Course of First Aid for 1st year Medical Students. Each year in the US. Time-Intervals of Management of Out-of-Hospital Cardiac Arrest

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1 Course of First Aid for 1st year Medical Students (1 lecture) Introducton to first aid. First aid management. Asphyxia and artificial ventilation. The most critical and visible health problems are the sudden death and disability caused by catastrophic accidents and illnesses Aleksander Sipria Clinic of Anaesthesiology and Intensive Care Tartu University ( Tel Most Causes of Out-of-Hospital Death Heart disease Accident injury Poisoning (alcohol and drug overdose) Each year in the US 1,5 million heart attack victims (50% die within two hours) Over people die from trauma and receive permanent injuries 5 million poisonings (90% of them children) More than people die because of the lack of adequate and available emergency medical services Major Causes of Mortality in Estonia Time-Intervals of Management of Out-of-Hospital Cardiac Arrest Over 3000 people die each year from sudden cardiac arrest of cardiac origin Time Collapse/Recognition First CPR-Bystanders About 2300 people die from trauma About 300 people die from alcohol poisoning 3 2 Call to Dispatch Center Call-Response Interval Vehicle stops First Defibrillation / ACLS 1

2 The Most Important Out-of-Hospital Care Problems in Estonia The weakest part in the chain of survival in Estonian EMS system is long collapse-to-call interval. Insufficient quality of first aid. The likelihood of survival after call-response interval more than 10 minutes is very low (main reason of bad results in rural areas) Further improvement of public education, early access to the EMS system, quality of medical dispatch and early defibrillation country-wide are needed What is first aid? First aid is the immediate or emergency assistance given on the scene to sick or injured person before professional medical care The Purposes of First Aid to save life provide reassurance and comfort to the ill or injured to prevent further injury or illness becoming worse to minimize or prevent infection and promote rapid recovery First aid measures are not meant to replace proper medical diagnosis and treatment Three Primary Objectives of First Aid to maintain an open airway to maintain breathing to maintain circulation During this process control bleeding and reduce or prevent shock Initial Assessment Safety (vehicle accidents, electrical accidents, gas, smoke and poisonous fumes, fires and collapsing buildings) Mechanism of injury Medical information devices Number of casualties Bystanders Introduce yourself 2

3 Responsibilities of First Aider and Legal Implications Verbal (actual) consent and implied consent If help is refused, remain with the person until help arrives If the casualty`s life is not danger and you do not know what to do, stay with him and send for help You use caution in giving first aid so that you do not aggravate or increase injury You give the help you would hope to receive if you were in similar circumstances Safety of the First Aider The energy source or factor that caused the original injury The hazards from secondary or external factors The hazards of rescue or first aid procedures Priority Action Approach (sequence of actions) 1. Take charge of the situation 2. Call to attract the attention of bystanders to assist you 3. Assess the hazards at the scene 4. Make the area safe for yourself and others 5. Identify yourself to the casualties as First Aider and offer to help Priority Action Approach (sequence of actions) 6. Quickly assess the victims for life-threatening conditions 7. Give first aid for life-threatening conditions 8. Send someone to call for help- ambulance, police etc. Calling Emergency Services (in Estonia 112) Address or location of the incident, giving cross-streets if applicable Telephone number from which the call is being placed (if needed) What`s happened? (Circumstances of the incident: trauma, illness?) Who is calling? Number of casualties involved? Is victim conscious? Is victim breathing? Be the last to hang up! Be prepared to act according to instructions of dispatcher When to Get Help It is vital for rescuers to get help as quickly as possible When more than one rescuer is available, one should start resuscitation while another rescuer goes for help Alone rescuer will have to decide: Call first or call fast? 3

4 Call first is important for early defibrillation If the victim is an adult, and the cause unconsciousness is no trauma (injury) or drowning, the rescuer should assume that the victim has a heart problem and go for help immediately when unresponsiveness is established or after the absence of breathing Call fast is important for early rescue breathing If the likely cause of unconsciousness is trauma (injury) or drowning or if the victim is an infant or child, the rescuer should perform resuscitation for about one minute before going for help Casualty Assessment History of the case Signs (objective evidence, vital signs: pulse, respiration, temperature) Symptoms (sensations that a person feels and describes) Keep the casualty lying down, head level with the body, until you determine the extent and seriousness of the illness or injury. The Conscious Casualty Ask where the injury or pain is located and examine that area first Ask if anything else is wrong and make sure there are no injuries that are masked by pain, numbness or drugs The Unconscious Casualty Primary examination - Severe external bleeding? - Unconsciousness? - Breathing? - Circulation (pulse)? Give first aid for life-threatening conditions in all victims before conducting a secondary examination The Unconscious Casualty Secondary examination - Look: for bleeding, respiration, skin colour, condition, and deformity -Listen:for patient responses or sounds - Feel: for pulse, temperature, for deformity (very gently), texture and swelling -Smell:the patient s breath and other odours to form an impression of other problems the patient may have 4

5 Body checks A full body check should be carried out in the following order Inform the casualty of what you are doing and why During your examination, move the casualty no more than is necessary. If you suspect head or neck injuries or are unsure of the casualty` s condition, keep them lying flat and wait for professional medical assistance Priorities in First Aid Multiple Injuries The highest priority - Asphyxia and breathing difficulties - Severe bleeding - Unconsciousness - Shock - Other immediate life-threatening medical emergencies Priorities in First Aid- Multiple Injuries Next in priority - Burns - Fractures - Back injuries The lowest priority - Minor fractures - Minor bleeding - Behavioural problems Do not attempt to straighten broken or dislocated bones because of the high risk of causing further injury. Splint them in the position in which they are found. First Aid Follow-up Care After immediate first aid is given: - Call emergency services if someone else has not already done so - Monitor the casualties continuously - Keep the casualty comfortable and warm enough to maintain normal body temperature - Do not give the casualty anything to eat or drink because it may cause vomiting, and because of the possible need for surgery - Protect and shelter the casualty while awaiting the arrival of medical aid - Safeguard the casualty` s personal belongings 5

6 First Aid Follow-Up Care Assist in the evacuation of the casualty by ambulance Ensure that casualties who do not require medical aid are placed in the care of friend or relatives Make notes of the names of the casualties and bystanders and record the first aid given Asphyxia (in the circulating blood 02, CO2 ) Airway obstruction (unconsciousness, choking, trauma, allergic reaction, drowning) Reduced oxygen supply (toxic gases) Deterioration of lung and heart functions (chest trauma, poisonings and illnesses) Signs of abnormal breathing (irregular or restricted chest movements, noisy sounds, low or high respiratory rate, blue coloration of the skin - late sign) Causes of respiratory arrest (A) Airway Opening (P.Safar 1981) Electric shock Drowning Suffocation Inhalation of poisonous gases Head injuries Seizures Airway obstruction Stroke Drug overdose Heart problems Allergy reactions In cases of the sudden primary respiratory arrest circulation (pulse) can be present during the first 1-2 min before cardiac arrest. Respiratory arrest is treated initially with artificial ventilation, together with treatment of the likely cause. Airway opening: head tilt and chin lift Triple Airway Manoeuvre (Esmarch, Heiberg, Safar) - Head Tilt, Mouth Open, Jaw Thrust (P.Safar 1981) ERC

7 If airway is open 1 2 Look for chest movement Listen at the victim`s mouth for breath sounds Feel for air on your cheek Look listen and feel for no more than 10 s to determine whether the victim is breathing normally If the breathing is normal Turn unconsciousness victim into the recovery position Send or go for help 3 4 Recovery position ERC 2010 Indirect methods (manual techniques) of artificial respiration before 1960`s (historical overview) Artificial ventilation (expired air resuscitation) Safar P, McMahon M. JAMA, 1958; 1666:1459 Direct Mouth-to-mouth and Mouth-to-nose Ventilation (P.Safar 1981) Mouth to mouth artificial ventilation (ERC 2010) Blow steadily into victim`s mouth whilst watching for his chest to rise Take your mouth away from the victim and watch to his chest to fall as air comes up Give each rescue breath over about 1s The time taken to 2 breath should not exceed 5s 7

8 The most common errors in artificial ventilation Loss of head tilt - ineffective ventilation and oxygenisation - distension of the stomach and risk of regurgitation (silent flow of stomach contents into mouth and nose) Hyperventilation (over-inflation) - increases intrathoracic pressure, decreases venous return to the heart and reduces cardiac output - distension of the stomach and risk of regurgitation Artificial ventilation (expired air resuscitation) Response assessment (level of consciousness) Breathing assessment Airway opening and breathing reassessment Lung ventilation Pulse assessment Risks during artificial ventilation Disease transmission - tuberculosis - meningitis - cold sores (herpes simplex) HIV and hepatitis have not been transmitted by resuscitation to date of publication, although transmission is theoretically possible Face Face shield Mouth-to-mask Ventilation Airway Obstruction Recognition of airway obstruction Partial airway obstruction (noisy breathing) Complete airway obstruction (victim unable to breath, cough and speak) 8

9 Differentiation between mild and severe foreign body airway obstruction (FBAO) Sign Mild obstruction Severe obstruction Are you choking? Yes Unable to speak, may nod Other signs Can speak, cough, breathe Cannot breathe/wheezy breathing/silent attempts to cough/unconsciousness Survival from cardiac arrest of FBAO etiology is strictly depending on the time interval between collapse and ACLS intervention General signs of FBAO: attack occurs while eating; victim may clutch his neck. ERC 2010 Foreign-body airway obstruction Back blows (A) and abdominal thrusts (B) for foreign body obstruction in the conscious standing or sitting victim (P.Safar 1981) First aid Manoeuvres for Choking - Back blows - Abdominal thrusts (Heimlich manoeuvre) - Finger sweep to remove any solid foreign body (only if it can be seen in the mouth) - Chest thrusts - Ventilations The restoration of breathing takes priority over all other measures Choking emergency device and first aid Back Blows and Chest Thrusts Infants (P.Safar 1981) The most significant difference from the adult algorithm is that abdominal thrusts should not be used for infants. Chest thrusts are similar to chest compressions but sharper and delivered at a slower rate 9

10 Prehospital Emergency Care and Crisis Intervention Third Edition by Brent Q. Hafen, Keith J.Karren Brady Morton Series 1989 ERC guidelines 2010 not recommended ERC 2010 An infant `s airway is more easily blocked than an adult`s because: The head is relatively large The neck is relatively short The tongue is large The trachea (windpipe) is soft and easily compressed The adenoids may be large ERC

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