumping it to the ventricles. The ventricles in turn pump the blood
out of the heart to the lungs and around the body.

The blood

60% of blood is made up of a clear yellow fluid called ‘plasma’. Within the plasma are red
blood cells, white blood cells, platelets and nutrients.

Red cells contain haemoglobin, which carries oxygen that is used by the body’s cells. Red cells
give blood its colour.

White cells are what help us fight infections.

Platelets trigger complicated chemical reactions if a blood vessel is damaged forming a

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clot.

Nutrients are derived from food by the digestive system. When nutrients are combined with oxygen
within the cells of the body they provide energy, keeping the cells alive.
• The blood carries carbon dioxide (waste gas produced by the cells) in the form of ‘carbonic
acid’, which is diluted within the plasma.
• The blood also circulates heat (generated mostly by the liver). This heat is carried to the skin
by the blood if the body needs cooling down.

The pulse

Whenever the heart contracts, blood is pumped through the arteries. The elastic walls of the
arteries expand as the blood flows through them, which can be felt wherever arteries come
close to the skin.

When you check a pulse use the pads of your fingers not your thumb, as thumbs have their own
pulse. The first aider should make a note of the following when checking for a pulse:

Rate – Is the pulse slow or fast? Count how many beats there are in a minute.

Rhythm – Is there a regular pulse? Are there any beats missed?

Strength – Is the pulse strong or weak?

The main areas you will find a pulse are in the neck (carotid pulse), the wrist
(radial pulse) and in the upper arm (brachial pulse).

Age Normal heart rate at

rest
Adult 60 - 90 bpm

Child 90 - 11 0 bpm
Baby 11 0 - 140 bpm

Capillary refill
Circulation to the end of the arms and legs can be momentarily checked by squeezing the tip
of a finger or toe. The skin will appear pale when squeezed – if the circulation is working
properly the colour will return within two seconds when released. This process can take a little
longer if the hands or feet are cold.

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 Angina

Angina (angina pectoris) is a condition that is usually caused by the build-up of cholesterol
plaque on the lining of a coronary artery. Cholesterol is a fatty chemical that is part of the outer
lining of cells in the body. Cholesterol plaque is a hard, thick substance which builds up from
the deposits of cholesterol on the artery wall. Over time the build-up of cholesterol plaque
causes the arteries to narrow and harden.

When we exercise or get excited the heart requires more oxygen, but the narrowed arteries
are not able to increase the blood supply that is being demanded. The result of this is an area
of the heart will suffer from a lack of oxygen. The casualty will feel pain in the chest
as a result.

Usually angina attacks occur with exertion but subside with rest. However, if the narrowing of
the artery reaches a critical level angina may occur during rest (known as ‘unstable angina’).
Casualties with angina, especially unstable angina, are at a high risk of suffering from a heart
attack in the near future.
Heart attack

A heart attack (myocardial infarction) is usually caused when the surface of a cholesterol
plaque build-up in a coronary artery cracks and develops a ‘rough surface’. This may lead
to a blood clot forming on the plaque which in turn completely blocks the artery resulting
in the death of an area of the heart muscle.

However, unlike angina, the death of the heart muscle from a heart attack is permanent
and will not be eased with rest.

Signs and symptoms

Please bear in mind that each heart attack is different. They may not show all the signs
below, in fact up to a quarter of heart attacks are ‘silent’ and happen without any chest
pain.

Angina Heart
Attack
Onset Sudden, during exertion, stress or Sudden and can occur at rest.
extreme
Pain w‘Viceateh elirk. e’ pain, can be ‘Vice like’ pain, can be described as
described as ‘dull’,‘tightness’ or ‘dull’, ‘tightness’ or ‘pressure’ in the
‘pressure’ in the chest. May be mistaken chest. May be mistaken for indigestion.
for indigestion.
Location of pain Central chest area, can radiate to either Central chest area, can radiate to either
arm (usually the left), the neck, jaw, back arm (usually the left), the neck, jaw, back
or shoulders. or shoulders.
Duration Normally lasts 3 to 8 minutes rarely Normally lasts more than 30 minutes.
longer.
Skin Pale, could be sweaty. Pale, ashen, may sweat a lot.
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 Pulse Varies, depending on which area has the Varies, depending on which area has the
lack of oxygen. Often the pulse is lack of oxygen. Often the pulse is
irregular or misses beats. irregular or misses beats.
Other signs & Shortness of breath, anxiety and Shortness of breath, dizziness, nausea,
symptoms weakness. vomiting.
Factors giving Rest, reduce stress, taking ‘G.T.N.’ AGi sveinngse ‘ Gof. T‘i.Nmp.’e
relief medication. mndeidnicatig dooonm m’. ay give
partial or no relief.

Treatment of angina / heart attack

• Sit the casualty down and make them comfortable. Try to stop them from walking around or doing
anything strenuous. Sit them in the Fowler position (or the ‘W’ position). Have them lean against a
wall, or your knees if no other option, and raise their knees.
• Ask the casualty if they have any medication with them. If they do, allow them to take their own
glyceryl tri-nitrate (G.T.N.) medication if they have it.
DO NOT GIVE IT TO THEM DIRECTLY BUT HELP THEM SELF
MEDICATE.
• Reassure the casualty. Remove any causes of stress or anxiety if possible.
• If you have any reason to suspect a heart attack – check if the casualty is allergic to aspirin, older
than 16 or if they are taking any ‘anti-coagulant’ drugs such as warfarin. If all is clear, allow them to
chew an aspirin tablet slowly, as this may be beneficial. If, however, you are unsure of any of the
above, wait for the ambulance to arrive.
• Monitor the casualty. If it is a heart attack and the casualty becomes unconscious it is more than
likely the heart has stopped and you will need to perform CPR, so be prepared.

Aspirin helps stop clotting in the blood. Having a casualty chew an aspirin tablet allows the
drug to be absorbed into the blood stream through the skin of the mouth, helping it work
faster. The ideal dose of aspirin is 300mg, but any strength will do in these cases.

Dial 999 for an ambulance if:

• You have any reason to suspect it is a heart attack.
• The casualty has no history of angina.
• The symptoms suffered are different or worse than the casualty’s usual angina attacks.
• The pain from an angina attack is not relieved by the casualty’s medication and rest after 15 minutes.
• You have any doubts at all. It is always better to be safe than sorry in these situations.

Left ventricular failure

Left ventricular failure (LVF) is where the left ventricular of the heart loses power and
cannot empty itself. The right side of the heart is still working and pumping blood into the
lungs. This causes a ‘back pressure’ of blood in the pulmonary veins and arteries in the
lungs. Fluid from the back pressure of blood seeps into the alveoli which results in severe
breathing difficulties.

The condition may be brought on by a heart attack, chronic heart failure or high blood pressure.
Casualties with chronic heart failure more often than not suffer attacks at night.

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Signs and symptoms
• Severe breathing difficulties.
• Crackly, wheezy breathing due to fluid on the lungs.
• Pale, sweaty skin.
• Cyanosis of the skin/lips (grey or bluish discolouration).
• Coughing up frothy, bloody sputum.
• Possibly the same signs and symptoms of heart attack.
• Casualty needs to sit up to be able to breathe.  Confusion, dizziness and anxiety.

Treatment of LVF
• Sit the casualty upright, with their feet dangling.
• Dial 999 for an ambulance as soon as you can.
• If the casualty has it, allow them to take their own G.T.N. medication.
• Be prepared to perform CPR as this condition can deteriorate rapidly.

Shock

The usual association with the word shock is a nasty surprise, an earthquake or electrical
shock.

The medical definition of shock is ‘inadequate tissue perfusion, caused by a fall in blood
pressure and blood volume’. This means there is an inadequate supply of oxygenated blood to
the tissues of the body.

Understanding what shock is can help understand why casualties who are in shock need
immediate treatment, or the condition can result in death.

The most common causes of life threatening shock are:

• Hypovolaemic Shock.
• Cardiogenic Shock.
• Anaphylactic Shock.

Hypovolaemic Shock
Hypo = low vol = volume aemic = blood

Hypovolaemic shock is caused by loss of bodily fluids, the result of which is low blood
volume. Hypovolaemic shock is usually caused by:
• External bleeding.
• Internal bleeding.
• Burns.
• Vomiting and diarrhoea.
• Excessive sweating.

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Signs and symptoms
Usually the first response is a release of adrenaline which will cause:
• Pulse rate to rise.
• Pale, clammy skin. For dark skinned casualties check the colour of the skin inside the lips.
As the condition deteriorates:
• Shallow, fast breathing.
• Nausea or vomiting.
• Weak, rapid pulse.
• Dizziness or weakness.
• Cyanosis (grey/blue tinge to lips and skin).
• Sweating.

As the brain receives less oxygen:

• Deep, sighing breathing (air hunger).
• Unconsciousness.
• Anxiety, confusion, possible aggression.

Treatment of Hypovolaemic Shock

• Try to treat the cause of the shock (e.g. external bleeding).
• Lay the casualty on a flat surface (preferably the floor) and raise their legs so they are above the chest
(heart). This will cause the blood to return to the vital organs as 40% of the body’s blood is in the
legs. Take care if you suspect a fracture.
• Dial 999 for an ambulance immediately.
• Keep the casualty warm – place a blanket or coat under the casualty if they are on the floor or other
cold surface. However, be careful not to overheat them as this dilates the blood vessels which will
cause their blood pressure to drop further.  Do not allow the casualty to drink, eat or smoke. Nil by
mouth is best!
• Loosen any tight clothing such as ties and belts.
• Monitor the casualty’s breathing, pulse and response levels.
• Be prepared to perform CPR.

Cardiogenic Shock
This form of shock occurs when there is a fall in blood pressure caused by the
heart not pumping properly. This is the most common type of shock.

Typical causes of cardiogenic shock are:

• Heart attack.
• Tension pneumothorax.
• Cardiac failure.
• Cardiac arrest.
• Heart valve disease.

Signs, symptoms and treatment of cardiogenic shock

See section on heart conditions (page 30).
Anaphylactic Shock
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Anaphylaxis is an extremely dangerous allergic reaction which is brought on by
a massive over-reaction of the body’s immune system (see page 22).

An anaphylactic reaction may result in shock due to a large quantity of histamine.

This can result in:
• Blood vessels dilating which causes blood pressure to fall.
• Blood capillary walls may become ‘leaky’ causing blood volume to fall.
• Weakening of the heart’s contractions which causes blood pressure to fall.

Signs, symptoms and treatment

See section on anaphylaxis (see page 22)

Fainting

This reaction is caused by poor nervous control of the blood vessels and the heart.

When a casualty faints the blood vessels in the lower body usually dilate which slows the
heart. This results in falling blood pressure and the casualty has a temporary reduction in
blood supply to the brain.

Typical causes of fainting are:

• Fright or pain.
• Extended periods of inactivity (such as standing or sitting).
• Lack of food.
• Emotional stress.
• Heat exhaustion.

Signs and symptoms

• Temporary loss of consciousness resulting in falling to the floor.
• Before fainting the casualty may have had nausea, blurred vision, stomach ache or dizziness.
• Slow pulse.
• Clammy, pale skin.
• Quick to recover.

Treatment of fainting
• Lay the casualty on a flat surface, preferably the floor and raise their legs which will return the blood
to the vital organs and raise blood pressure.
• Check the casualty’s airway and breathing.
• Try to remove the cause of stress such as people crowding the casualty and allow plenty of fresh air.
• Reassure the casualty as they come to. Try to stop them from sitting up suddenly.
• If the casualty feels faint again, repeat the treatment and check for an underlying cause.
• If the casualty does not recover in a short amount of time and remain unconscious, or you are unsure:
check the airway and breathing again, place them in the recovery position and dial 999 for an
ambulance.
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 Wounds and bleeding

A wound is an abnormal break in the continuity of the tissues of the body. Any wound will, to
a greater or lesser extent, result in either internal or external bleeding. Severe blood loss
could result in shock, so it is important to treat wounds promptly. There are several types of
wound – identification and treatment are detailed here.

Types and basic treatment of wounds

Contusion is a bruise. Contusions are caused by ruptured capillaries bleeding under the skin.
Typically these are caused by a blow or by bleeds caused by an underlying problem such as
a fracture.
• Put an ice pack on the affected area, or place the area under cold running water as soon as
possible.

Abrasion is a graze. This is the result of the top layer of skin being scraped off, usually as the
result of a sliding fall or a friction burn. Abrasions can often contain particles of dirt which could
lead to infection.
• Any dirt that is not embedded in the graze should be removed with clean water and sterile swabs.
• Always clean from the centre of the wound outwards to reduce the risk of introducing more dirt into
the wound.

Laceration is a rip or tear in the skin. These are more likely to have particles of dirt than a cut
but tend to bleed less.
• Treat as a bleed (see page 36) and prevent infection.

Incision is a clean cut. These wounds are usually caused by a sharp object, such as broken
glass or a knife. If the wound is deep it could provide complications such as severed tendons
or blood vessels. These wounds tend to bleed freely and may even ‘gape open’.
• Treat as a bleed (see page 36) and prevent infection.

Puncture is a stab wound. These wounds can be caused by such implements as

a nail or actually being stabbed. The wound is likely to be deep but may appear to be small in
diameter. Damage may be deep, hitting underlying organs such as the lungs or heart, and
may cause severe internal bleeding.
• Dial 999 for an ambulance if you suspect the wound has penetrated deep enough to damage any
organs or cause internal bleeding.
• If the object is embedded in the puncture do not remove it as it may be stemming the bleed, and
removal may cause further damage.

Gun shot is caused by a bullet or other missile travelling at a high enough speed to drive into
and possibly exit the body. There may be a small entry wound and a larger, ‘crater’ exit wound.

Page | 40
Severe damage to internal organs should be assumed, and will be accompanied by severe
bleeding.
• Dial 999 for both an ambulance and the police.
• Clear the casualty’s airway and check for breathing first. Be prepared to commence CPR.
• Pack the wound with dressings if possible to prevent further bleeding.

Amputation is the complete or partial removal of a limb.

• See the section on amputation (see page 43).

De-gloved is the severing of the skin from the body, which results in a ‘creasing’ or a flap of
skin coming away and leaving a bare area of tissue. These wounds are usually caused by the
force of an object sliding along the length of the skin, in effect skinning it.
• If possible, put the skin back in place.
• Arrange transport to hospital urgently.

Blood loss

How much blood does a body have?

The amount of blood in a body varies depending on the size of the person. However, a rough
guide is that we have approximately a pint of blood for every stone in weight (0.5 litres per
7kg) so the average adult will have between 8 and
12 pints (4.5 to 6.5 litres) of blood depending on their size. However, this rule does not
work for someone who is overweight.

Bear in mind that children have less blood than adults and cannot afford to lose anywhere
near the same amount. A baby has only approximately 1 pint of blood and can only afford to
lose 1/3 of a pint before their blood pressure falls.

Types of bleeding
Arterial bleeds tend to spurt from wounds in time with the heart-beat, as blood
in the arteries is under direct pressure from the heart. A wound to a major artery
may result in the blood ‘spurting’ several meters instantly with the blood volume
rapidly reducing over time. Blood in the arteries is highly oxygenated and will
be bright red, however this may be difficult to assess so do not rely on it as a
form of identification. More importantly is how the wound is bleeding.

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Venous wounds are damage to veins which carry blood that is not under direct pressure from
the heart, but may carry the same volume of blood as the arteries. Wounds to a major vein
could ‘ooze’ profusely.

Capillary bleeds occur in all wounds. These bleeds may appear fast at first, blood loss
form capillary bleeds tend to be slight and is easily controlled. Capillary bleeds tend to
be described as a ‘trickle’.

Dealing with wounds hygienically

• Be sure to protect yourself by covering any of your own cuts or abrasions with a
waterproof dressing, especially if they are on your hands or arms.
• If they are available, wear disposable gloves and apron when administering first aid to
wounds.
• Use specific cleaning products for cleaning up bodily fluids. Always follow the instructions
and use disposable towels.
• Always dispose of soiled dressings or disposable towels used to clean up bodily fluid in a
yellow ‘clinical waste’ container. These need to be taken away and incinerated (send the
container to the hospital with the casualty if you have no clinical waste facilities where you
are).
• Always wash your hands thoroughly before and after dealing with a casualty. This helps
reduce the risk of infection.
• If you are dealing with body fluids on a regular basis, ask your doctor about vaccination
against hepatitis ‘B’.
Page | 42
The effects of blood loss
Please see the table below for the effects, signs and symptoms of blood loss.
The table gives the volume of blood loss as a percentage as we all have different quantities of
blood, depending on the size of the person.

Please note that a casualty who has lost 30% of their blood is in a critical condition, and
will deteriorate rapidly from this point onwards. Blood vessels cannot constrict anymore
and the heart cannot beat any faster so their blood pressure will fall, resulting in
unconsciousness and death.

Also, please be aware that any casualty who has lost over 10% of their blood should be
treated for shock (see page 33). See also hypovolaemic shock (see page 33/4) and
hypoxia (see page 16).

10% Blood loss 20% Blood loss 30% Blood loss40% + Blood
loss
Consciousness Normal Could feel dizzy Lowered levels of Unresponsive
while standing Consciousness
Restless &
Skin Normal Pale Cyanosis Severe cyanosis,
(blue/grey tinge of cold and clammy
skin & lips), cold
and clammy
Pulse Normal (this is Slightly raised Rapid (over 100 Undetectable
the usual amount bpm), hard to
taken when detect
donating)
Breathing Normal Slightly raised Rapid Deep sighing
breaths
(air hunger)
Treatment of external bleeding

The aim of treating external bleeding is firstly to stop the bleed, then prevent the casualty from
going into shock and finally to prevent infection.

The acronym SEEP should help you to remember the following steps:

Sit or lay Sit or lay the casualty down, ensuring they are in a position that is appropriate
for the location of the wound.

Examine Examine the wound for foreign objects and make a note of how the wound is
bleeding. Make sure to tell the medical staff how the wound was bleeding
once it is covered with a bandage.
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 Elevate Elevate the wound so that it is above the heart, which will use gravity to
restrict the flow of blood to the injury.

Pressure Apply direct or indirect pressure to help slow the bleeding.

Direct pressure:
Direct pressure to the wound is the best way of stemming a bleed. You can use your
hands to do this, but you should take precautions to minimise the risk of coming in
contact with the casualty’s blood, preferably by wearing disposable gloves. Keep
pressure on the wound continuously for at least ten minutes.
Using a firm bandage usually stops the bleeding with most minor wounds (make sure the
bandage is not so tight as to cut off the circulation to the limb altogether). If there is a
foreign object embedded in the wound do not remove it but you may be able to apply
pressure at either side of the object.

Indirect pressure:
If it is not possible or effective to apply direct pressure to a wound, you can use indirect
pressure as a last resort. This is achieved by applying pressure to the artery which is
supplying blood to the limb, pressing it against the bone beneath, reducing the blood
flow. This should be done for a maximum of ten minutes.

There are two indirect pressure points:

Brachial This artery runs along the inside of the upper arm. To help with this, ask the
casualty to make a fist with the opposite hand and place it under the arm pit of the injured arm
and ask them to squeeze down on the fist.

Femoral This artery is located where the thigh bone (femur) crosses the
‘bikini’ line. If applying indirect pressure here, be sure to explain briefly to the casualty what
you are doing and why. One way of applying indirect pressure here is to use the heel of your
foot.

Dressings:
Dressings should be sterile and just large enough to cover the wound. They should be made
out of a material that will not stick to the clotting blood and be absorbent (a ‘non-adherent’
dressing).

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Usually, a firmly applied dressing is enough to stem bleeding from the majority of minor
wounds, but any dressing should not restrict the flow of blood to the rest of the limb (you can
check the circulation with a ‘capillary refill’ test, see page 30).

If the bleeding is severe, it may be necessary to apply direct pressure by hand and elevate the
wound. If the dressing becomes soaked with blood, put a larger dressing on the top. If the
bleeding continues and soaks the second dressing, remove both dressings and start again. This is
to ensure any bacteria is removed from the wound with the first bandage.

Embedded objects

Objects embedded in a wound:

If there is an object embedded in the wound (other than a small splinter) you should
not attempt to remove it as it may be stemming a severe bleed, or further damage may
result.

Use sterile dressings and bandages to build up around the object, which will supply the
pressure needed to stem the bleed and help support the object. Take the casualty to hospital to
have the object removed safely.

Splinters:
If there is a splinter deeply embedded, difficult to remove or in a joint, do not try to
remove it but follow the advice for embedded objects as above. If the splinter can be
removed, follow the below advice:
• Carefully use warm soapy water to clean the area.
• Use a clean pair of tweezers to grip the splinter as close to the visible base as possible.
Gently pull the splinter out at the same angle it entered at.
• Gently squeeze around the wound to encourage a little bleeding then wash the wound and cover
with a dry dressing.
• Ask the casualty if they have had a tetanus shot in the last ten years, if not suggest they get one as
soon as possible.

Objects embedded in the ears, nose or other orifice:

If there is a foreign body stuck in a casualty’s ear, nose or other orifice, do not

Page | 45
attempt to remove it. Take them directly to hospital where it will be safely removed.

Nose bleeds

Nose bleeds are usually the result of weakened or dried out blood tissues in the nose. A nose
bleed can be triggered by a bang to the nose, picking or blowing it. However, it can be the
symptom of a more serious problem such as high blood pressure or a fractured skull.

• Have the casualty sit with their head tipped forward to allow the blood to drain.
• Gently pinch the soft part of the nose, and maintain constant pressure for 10 minutes.
• Tell the casualty to breathe through their mouth.
• Give the casualty some tissues or a cloth to clean up the blood while you maintain
pressure on the soft part of the nose.
• Once the bleeding has stopped, recommend to the casualty that they try to continue
breathing through their mouth and not blow their nose for the next couple of hours as this
may trigger another nose bleed.
• However, if the bleeding continues for more than 30 minutes, or they take an
‘anti-coagulant’ drug (e.g. warfarin), get them to hospital ensuring they stay in an upright
position.
• If the casualty has a history of frequent nose bleeds, recommend they visit their doctor to
determine why.

Internal bleeding

This is a very serious condition, but it can be very hard to recognise in the early stages.
Internal bleeding can be attributed to lung or abdominal injuries, but can also happen
spontaneously to someone who appears well, such as a bleeding stomach ulcer or a weak
artery.

Even though the blood is not lost from the body, it is lost internally out of veins or arteries
and can quickly cause the casualty to go into shock.

Internal bleeding can result in serious, life threatening complications such as a brain
haemorrhage or bleeding into the lungs.

Signs and symptoms:

You should be aware and looking for internal bleeding if there are signs of the casualty
going into shock, but there is no obvious cause such as external bleeding.

There may be:



• Shock (see page 33).

• Pain or a recent history of pain at the site of the bleed.
P aBrge u| 46isi ng and/or swelling.
Other symptoms at the site of the bleed (such as difficulty with breathing if there is
bleeding in the lungs).

Treatment of internal bleeding:

• Dial 999 for an ambulance immediately.

Page | 47


Treat the casualty for shock (see page 33).

Poisons

Poisons can be defined as a liquid, solid or gaseous substance that causes damage to
the body when it enters in sufficient quantity.

There are 4 ways a poison can enter the body:

Ingested The substance is swallowed, either by accident or on purpose.

Inhaled The substance is breathed in, entering the blood stream very quickly
through the alveoli.

Absorbed The substance comes in contact with skin (see chemical burns, page 49).

Injected The substance is introduced through the skin directly into tissue or a blood
vessel.

A poison can be one of two things:

Corrosive These include acids, bleach, petrol, ammonia, dishwasher powder,

turpentine, etc.

Non-Corrosive These include tablets, plants, drugs, perfume, alcohol, etc.

Signs and symptoms:

There are a wide variety of signs and symptoms for poisoning, depending on the substance.
Some clues you can look for are:
• Bottles or containers.
• Tablets or drugs.
• Syringes or drug taking paraphernalia.
• Smell on the casualty’s breath.

Some other signs that can accompany poisoning may be:

• Nausea, retching or vomiting.
• Abdominal pain.
• Burns (or a burning sensation) around the area of entry.
• Problems breathing.
• Hallucinations or confusion.

Page | 48


• Headache.
• Unconscious. Sometimes the casualty may start fitting.
Cyanosis.

Treatment for poisoning:

For a corrosive substance firstly make sure that your safety is secure – is it safe to help the
casualty?

Dilute or wash away the substance if possible:

• Substance on the skin – see chemical burns (see page 49).
• Ingested substances – try to get the casualty to rinse their mouth, then give frequent sips
of milk or cold water.
• Dial 999 for an ambulance immediately. Give clear and concise information about the
poison if possible. Follow any advice given by the ambulance operator.

• If the casualty becomes unconscious, immediately open the airway and check for
breathing. If they are not breathing commence CPR using a protective face shield. If the
casualty is breathing but unconscious, place them in the recovery position and dial 999
for an ambulance immediately.

Never try to get the casualty to vomit as this may damage the airway.

For non-corrosive substances:

• Dial 999 for an ambulance immediately. Give clear and concise information about the
poison if possible. Follow any advice given by the ambulance operator.
• If the casualty becomes unconscious, immediately open the airway and check for
breathing. If they are not breathing commence CPR using a protective face shield. If the
casualty is breathing but unconscious, place them in the recovery position and dial 999
for an ambulance immediately.

It will be of help to the paramedics if you:

• Pass on the container the substance was in, or pass on any information you may have
regarding what the casualty has taken.
• Let them know how much was taken, if you are able to ascertain this information.
• Let them know when the substance was taken, if you can ascertain this information.
• Keep any sample of vomit from the casualty for hospital analysis.

Burns and scalds

Estimating the severity of a burn:

There are five factors that affect the seriousness of a burn:

Page | 49
Size The larger the area of the burn the more severe it is likely to be. The size is usually
given as a percentage of the body’s surface area. An easy way to work out the
percentage is to compare the size of the burn to the casualty’s hand. The casualty’s
open hand (including the fingers) is the equivalent to 1% of their body
area.

Cause The cause of the burn will influence the severity of the burn, for example
electrical burns could leave the casualty with internal burns and some chemicals
(such as hydrofluoric acid) may cause poisoning to the burns as an added
complication.

Age The casualty’s age will affect the severity of the burn and how long their
recovery rate will be. Babies and young children will burn at a lower temperature
than adults will. The elderly will take longer to heal from a burn and they may be
more susceptible to infection.

Location The location of the burn may affect the severity, in particular the inhaling of hot
gasses will burn the airway resulting in instant death. Burns to the eye may well
result in permanent blindness.

Depth The deeper the burn, the more severe it is going to be.

Depth of burns:
Skin consists of three layers, these are the epidermis on the outside, the dermis
underneath which lies on a layer of subcutaneous fat.

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The depth of a burn can be defined as:

Superficial This is a burn only to the outer epidermis layer. This is most
commonly caused by scalds. The burn looks sore, red and swollen.

Intermediate These burns affect both the epidermis and the dermis. These burns
look raw and blisters will form.

Full thickness With this type of burn, both the epidermis and dermis are burned away
completely, leaving the exposed subcutaneous
fat or beyond. These burns may appear pale, charred or waxy. The
casualty’s nerve endings will have been burned away so pain may well be
absent which can mislead both you and the casualty.

Causes of burns and treatment

Burns can be separated into five different areas, the treatment for each burn will differ
slightly depending on the cause.

Electrical burns:
These burns are caused by heat from an electrical charge flowing through the bodily tissue.
You may be able to determine where the current entered the body, and the point of exit, but
there will certainly be deep internal burns which are
not visible to the eye between the entry and exit burns. The extent of the internal damage can
usually be guessed at by the severity of the entry and exit
burns.

An electric shock may well cause cardiac arrest, so be prepared to perform CPR.
Remember in this case that the casualty’s airway and breathing are the priority.
• Ensure that it is safe to approach and help the casualty – never put yourself in harm’s way.
Make sure the contact between the casualty and the electrical current is broken.
• Make sure to maintain the casualty’s airway and breathing.
• Try to irrigate the area of the burn, including the area between the entry and exit burns for
at least ten minutes.
• Dial 999 for an ambulance immediately.
• Continue treating the casualty as you would for a ‘dry heat’ burn.
Dry heat burns:
These burns are caused by any dry heat source or friction.

• Ensure it is safe to approach and help the casualty – never put yourself in harm’s way.
• Make sure to maintain the casualty’s airway and breathing.

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• Try to take the heat out of the burn by using cold (preferably running) water for about 10 to
15 minutes. If water is not readily available, any other cold, non-harmful liquid such as
milk may be used, as some cooling to the burn is better than none. Do this initially, and
move to an area where there is running water available if possible. Be careful not to cool
large areas too much as this may cause hypothermia.
• If possible, remove any rings, watches, bangles, etc., during cooling as the burned area will
swell. If there is any clothing that is not stuck to the burn it may be removed very
carefully.
• Use a sterile dressing on the burn, making sure it is one that will not stick.
Cling film is one of the best ways of dressing a burn, as it doesn’t stick and will stop
any infection entering the wound. Remove the first two turns of the roll and apply it
lengthwise to the burn. Do not wrap it tightly around the burn as the area may swell and
cause further discomfort to the casualty. Secure the cling film with a bandage.
• Alternatively, you can use a new, clean plastic bag, low adherent dressing or specialised
burn dressings if they are available. However, do not rely on the specialised burn dressing
to cool the burn, use cold water to do this.
• Dial 999 if the burn appears to be severe or the casualty has breathed in smoke or
fumes.

Wet heat burns (scalds):

Scalds most commonly occur due to contact with boiling water, but can also be from hot fat
or other liquids that reach higher temperature than water.

• Treat as you would a dry heat burn.

Chemical burns:
These are caused by chemicals coming into contact with the skin which either corrode,
create heat, or both.

If chemicals are used in your place of work, it is very important for you to learn the
correct first aid procedures. Remember, different chemicals require different first aid
treatment.

• Make sure the area is safe, try to contain the chemical and ensure that you will not come
into contact with it.
• If the chemical is a dry powder, it can be brushed off the casualty’s skin before treatment.
Make sure that you protect yourself.
• Use lots of cold running water to wash the chemicals off the skin. This should be done for a
longer period of time than for a thermal burn, at least 20 minutes. Be careful not to wash
the chemical onto unaffected areas of the body. Try not to let any contaminated pools of
water collect under the casualty.
• Dial 999 for an ambulance immediately. Take note of what the chemical is and give this
information to the ambulance operator if you can.
• Carefully remove any contaminated clothing from the casualty while you are washing the
burn.

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• If the chemical is in the casualty’s eye, wash it as recommended on page 43, making sure
the water runs away from the casualty’s uninjured eye.
• Some chemicals cannot be safely diluted with water, in this case health & safety regulations
insist that an ‘antidote’ be available in case of an emergency. You and any other first aider
should be trained in the use of the antidote.

Radiation (sun) burns:

These are most commonly seen as sunburn.

• Persuade the casualty to get out of the sun, preferably indoors.

• Give the casualty frequent sips of water to stave off heat exhaustion (see page 63).
• Cool the burns with cold water. If, however, the burns are extensive, cool them under a cool
shower or get the casualty to sit in a bath of cool water for 10 minutes.
• If the burns are extensive and blistering, or you are unsure, seek medical advice.
• If the burns are mild, then you can apply after sun cream or calamine lotion to help soothe
the area.

Seek medical advice for burns if:

• The burn is larger than 1 square inch.
• The casualty is a baby or child.
• The burn is all the way around a limb.
• Any part of the burn appears to be full thickness.
• The burn is to the hands, feet, genitals or face.
• You are not sure.

Never do any of the following when burns are concerned:

• Burst a blister or blisters (the blisters are there to protect against infection).  Touch the
burn.
• Apply lotions, ointments or fats to a burn as they may introduce infection and will need to
be removed once the casualty is in hospital
• Apply adhesive tape or dressings as the burn may be larger than it first appears.
• Remove clothing that is stuck to the wound, as this will invariably cause more damage.

The skeletal system

There are 206 bones in the human skeleton, the functions of which are:

• To provide support to the body’s soft tissue. This gives the body its shape.
• To provide protection for vital organs such as the brain, lungs and spinal cord.
• To allow movement by incorporating different types of joints and attachment for muscles.
• To produce red blood cells, some white blood cells and platelets within the marrow of
bones such as the femur.
• To provide a store of minerals and energy, such as calcium and fats.

Page | 53
 Causes of injury

Different types of force can cause injury to the bones, muscles and joints.

Direct force Damage will result at the location of the force, such as a kick or
blow.

Indirect force Damage will result away from the point where the force was
applied, for example a fractured collar bone may result from
landing on an outstretched arm.

Twisting force Damage will result from torsion force on the bones and muscles,
for example a twisted ankle.

Violent movement Damage will result from sudden, violent movements, for example
a knee injury from violently kicking.

Page | 54
Pathological Damage will result from the bones becoming weak or brittle
due to disease or old age.

Types of fracture

A fracture is a ‘break in the continuity of the bone’. These are the basic categories
for a fracture:

Closed A clean break or crack to the bone with no complications arising.

Open A broken bone will break the skin, and may or may not still be protruding from the
wound. Please bear in mind that these types of injury carry a high risk of
infection.

Complicated There are usually complications with this type of fracture, such as trapped
blood vessels or nerves.

Green stick These are more likely to occur in children who have young, more flexible
bones. The bone splits, but is not completely severed. Green stick fractures
can easily be mistaken for sprains and strains as only a few of the signs of
fracture are present.

Dislocations

A dislocation occurs when a bone becomes partially or completely dislodged at the joint,
usually resulting from a wrenching movement or sudden muscular
contraction. The most common areas of dislocation are the jaw, thumb, knee cap, shoulder
or finger.

Fractures can occur at or near the site of a dislocation, along with damage to ligaments,
tendons and cartilage. It is sometimes difficult to distinguish between a fracture and a
dislocation.

Never try to manipulate a dislocated joint back into place as this is best left to medical
experts, and the process can be extremely pa inful and traumatic to the casualty. Also, you
may inadvertently cause further damage.

Sprains and strains

A sprain is an injury to the ligament at a joint. A strain is an injury to a muscle. These types
of injury are usually caused by sudden wrenching which causes the joint to over stretch
tearing the surrounding muscles and ligaments.

Page | 55
Minor fractures can be easily mistaken for a sprain or a strain. If you have any doubts, treat
the injury as if it were a fracture to be on the safe side. The only way you can be sure if it is
or is not a fracture is by x-ray.

Signs and symptoms of fracture:

Pain Pain will occur at the site of the fracture. The casualty may have
taken strong pain killers, have nerve damage or dementia, so be
aware.

Loss of power For example, the casualty will not be able to lift
anything with a fractured arm.

Unnatural movement If a limb is moving in an unnatural way, it is likely to be an

‘unstable’ fracture and care should be taken to prevent the
fracture from moving and causing further damage.

Swelling and bruising This usually occurs around the site of the fracture.

Deformity If the limb is bent in the wrong place, it is broken.

Irregularity There will be lumps or depressions along the surface of a bone

where the broken ends overlap.
Crepitus This is the feeling, or sound, of bone grating on bone when the
broken ends rub together.

Tenderness This occurs at the site of the injury.

Treatment of a basic fracture:

See also:
• Head injuries (see page 13)
• Flail chest (see page 27)
• Spinal injuries (see page 55)

• Reassure the casualty and tell them not to move.

• Use your hands to keep the injury still until it can be immobilised professionally. The
casualty may be able to do this on their own, but bear in mind they may be in shock.
• Do not move the casualty before the injury is immobilised, unless they are in direct danger
(as in the middle of a road).

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• Do not try to bandage the injury if you have already called for an ambulance, just keep it
still. If there is an open wound, you may cover it with a sterile dressing while you wait for
help.
• Do not allow the casualty to eat, drink or smoke, as they may need surgery later.

For injury to an upper limb:

• Carefully, and gently place the arm in a sling against the body. It is common to use a
support sling for arm fractures. For collar bone fractures, it is common to use an elevated
sling (keep the casualty’s elbow down at their side when using an elevated sling for a
fractured collar bone).
• Should the casualty be in severe pain, circulation or nerves to the arm are affected, the
casualty is having problems breathing or you are at all unsure dial 999 for an ambulance
immediately.
• Arrange for the casualty to be transported to hospital.

For injury to a lower limb:

• Keep the casualty still, and ensure they are kept warm. Dial 999 for an ambulance
immediately.
• If there is any delay to the ambulance reaching you (for example you are in a remote part
of the country) immobilise the injury by gently bandaging the injured leg to the uninjured
one.
• Check that their circulation has not been cut off beyond the injury and bandages.
If necessary, loosen the bandages.
Treatment of sprains and strains:
The best way to treat sprains and strains is to follow the RICE mnemonic:

Rest Ensure the casualty rests the injury. For example, do not allow a sportsman to
continue (remind them it is better to miss one game than the next ten!).

Ice As soon as you can, apply an ice pack (frozen vegetables such as peas or,
if you have it, a refrigerant gel pack). This helps to reduce swelling and
speeds recovery. Be sure not to place the ice pack directly onto the skin, as
this can cause frostbite. A tea towel or any sort of thin barrier will suffice.
Do this for 10 minutes every 2 hours

for 24 hours for maximum effect.

Compression Apply a firm (not constricting) bandage to the injured area. This also will
help reduce the swelling, and provide support. The bandage can be applied
over an ice pack for the first ten minutes, but be sure to remove the ice pack
after this time.

Elevate Elevate the injury, as this helps reduce swelling.

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Please bear in mind that minor fractures can very easily be mistaken for a sprain or strain.
The only way to be sure there is no fracture is to send or take the casualty to hospital for an
x-
ray.

Spi na l i njuri es

Approximately 2% of trauma (injury) casualties suffer spinal injury. Although this percentage
appears to be fairly low, suspecting and correctly treating a spinal injury is essential. Poor
treatment of a casualty with a suspected spinal injury may result in them being crippled for
life, or even in death.

The spinal cord is an extension of the brain stem, and is located down the back of the spinal
vertebrae. The spinal cord houses vital nerves which control breathing and movement. The
most vulnerable part of the spinal column is the neck, and a neck injury can often be the most
severe type of spinal injury. This is because as mentioned, the nerves controlling breathing
are

housed here and may become severed.

Suspected spinal injury:

Always assume the worst if the casualty has:
• Received a blow to the head, neck or back (this is especially important if the blow results in
a loss of consciousness).

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• Fallen from a height. For example, from a horse, a ladder or off a roof.
• Dived into shallow water.
• Been involved in a speed accident like a car accident, or been knocked down.
• Been in a ‘cave in’ type accident (e.g. crushing, or a scrum in rugby union).
• Multiple injuries.
• Any pain or tenderness to the neck or back after being involved in an accident. However, be
aware that strong pain killers or other severe injuries may mask the pain that would
normally alert you to a spinal injury.
• You are in any doubt at all. Remember with this kind of injury it is better to be safe than
sorry.

Possible signs and symptoms of a spinal injury:

Please remember – if any of the signs and symptoms below are present, nerves may already
have suffered damage. Always treat a casualty that you s usp ect of having a spinal injury to
p reven t the signs and symptoms developing.

• Any pain or tenderness in the neck or back.

• Any sign of a fracture to the neck or back.
• Loss of control or sensation in limbs below the site of the injury.
• A feeling of pins and needles, or a burning sensation in the limbs.
• Difficulty breathing.
• Incontinence.

Treatment of spinal injury:

If the casualty is conscious:
• Tell the casualty not to move and keep reassuring them.
• Do not allow the casualty to move or be moved, keep them in the position you found them
in until help arrives. They should only be moved if they are in severe and immediate
danger.
• It is vitally important to immobilise the casualty’s head. Do this with your hands on either
side and try to keep their head and neck in line with the upper body.
• Dial 999 for an ambulance immediately. Keep the casualty still and warm until help
arrives.

If the casualty is unconscious:

• Do not move, or allow the casualty to be moved unless they are in severe and
immediate danger.
• Check their airway and breathing. If they are breathing fine on their own, the airway is
clear so there is no need to move the head back. However, if need be you can use the ‘jaw
thrust’ technique to keep the airway open without moving the head (this technique is
explained on page 58). Keep a close eye on their breathing.
• Dial 999 for an ambulance immediately.
• Using your hands, keep their head still and in line with their upper body.
• If for any reason you have to leave the casualty, if they begin to vomit or if you have
concerns about their airway at all, place the casualty in the recovery
position. Make sure you keep the head, neck and upper body in line when you turn the
casualty. To do this effectively, you will inevitably need more than one rescuer, so get

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 local help if you can (see page 55 for instructions on how to place a suspected spinal
injury casualty in the recovery position).
• Keep the casualty still and warm. Keep a close eye on the airway and breathing until help
arrives.

If the casualty is not breathing normally:

• If the casualty is having trouble breathing the airway will need to be opened. The head tilt
may be used, but the tilt should be kept to a minimum to allow unobstructed rescue breaths
to be administered.
• Only if you are trained and confident, you can try to use the ‘jaw thrust’ technique. If
this does not work and the casualty is still not breathing normally, you should open the
airway using the head tilt method before carrying out resuscitation.
• Check their breathing once the airway has been opened.
• If this does not help and the casualty is still having problems breathing dial 999 for an
ambulance immediately, then carry out resuscitation.
• Try to obtain the help of others; they can support the head while you perform
resuscitation.

Remember – if the resuscitation results in paralysis from a neck injury it is a tragedy, but
failing to maintain an open airway will result in death.

Managing the airway with a spinal injury casualty

If an unconscious casualty is laid on their back, the airway is in danger of becoming

blocked by vomit or their tongue sliding back.

An uninjured but unconscious casualty can simply be turned into the recovery position to
help protect the airway. However, if a spinal injury is suspected, you must take great care not
to move the spine.
If the casualty is already lying on their side (not on their backs) you may not need to move
them at all. Check that the airway is not in danger of becoming blocked by vomit or their
tongue. If not, keep the casualty in the position you find them.

Try to monitor the casualty’s breathing, if it is normal you may be able to keep them still until
the ambulance arrives, even if the casualty is on their back.

However, should the tongue slide back or the casualty vomit then immediate action is
required to keep their airway clear.

Jaw thrust:
If the casualty is breathing, but the tongue is starting to slide back and obstruct the airway

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(the casualty starts making a snoring sound when they breathe) then
the jaw thrust technique can be employed to keep the airway open:
• Kneel at the casualty’s head, knees apart to keep your balance.
• Rest your elbows on your legs (or the floor) for support and hold the casualty’s head with
your hands, keeping their head and neck in line with the body.
• Place your middle and index fingers under their jaw line (under the ears).
• Keeping their head still, lift the jaw upwards with your fingers. This action gently lifts the
tongue away from the back of the throat keeping the airway clear.

Do not attempt the jaw thrust technique during CPR – tilt their head back instead to
open the airway.

Log roll:
If you have to leave the casualty for any reason, if they begin to vomit or you are at all
concerned about their airway being clear, the casualty will have to be put on their side.
Always remember to keep the head, neck and upper body in line when you turn the
casualty.

The most effective method of turning a casualty with a suspected spinal injury is the log roll
technique.
However, you will need at least three helpers to perform this on the casualty:
• Supporting the head of the casualty, keep the head, neck and upper body in line.
• The helpers should kneel along one side of the casualty. Ask them to gently straighten the
casualty’s arms and legs.
• Ensuring that you all work together, ask the helpers to roll the casualty towards them on
your count of three. You should gently move the head in time with the body as the helpers
roll the casualty onto their side.
• Make sure you keep the head, neck, body and legs in line the whole time. If
you can, keep the casualty in this position until the ambulance arrives.

Recovery position:
In the event that you have to turn a casualty onto their side to protect their airway, but
you are on your own, you will have to use the recovery position
method. Keep the head, neck and body in line to the best of your ability as you roll the
casualty onto their side. Have some form of padding to hand (e.g. a folded coat or
jumper) to help support the casualty’s head once they are on their side.

If you do have one or two others with you, you should keep the casualty’s head supported
while the helper(s) turn the casualty.
• Start by keeping the casualty’s head supported, keeping the head, neck and upper body in
line.
• Ask your helper(s) to gently manoeuvre the casualty’s arms and legs into position, ready to
turn the casualty into the recovery position.
• Ensuring that you work together, the helper(s) should roll the casualty into the recovery
position. The helper(s) should pull equally on the casualty’s far leg and shoulder as they

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 turn the casualty, keeping the spine in line. You need to gently move the head to keep it in
line with the upper body as the casualty is turned.

Effects of heat and cold

This part of the notes deals with the effects of over exposure to both heat and cold on the
body.

Severe Hypothermia or Heat Stroke can be potentially fatal conditions and require
skilful treatment from the first aider.

Those who are most at risk from these conditions are babies, children, the elderly or
infirm and people who take part in outdoor activities like hiking, sailing or running a
marathon.

Body temperature

The ideal temperature for the body to work at is 37°C (98.6°F). The temperature is
maintained by an area of the brain known as the ‘hypothalamus’. If the body should become
too hot we start to sweat, which evaporates from the skin cooling it down. Blood vessels near
the surface of the skin dilate (which causes skin to flush) and the cooled blood is then
circulated around the body.

If the body should become too cold we start to shiver, which creates heat from
our muscles moving. Blood vessels near the surface of the skin constrict (which causes skin
to appear pale), keeping the blood closer to the warmer core of the body. The hair on the skin
stands up, trapping warm air (better known as goose pimples).

Injuries that result from exposure to extremes of temperature can be ‘localised’ (for example
sunburn and frostbite), or ‘generalised’ (for example hypothermia and heat stroke).

Signs and symptoms of changes to body temperature:

The symptoms of over-exposure to heat or cold can be seen in the table below. As the body’s
temperature rises and becomes too hot or drops and becomes too cold, the hypothalamus
stops working, and the condition rapidly deteriorates as the body stops fighting the
condition.

Temperature Conditin Symptom

s
109.4-104°F / 43-40°C Heat Unconsciousness / fitting.
stroke Confused / restless.

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 Headache, dizzy,
uncomfortable.
Strong, pounding
pulse.
Flushed, dry skin, hot to the touch.
104-100.4°F / 40-38°C Heat exhaustion Cramps in stomach / arms / legs.
Pale, sweaty skin.
Nausea / loss of appetite.
100.4-96.8°F / 38-36°C Norma Normal body temperature.

96.8-89.6°F / 36-32°C l Shivering.

Mild hy po thermia
Fatigue, slurred speech.
Confusion,
forgetfulness. Shivering
stops, muscle rigidity.
Very slow, very weak
pulse. Noticeable
drowsiness.
87.8-75.2°F / 31-24°C Severe hypothermia Severe reduction in response
levels. Unconsciousnes s. Dilated
pupils. Pulse undetectable.
Appearance of death. Death.

Hypothermia

Hypothermia will occur when the core temperature of the body falls below
35°C. If the casualty is suffering from the mildest form of hypothermia, they will usually
make a full recovery with professional treatment. Should the casualty’s core body
temperature fall below 26°C, it will most likely be fatal. However, there have been cases
of successful resuscitation of casualties with body temperatures of as low as 10°C, so it’s
always worth the attempt.
The usual cause of hypothermia is over exposure to cold temperatures, but the different
types of casualty and condition may have an effect on the risk:

• The hypothalamus of a baby or young child is underdeveloped, which can lead to

hypothermia from as little as a cold room.
• The elderly or infirm tend not to generate as much body heat so any prolonged time in the
cold will lower their core temperature.
• Wet clothes or submersion in cold water results in the body cooling much faster than when
dry, as water conducts heat away from the body.
• Inadequate clothing in windy weather will result in cold air in continuous contact with skin,
resulting in the body cooling faster.

Signs and symptoms:

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• Skin appears pale and cold to the touch.
• Initial shivering, with the body stiffening as the body cools further.
• Bodily functions slow, including pulse, speech, breathing and thought.
• Appears to be drunk – lethargic, confused, disorientated.
• Lowered levels of response leading to unconsciousness and finally death.

Treatment of hypothermia:

If the casualty is unconscious:

• Clear the airway and check the casualty is breathing. If not, commence CPR.  Dial 999
for an ambulance immediately.
• If the casualty is breathing, carefully place them in the recovery position. Do not move the
casualty unnecessarily as the slightest jolt may cause the heart to stop.
• Place insulating materials, such as blankets, under and around the casualty making sure to
cover the head.
• Remember to monitor the casualty’s breathing. Their pulse may be hard to locate, but it
is safe to assume the casualty’s heart is beating if they are breathing.

If the casualty is conscious:

• Try to get the casualty to shelter if possible, remove any wet clothing and replace with dry,
warm clothing. Cover the head, as a lot of heat is lost here.
• If the casualty is young, fit and able then ask them to get into a warm bath (40°C / 104°F).
Do not allow an elderly casualty to do this.
• If the option of a bath is not viable, wrap them in warm blankets, heat the room to a warm
temperature (25°C / 77°F).
• If the casualty is outdoors, try to insulate them from the environment as much as possible.
Use a survival bag and shelter if you have them. Also share your body heat with them.
• Give the casualty something warm to drink and eat.
• Seek medical advice if the casualty is a child, elderly or you are unsure about their
condition.
• If their condition appears severe, dial 999 for an ambulance immediately.

It is vital to NEVER:
• Give the casualty alcohol, as it dilates blood vessels which will cool the casualty further.
• Place a heat source directly on or near the casualty, this will draw the blood to the skin
causing the blood pressure to fall and place stress on the heart.
• Try to warm a baby or elderly person quickly by placing them in a warm bath.

A hypothermia casualty’s heart is in grave danger of ‘ventricular fibrillation’, which causes

cardiac arrest. Always handle a hypothermic casualty with care as the slightest jolt can
induce
the condition.

Health & Safety (first aid) Regulations 19 81

Employer’s responsibility:
It is the responsibility of the employer to make sure sufficient first aid provision is made in
the workplace, under Health & Safety law. This includes:

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• Assessing the first aid needs of the workplace – how many first aiders are needed, what
type of training is required, are they following the guidance from the HSE (Health & Safety
Executive).
• Provide training and re-qualification courses for the appointed first aiders.
• Ensure there are enough first aid kits and equipment for the workplace, and that they are
well stocked.
• Ensure that all staff are aware who the first aiders are and where to find them should they
need treatment.

Following is advice for employers on their responsibilities, but first aid training organisations
are usually happy to give further advice if needed.

First aid kits

The first aid kit should be easily accessible; preferably near somewhere the first aider can
wash their hands. The kits should be easily identified by a large white cross on a green
background. The container should protect the contents from dust and damp.
First aid kits should be available at all workplaces. However, larger sites will need more than
one first aid kit to cover the greater amount of people. The kits should contain the following,
as a guide only:
• A leaflet with general guidance on first aid.
• 20 individually wrapped sticking plasters of assorted sizes and absorption, suited to the type
of work (e.g., blue plasters are to be used by food handlers, as they are highly visible).
Hypoallergenic plasters can be provided too.
• 2 sterile eye pads.
• 4 individually wrapped triangular bandages, preferably sterile.
• 6 safety pins.
• 6 individually wrapped medium, sterile wound dressings (approx. 12cm x 12cm).
• 2 individually wrapped large, sterile wound dressings (approx. 18cm x 18cm).
• 1 pair of disposable gloves. Please remember some people are allergic to latex, so try to
find an alternative (such as Nitrile).

The above contents are not mandatory and equivalent items can be used. You can also add
items such as scissors, adhesive tape, disposable aprons, individually wrapped moist wipes,
face shields, etc. Keep them in the first aid kit, if there is room, or nearby if not.

You may also wish to consider keeping other equipment close to the first aid kit such as
blankets (to help protect casualties from the elements, keep them warm if they are in shock,
etc.), breathing apparatus (should the first aider need to enter a dangerous atmosphere), etc.

Eye wash:
If there is no access to tap water for eye irrigation, there should be at least 1 litre of sterile
water, or ‘saline’ solution available in a sealed, disposable
container(s).

Travelling first aid kits

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If the employees travel, it is advisable to provide them with a first aid kit, which will
typically include:
• A leaflet with general guidance on first aid.
• 6 individually wrapped sterile plasters.
• 2 individually wrapped triangular bandages, preferably sterile.
• 2 safety pins.
• 1 individually wrapped large, sterile wound dressing (approx. 18cm x 18cm).
• Individually wrapped moist cleansing wipes.
• 1 pair of disposable gloves. Please remember some people are allergic to latex, so try to
find an alternative (such as Nitrile).

First aid needs assessment

Employers must carry out a first aid needs assessment, which should answer the following
questions:
• What is the nature of the work? What are the hazards and risks of the workplace?
• What is the size of the organization?
• What is the nature of the workforce?
• What is the organization’s history of illness and accidents?
• What are the needs of travelling, remote or lone workers, if applicable?
• What are the work patterns (such as shift work)?
• What is the distribution of the workforce?
• How far away is the closest emergency medical service (medical centre, etc.)?
• How many employees are there working on shared or multi-occupied sites?
• Are there enough first aiders to cover each other over annual leave and other absences?
• Is there first aid provision for non-employees?

Workplace hazards and risks

One of the more difficult areas of a first aid needs assessment is taking into
consideration the nature of the work and workplace hazards and risks.

Employers should take into consideration the risks and identify the possible injuries which
could occur in order to ensure the first aid provision is sufficient. The table below, compiled
using information from the HSE, should help in identifying some common workplace risks,
and the possible resulting injuries:

Risk Possible
injuries
Manual Handling Fracture, laceration, strain and sprain
Slip / Trip Hazard Fracture, laceration, strain and sprain
Machinery Crush injury, amputation, fracture, eye injury, laceration
Work at Height Head injury, unconsciousness, spinal injury, fracture, strain and
sprain
Workplace Crush injury, fracture, spinal injury, strain and sprain
Transport
Electricity Electric shock,

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 burns
Chemicals Poison, unconsciousness, burns, eye injury
All these aspects should be taken into consideration by the employer to
determine how many people should be trained in first aid, and to what level to
ensure their workplace is safely covered.

First aiders

An employer should consider a number of things when choosing an employee

to be a first aider. Ideally, a first aider will have the following:  Reliability,
good disposition and communication skills
• An aptitude and ability to absorb new skills and knowledge
• An ability to cope with stressful and physically demanding emergency procedure
• Normal workplace duties that can be left if an emergency situation arises

As of October 2009, there have been introduced a new training regime for first
aiders. The HSE (Health & Safety Executive) have introduced two levels of first
aider:
• First Aider at Work
• Emergency First Aider at Work

Child resuscitation:
Danger
Make sure you are safe to help, do not put yourself in danger

Response
• Gently tap the child’s shoulders and shout ‘are you alright?’
• If the child does not respond shout for help, but don’t leave the child yet

Airway
Carefully ensure the airway is open by gently tipping the child’s head back with the ‘chin
lift’:
• Place your hand on the child’s forehead and gently tilt their head back
• Using your fingertips under the point of the chin, lift the chin to open the airway

Breathing
Ensuring the airway is kept open; look, listen and feel to ascertain whether the child is
breathing normally. Do not take more than ten seconds to do this.
• If the child is able to breath normally, carry out a secondary survey and place the child in
the recovery position (see page 12)

If the child is not breathing normally:

• If you are not alone, ask the nearest person to dial 999 for an ambulance immediately. If
you are alone and need to leave the child to ensure help is on the way, perform resuscitation
for about 1 minute first:
• Maintain the child’s airway by tilting their head and lifting the chin
• Pinch the fleshy part of the nose and seal your mouth around the child’s

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• Give 5 initial rescue breaths. Blow in just enough air to make the child’s chest rise visibly
Combine rescue breaths with chest compressions:
• Using 1 or 2 hands as required to depress the child’s chest a third of its depth
• Give 30 chest compressions at a rate of 100 compressions per minute
• Open the airway again by tilting the child’s head and lifting the chin, and give 2 more
rescue breaths
• Continue to administer 30 chest compressions followed by 2 rescue breaths

If your rescue breaths do not make the child’s chest rise effectively:
Give a further 30 chest compressions before attempting the following:
• Check inside the mouth and remove any clearly visible obstruction (do not reach blindly
into the child’s throat)
• Recheck that the head is adequately tilted back, and the chin is lifted
• Do not administer more than 2 rescue breaths before resuming chest compressions

Note: If there is another rescuer with you, change over every two minutes to prevent either of
you getting fatigued. Ensure as short a delay as possible as you change over.

Appendix: Resuscitation – baby under 1 year:

NOTE: This section deals with the differences between adult and baby resuscitation.

REMEMBER: If you are at all unsure, it is better to perform the adult sequence on a child
who is unresponsive and not breathing than not to do anything at all.

Baby resuscitation:
Danger
Make sure you are safe to help, do not put yourself in danger

Response
• Gently tap the baby’s shoulders and shout to try to wake the baby
• If the baby does not respond shout for help, but don’t leave the baby yet

Airway
Carefully ensure the airway is open by gently tipping the baby’s head back with the ‘chin
lift’:
• Place your hand on the baby’s forehead and gently tilt their head back. DO NOT OVER-
EXTEND THE BABY’S NECK
• Using your fingertips under the point of the chin, lift the chin to open the airway

Breathing
Ensuring the airway is kept open; look, listen and feel to ascertain whether the baby is
breathing normally. Do not take more than ten seconds to do this.

• If the baby is able to breath normally, consider the baby’s injuries and place them in the
recovery position (see page 12)

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If the baby is not breathing normally:
• If you are not alone, ask the nearest person to dial 999 for an ambulance immediately. If
you are alone and need to leave the baby to ensure help is on the way, perform resuscitation
for about 1 minute first:
• Maintain the baby’s airway by tilting their head and lifting the chin ensuring you do not
over-extend the baby’s neck
• Seal your mouth around the baby’s nose and mouth
• Give 5 initial rescue breaths. Blow in just enough air to make the baby’s chest rise visibly.
Be careful not to over inflate the baby’s lungs

Combine rescue breaths with chest compressions:

• Use 2 fingers to depress the baby’s chest to a third of its depth
• Give 30 chest compressions at a rate of 100 compressions per minute
• Open the airway again by tilting the baby’s head and lifting the chin, and give 2 more
rescue breaths
• Continue to administer 30 chest compressions followed by 2 rescue breaths
If your rescue breaths do not make the baby’s chest rise effectively:
Give a further 30 chest compressions before attempting the following:
• Check inside the mouth and remove any clearly visible obstruction (do not reach blindly
into the baby’s throat)
• Recheck that the head is adequately tilted back and the chin is lifted
• Do not administer more than 2 rescue breaths before resuming chest compressions

Appendix: Resuscitation with an Automated External Defibrillator (AED):

The most common cause of a heart stopping (cardiac arrest) is a ‘heart attack’ (see page 30).
It is worth noting that a heart attack does not always result in cardiac arrest. The majority of
heart attack victims remain conscious and survive.

If a heart attack, or another cause, results in cardiac arrest, it is usually because it has
interrupted the heart’s electrical impulses. When this happens the heart ‘quivers’ chaotically
instead of beating in the usual coordinated rhythm. This is known as ‘Ventricular
Fibrillation’ (VF).

Normal Sinus Rhythm Ventricular Fibrillation

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The definitive treatment for ventricular fibrillation is to administer a controlled electric shock
to the heart, which stops the ‘quiver’ and enables it to start beating normally again. This
treatment is called ‘defibrillation’.

An Automated External Defibrillator (AED) is a safe and reliable computerised device that
analyses the heart rhythms and enables a non-medically qualified person to safely administer
the life-saving shock, with some small amount of training.

Using an AED can drastically increase the chances of a casualty’s survival if their heart stops
beating, but prompt use is paramount. For every minute’s delay in delivering the shock, the
casualty’s chance of survival is reduced by 10%.

Resuscitation with an AED

Danger
• Make sure you are safe to help, do not put yourself in danger
• Consider the safety implications of using an AED in this situation

Response
• Gently shake the shoulders and ask in a loud voice ‘Are you alright?’ If there is no response
from the casualty:
• Shout for help immediately
• If you have people with you, ask one helper to dial 999 for an ambulance and ask the
other to get the AED, but do not leave the casualty yourself just yet

Airway
• Carefully ensure the airway is open by gently tipping the head back lifting the chin
Breathing
Ensuring the airway is kept open; look, listen and feel to ascertain whether the casualty is
breathing normally. Do not take more than ten seconds to do this.
• If the casualty is able to breath normally, consider possible injuries and carefully place
them in the recovery position (see page 12)

If the casualty is not breathing normally:

• If you are alone, dial 999 for an ambulance and get the AED – you may have to leave the
casualty to do this
• If you have people with you, start CPR immediately while one helper dials 999 for an
ambulance and the other helper gets the AED. Continue CPR yourself until the AED
arrives

When the AED arrives:

• If you have someone helping you ask them to take over CPR while you get the AED ready.
NOTE: If the person with you is untrained in CPR it may be easier for them to administer
the chest Compressions only (see page 4).

Switch on the AED immediately and follow the voice prompts:

• Attach the leads to the AED if they are not already attached, and attach the pads to the
casualty’s bare chest (if possible, do this while the person helping you continues CPR)

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• It may be necessary for you to towel dry or even shave the casualty’s chest so the pads
adhere to their skin properly. Only shave where the pads are going to go, try to delay
defibrillation as little as possible
• Peel the backing from the pads one at a time and place them firmly in position, following
the instruction on the pads
• Place the first pad below the casualty’s right collar bone
• Place the second pad on the casualty’s left side, over the lower ribs. Try to place the second
pad vertically if possible.

DO NOT REMOVE THE PADS ONCE YOU HAVE PLACED THEM IF THEY ARE THE
WRONG WAY ROUND – THE AED WILL STILL WORK.

Wait while the AED analyses the casualty’s heart rhythm – stop CPR while this happens and
ensure no one touches the casualty

If the AED advises a shock:

• Ensure no one is touching the casualty (check from top to toe and clearly shout ‘stand
clear!’)
• Push the shock button when prompted (if the AED is fully automated it will deliver the
shock automatically)
• Continue as directed by the voice or visual prompts from the AED

If the AED does not advise a shock:

• Immediately resume CPR using the ratio of 30 chest compressions to 2 rescue breaths
• Continue as directed by the voice or visual prompts from the AED
Placements of the pads:

Wet chest
If the casualty’s chest is wet (from sweating for example) it must be dried before the pads can
be applied so they can stick to the skin properly. Also be sure to dry the area of the chest
between the pads, as electricity can ‘arc’ across the wet skin.

Excessive chest hair

Hair on the chest will stop the pads from sticking to the skin properly and will interfere with
electrical contact. You only need to shave the chest if the hair is excessive, and even then
take as little time as possible as you don’t want to delay defibrillation by any longer than is
absolutely necessary. If there is no razor immediately available, do not delay defibrillation.

Pad positioning
Research shows that the position of the pad on the lower left side of the chest has an impact
on the effectiveness of the shock. When placing the pad, make sure it is placed around the
side of the chest (not on the front) and place it vertically. This will help ensure the maximum
electricity flows through the heart rather than across the surface of the chest. If the AED has
not been updated, the pads will have a diagram showing horizontal placement – ignore this
advice and place the pad vertically.

AED safety considerations:

Electric shock

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Studies have shown that, providing the pads are stuck to a dry chest in the correct positions,
the risk of electrical shock is very low as the electricity wants to travel from one pad to the
other, not to ‘earth’ itself like mains electricity. However, to be on the safe side, always
briefly check that no one is touching the casualty before a shock is delivered.

DO NOT delay defibrillation because the casualty is lying on a wet or metal surface,
providing the chest area is dry it is safe to administer the shock.

Medication patches
Some casualties will wear a patch to administer their medication (e.g. a nicotine patch).
Some heart patients wear a ‘glyceryl tri-nitrate’ (GTN) patch. Please be aware that this type
of patch can explode if electricity is passed through it. Remove any visible medication
patches before administering a shock as a precaution.

Jewelry
Be aware when placing the pads that you do not place them on any jewelry, such as a
necklace. This would conduct the electricity and burn the casualty. There is no need to
remove any piercings but avoid placing the pads over any.

Implanted devices
Some heart patients have pacemakers or defibrillator implants. These can usually be seen or
felt under the skin when the chest is exposed, there may also be a scar. The implants are
usually situated just below the left collar bone and should not be in the way of the AED pad.
However, if the device has been implanted elsewhere, try not to place the pad directly over it.
Highly flammable atmosphere
As with any electrical equipment, there is a possibility of the AED creating a spark when the
shock is administered, so it should not be used in a highly flammable atmosphere (in the
presence of a gas leak for example).

Inappropriate shock
AED machines have been proven to analyse the heart’s rhythm extremely accurately.
However, the casualty needs to be motionless while the AED does the analysis. You must not
use an AED on a casualty who is fitting (violent, jerking movements), and ensure vehicle
engines or vibrating machines are switched off wherever possible.

AED use on children:

The AED pads are suitable for both adults and children older than 8 years. Smaller pads that
reduce the current delivered in a shock are available for children aged 1 to 8 years. These
should be used for the appropriate age range whenever possible. Some AEDs have a
‘paediatric’ setting.

If the child is over 1 year and you do not have smaller pads, use the AED as it is. But please
note that the use of adult sized pads on a child under 1 year old is not recommended.

Most paediatric pads are designed to be placed with one in the centre of the child’s chest and
the other in the centre of the child’s back. The pads should have a diagram showing their
correct positions.

Some paediatric pads are designed to be placed in the same position as the adult pads –
always follow the diagrams on the pads to ensure you are placing them in the correct place.

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 Glossary

Abdomen the area between the lowest ribs and the pelvis
Acute sudden onset
Adrenaline Hormone secreted by the body in times of shock
Airway the passage from the mouth and nose to the lungs
Alveoli minute air sacks in the lungs, through which the exchange of
gasses take place
Asphyxia deficiency of oxygen caused by an interruption in the passage of
air to the lungs
Atrium top, ‘collecting’ chamber of the heart (of which there are two)
Baby person under 1 year old
Breathing inspiration and expiration of air into and out of the lungs
Bronchioles small air passages in the lungs, leading to the alveoli
Cardiac / cardiogenic concerned with the heart
Cell smallest structural living unit of an organism
Cerebral-spinal fluid (CSF) fluid that surrounds the brain and spinal cord, to cushion it and
provide nutrients
Cerebrum the largest part of the brain
Cervical concerned with the neck
Child person between 1 year old and puberty
Chronic long term
Circulation the movement of blood around the body
Compression bleeding or swelling in the cranial cavity, exerting pressure on
the brain
Concussion shaking of the brain, causing temporary loss of consciousness or
function
Consciousness alertness, ‘normal’ activity of the brain
Constrict to close down, become narrower
Convulsion fit or seizure
CPR Cardiopulmonary Resuscitation, manually squeezing the heart
and breathing for a casualty
Cranium the cavity in the skull in which the brain lies
Cyanosis blue/grey tinges to the skin, especially the lips, due to lack of
oxygen
Defibrillation the delivery of a large electric shock to the chest in an attempt
to re-start the heart
Dilate become wider, open up
Enzyme substance that enables a biological reaction to happen
Epistaxis nosebleed
Face shield protective mask with a one-way valve for performing mouth-to-
mouth rescue breaths
Febrile relating to fever or high body temperature
Haemothorax bleeding into the pleural cavity of the lungs
Hepatic relating to the liver
Hyper… high
Hypo… low
Hypothalamus area of the brain that controls the body’s temperature
Hypovolaemic low volume of blood, a type of shock
Hypoxia low levels of oxygen in the blood

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Inferior below
Insulin hormone secreted by the pancreas that enables the usage and
storage of sugar
Jaw thrust manoeuvre to open the airway without moving the head, by
thrusting the jaw forwards
Mesenteric relating to an area of the intestines
Nausea feeling sick
Neurogenic concerned with the brain and nervous system
Perfusion supply of oxygen and nutrients, and the removal of waste gases
and products
Pleura a two layered membrane surrounding the lungs, between which
is a ‘serous’ fluid
Pneumothorax air entry into the pleural cavity of the lung
Pulmonary concerned with the lungs
Regurgitation vomiting, being sick
Rescue breath blowing air into the casualty’s lungs, sufficient to make the
chest rise
Respiration breathing
Seizure fit or convulsion
Shock inadequate supply of oxygen to the tissues as a result of a fall in
blood pressure or volume
Spinal cord group of nerves which emanate from the brain and pass down
the spinal column
Spine the column of vertebrae which form the back
Stroke bleed or blockage of a blood vessel within the brain
Superior above
Symptoms the feelings of a casualty e.g. ‘I feel sick’
Syncope faint
Tension pneumothorax air entry into the pleural cavity of the lung that has become
pressurised, impairing the function of the good lung and the
heart
Thoracic the area within the rib cage containing the lungs
Tourniquet a tight band placed around a limb which was used to stop blood
flow, no longer used in first aid
Ventricle lower, larger ‘pumping’ chamber of the heart (of which there
are two)
Ventricular Fibrillation quivering, vibrating movements of the ventricles of the heart,
producing no effective pumping action

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