MB Randa & T Zana ©2015 Revised & Edited Page 1

FACULTY OF HEALTH SCIENCES

MPOM 010: Practice of Medicine 1

SEFAKO MAKGATHO HEALTH SCIENCES UNIVERSITY

Primary Emergency Care Block

2015

THIS LEARNING GUIDE BELONGS TO:

INITIAL)S)NAME : __________________________________________________

STUDENT NUMBER : __________________________________________________

CELL NR : __________________________________________________

E-MAIL : __________________________________________________

GROUP NR : …………………………………………………………………………………………….

MB Randa & T Zana ©2015 Revised & Edited Page 2

LECTURER CONTACT INFORMATION

Course Presenter(s) : Ms MB Randa

: Mr T Zana

Office : Nursing Science Department

Telephone number : 3751 / 4170

Email address : Moreoagae.Randa@ul.ac.za

MB Randa & T Zana ©2015 Revised & Edited Page 3

TABLE OF CONTENTS

PAGE

1. CURRICULUM MAP 4

1.1. Introduction 5

2. ORGANISATIONAL COMPONENT 6

2.1. General principles and educational approach 6

2.2. The importance of this module 6

2.3. Instructions for the use of the study manual 7

2.4. Study materials 7

2.5. General behavior 7

3. STUDY / LEARNING COMPONENT 8-13

4. CONTENT GUIDE 13

4.1. Principles of Primary Emergency Care (PEC) 13

4.2. Legal and Ethical responsibilities of a PEC giver 13

4.3. Emergency Scene Management (Priority action approach) 15

5. PRACTICE OF PRIMARY EMERGENCY CARE (PEC) 19

5.1. Asphyxia 19

5.2. Choking 20

5.3. Artificial ventilation / respiration 23

5.4. Cardio pulmonary resuscitation 24

5.5. Automated external defibrillator (AED) 26

5.6. Wounds 27

5.7. Burns 29

5.8. Bleeding 30

5.9. Nose bleed 32

5.10. Shock 33

5.11. Fractures 35

6. LIST OF REFERENCES 36

MB Randa & T Zana ©2015 Revised & Edited Page 4

1. CURRICULUM MAP

Emergency

First Year

Principles of PEC

Legal & ethical responsibilities

Emergency scene management

management

Asphyxia & choking

Fourth Year AV, CPR & AED

Wounds, bleeding& burns

management

Fractures & shock

CPR update

Trauma

Emergency care skills Sixth Year

Medical emergencies Prioritise & initiate emergency treatment

Management of trauma patient

Environmental emergencies

Management of emergencies: infant & adult

Management of cardiac emergencies

MB Randa & T Zana ©2015 Revised & Edited Page 5

1.1. INTRODUCTION

For the purpose of your curriculum First Aid is referred to as Primary Emergency Care. The study

guide has been designed as an aid to assist you in your training. It outlines the specific objectives,

which must be attained for each lesson that will assist you to provide the best First Aid / Primary

Emergency Care.

There are risks in most activities of daily living. The use of mechanical, electrical appliances and

chemicals at work, home and leisure increases the risks of injury. Home and road accidents

increase the risks of injuries. Injuries can be prevented from becoming worse and reduce mortality

rate by applying skills and knowledge acquired during Primary Emergency Training.

Primary Emergency Training forms the basis for pre-hospital care which requires the provider to be

well skilled, knowledgeable and possess skills and ability to use the available equipment. In the

absence of a medical practitioner, nurse or paramedic, a person trained in First Aid must provide

emergency care.

PLEASE ENJOY THE LEARNING EXPERIENCE

OUTCOME

The learner will be able to manage medical emergencies and injuries according to PEC standards.

COURSE OVERVIEW

Duration

Theory and Practica 22 hours

Teaching and learning strategies

Lectures

Demonstration

Group activities

Simulation

Evaluation

Examination of theory and practica at the end of the block

A minimum of 50% in both theory and practica should be obtained

Individual or team – Resuscitation procedures

If less than 50% is obtained the student will have to repeat the skill and / or theory

(As per University General Rules)

MB Randa & T Zana ©2015 Revised & Edited Page 6

2. ORGANISATIONAL COMPONENT

2.1 GENERAL PRINCIPLES AND EDUCATIONAL APPROACH

The purpose of this module is to assist you in acquiring emergency care skills. This will assist you to be

professional and proficient once you start engaging with patients and other health care providers in the

emergency setting.

Although the theory of emergency care will be offered and available on Blackboard, the focus will be on

hands- on experience. You will learn your emergency care skills by performing procedures on simulated

patients and manikins. Your practical sessions will be scenario based and this will help you relate theory

to real life situations. You will find extra reading material on Blackboard by clicking on links to useful

websites. There are also numerous books on emergency care available from the library. You are strongly

encouraged to make use of the library as well as the knowledgeable staff that are ready to assist you.

Also please let me know should you require additional resources to be ordered for the library.

Please note that we have specific supervisors assigned to supervise you during practice sessions and

give you feedback on your performance.

Remember that the Skills Centre personnel are there to assist you in becoming proficient in your

skills; do not hesitate to make an appointment with the lecturer for additional practical learning

sessions and guidance.

2.2 THE IMPORTANCE OF THIS MODULE

There are risks in most activities of daily living. Use of mechanical, electrical appliances and

chemicals at work, home and at leisure increases the risks of injury as well as home and road

accidents. The number of deaths due to injuries could be substantially reduced if every person is

trained in basic emergency care.

Proper pre-hospital care could not only save lives but will also reduce the complications. Some of the

injuries may be minor, but even a slight wound may, in dirty surroundings become infected and may

cost a person’s life. In the absence of a medical practitioner, nurse or paramedic, a person trained in

PEC must provide emergency care.

This module is aimed at making you proficient in the rendering of basic care to victims of trauma,

sudden illnesses and environmental emergencies. The use of drugs and adjuncts is not included in

this module.

MB Randa & T Zana ©2015 Revised & Edited Page 7

2.3 INSTRUCTIONS FOR THE USE OF THE STUDY MANUAL

To participate in class discussions and activities it is essential to bring this learning guide to every

class. The first section of this guide is for your general information. The second part is the study

component which should be used as a workbook. Each section will guide you regarding what

you should know and which activities you should complete. The class notes as set out in this

guide are just a basic outline and you will be required to make supplementary notes during class

discussions as well as additional readings. Please ensure that all the skills are signed off in your

logbook or lecturer’s register. Learners who are not in class will not be able to sign off on the

skills and will therefore forfeit the opportunity to do their practical examination.

2.4 STUDY MATERIALS

Your workbook will form basis for this module. Throughout the workbook you will be led in terms of self-

study and additional readings. All activities should be reviewed when preparing for tests and exams.

2.5 GENERAL BEHAVIOUR

You are expected to act in a professional manner and act ethically responsible at all times. This

includes, but is not limited to:

Conduct in class: Behave appropriately during lectures, respecting Professional, Departmental and

University regulations. Please participate in class discussions. This will help you to form your

thoughts and facilitate learning. Punctuality is of utmost importance and also shows your respect

for both me and your classmates. Unless you make special arrangements you will not be allowed

to join scheduled periods if you arrive late for class. If you missed class, make sure that you catch

up with colleagues and any assessment done in class cannot be completed after the scheduled

session (unless a medical certificate is presented).

Grievance procedures: All complaints to be directed to me personally during the course of this

module.

Academic dishonesty: Please familiarize yourself with the University Rules (G 14, 15, 17 & 21)

regarding supplementary assessment, special summative assessment and assessment fraud. Any

academic dishonesty will be reflected in your academic records.

Only an original medical certificate will be accepted when you are absent from scheduled activities

and has to be submitted within 7 days.

It is your responsibility to check the notice board and Blackboard regularly for notices concerning this

module. Any information presented in this study guide may be changed if necessary.

Students have to wear identification cards at all times.

No eating and drinking is allowed in class in the Skills Centre.

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3. STUDY / LEARNING COMPONENT

Reviewing the outcomes specified for this module will direct you in terms of what we are aiming for i.e. where are we going. You will be able to identify your own part in the learning process. The outcomes also indicate what evidence is needed to prove that certain knowledge and skills have been acquired.

Module name: PRIMARY EMERGENCY CARE (PEC) Contact hours: 16 hours

Lectures per week Clinicals per week Tutorials per week Semester Venue

4 per week per subgroup Practicals Week 1,2 & 3

Practica incorporated

6 subgroups per year Skills Centre

Pre-requisites: learning assumed to be in place

Grade 12, Life Orientation

Must have basic understanding of the definition of First Aid

Co-requisites: units of learning contributing during the current year

Units covering Microbiology, Anatomy, Vital signs and communication as applicable in various departments

Module facilitator Facilitator details provided on page 1

Purpose of the module

To assist the students to:

develop the ability to identify problems and find solutions through critical thinking

be able to render Primary Emergency Care (PEC) to victims of trauma, sudden illness and environmental emergencies.

develop the affective and psychomotor skills when rendering PEC to the victims of trauma

Critical cross-field outcomes / Professional attributes to be developed as generic skills: o Critical thinking skills (reflection and evaluation) o Communication skills (patients, peers, lecturers both verbally and non-verbally-written formats) o Team work (small group work as well as with other professionals such lecturers) o Social responsiveness (responsive to needs of patients, reflect and adapt what is necessary based on the needs of the patient/community)

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Specific Outcomes Assessment Criteria Teaching strategy Assessment task/method

At the end of this module you should be able to :

be able to:

You should be able to answer the following questions :

following questions:

This is the method to study the material

material

This is how you will gain marks and monitor your progress

monitor your progress S01 Apply principles of Emergency

Scene Management (ESM)

AC1 Describe steps taken by the first

person to arrive at an emergency scene

TS1

Formal lecture

Directed Instruction

Demonstration

A AT1

Summative assessment

SO 2 Apply legal and ethical responsibilities of PEC giver

AC2 Describe legal and ethical

responsibilities of a primary emergency care giver

TS2

Formal lecture

Role play on ESM

Self- directed learning

AT2

Summative assessment

SO 3 Perform CPR on an Adult, Child and Infant casualties according to the latest guidelines

AC3 Define the following:

Asphyxia

CPR List signs of successful CPR

TS3

Formal lecture

Audio visual material

Demonstration

AT3

Summative assessment

OSCE

S04 Perform Heimlich

manoeuvre on an adult, child and infant casualties

AC4 Define the following:

Choking

Describe the emergency care to be rendered in a given scenario

TS4

Formal lecture

Directed Instruction

Demonstration

AT4

Summative assessment

OSCE

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S05 Use Automated External Defibrillation (AED) safely

AC5

Define AED

State indications for the use of AED

TS5

Directed Instruction

Demonstration

Self -directed learning

AT5

Summative assessment

OSCE

S06 Perform log roll on an adult

and child casualties

AC6

Describe the indications to perform log roll

TS6

Formal lecture

Direct Instruction

Demonstration

Self- directed learning

AT6

Summative assessment

OSCE

S07 Manage burns, wounds

and bleeding

AC7

Name different types of wounds

Describe methods of controlling bleeding

TS7

Formal lecture

Audio visual

Demonstration

Self-directed learning

AT7

Summative assessment

OSCE

S08 Recognise signs and

symptoms of fractures, sprains, strains and immobilise appropriately

AC8

List signs and symptoms of fractures

TS8

Formal lecture

Audio visual

Directed Instruction

Demonstration

Self -directed learning

AT8

Summative assessment

OSCE

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S09 Perform rapid trauma

assessment

AC9 Identify abnormal physical

findings

TS9

Directed Instruction

Demonstration

Self- directed learning

AT9

Summative assessment

OSCE

Critical cross-field outcomes Skills achieved for lifelong learning

Critical thinking skills

Teamwork

Leadership Skills

Communication skills

Resources (prescribed text that you need to read in order to learn what you need to know)

Learner guide

Additional information posted on Blackboard

First Aid books

American Heart Association (AHA) 2010 guidelines (Endorsed by the SA Resuscitation Council)

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Level of cognition Def n on Typical action ver s Skills demonstrated

1. Knowledge

..... %

Remembering previously learned information

Arrange, define, describe, identify, label, list, match, name, outline, show, label, collect, examine, tabulate, quote

observe and recall information

knowledge of dates, events, places

knowledge of major ideas

mastery of subject matter

2. Comprehension

.....%

Understanding the meaning of Information

Classify, discuss, estimate, explain, give example(s), identify, predict, report, review, select, summarise, interpret, ‘in your own words’, contrast, predict, associate, distinguish, estimate, differentiate

understand information

grasp meaning

translate knowledge into new context

interpret facts, compare, contrast

order, group, infer causes

predict consequences

3. Application

..... %

Using the information appropriately in different

situations

Apply, calculate, demonstrate, illustrate, interpret, modify, predict, prepare, produce, solve, use, manipulate, put into practice, calculate, examine, relate, change, classify

use information

use methods, concepts & theories in new situations

solve problems using required skills or knowledge

4. Analysis

..... %

Breaking down the information into the component parts and

seeing the relationships

Analyze, appraise, calculate, compare, criticise, derive, differentiate, choose, distinguish, examine, subdivide, organise, deduce, separate, order, connect, infer, divide

seeing patterns

organisation of parts

recognition of hidden meanings

identification of components

5. Synthesis

..... %

Putting the component parts together to form new

products and ideas

Assemble, compose, construct, create, design, determine, develop, devise, formulate, propose, synthesize, plan, discuss, support, combine, integrate, modify, rearrange,

substitute, design, invent, what if?, prepare, generalize, rewrite

use old ideas to create new ones

generalize from given facts

relate knowledge from several areas

predict, draw conclusions

6. Evaluation

..... %

Making judgements of an idea, theory, opinion, etc., based on criteria

Appraise, assess, compare, conclude, defend, determine, evaluate, judge, justify, optimise, predict, criticise, assess, decide, rank, grade, test, measure, recommend, convince, select, judge, explain, discriminate, support, summarise

compare & discriminate between ideas

assess value of theories, presentations

make choices based on reasoned argument

verify value of evidence

recognise subjectivity

The statements used to define and assess the outcomes are classified in terms of a series of lower to higher-order thinking skills (cognitive domains), in accordance with

Bloom's

Taxonomy of Educational Objectives (Bloom BS and Krathwohl DR, Taxonomy of educational objectives. Handbook 1. Cognitive domain, Addison-

Wesley, 1984): The characterization of the cognitive domain:

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4. CONTENT GUIDE

4.1 PRINCIPLES OF PRIMARY EMERGENCY CARE (PEC)

Learning outcomes

At the end of this block, the student must be able to:

-To preserve life by:

*Ensuring that the patient’s airway is open

*Ensuring that the patient has a heartbeat

*Ensuring that the patient is breathing

*Manage bleeding

-To prevent the illness or injury from becoming worse by:

*Controlling further bleeding

*Immobilizing the casualty’s fractures

*Treating casualty for shock

*Preventing infection

-To promote recovery by:

*Positioning the casualty correctly

*Protecting the casualty from extreme temperatures

4.2 LEGAL AND ETHICAL RESPONSIBILITIES OF A PEC GIVER

When a PEC giver goes to someone’s aid, s/he undertakes to provide any assistance s/he can give and

remain on the scene until the casualty can be handed over to medical assistance or some authority.

Once you give assistance, you should use reasonable skill and knowledge based on your level of

training. In this role of a Good Samaritan, the PEC giver is given certain protections under the law.

Therefore he should not be overly concerned about legal liability.

Identification

The PEC giver must always identify him /herself and indicate to the casualty that s/he is trained

in PEC before attempting to offer help to the casualty in order to gain cooperation and

confidence.

Consent

A person has the right to accept (consent) or to refuse help. A conscious adult or older child who

agrees or makes no objection to your offer or help gives his consent. If a person refuses help,

call for help, stay with him and keep a close eye on his condition until medical assistance arrives.

If he becomes unconscious and his life is threatened, do whatever is necessary to save his life.

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*Obtaining consent on an unconscious person and a young adult

It is assumed that an unconscious person or a young child, whose parents are not

available, would consent to your help if he could. A parent with a young child has a

right to refuse help given to her child. In this case, advise a parent to seek help or to

take the child for medical assistance. If the child’s life is in danger, call for help and

stay with the parent.

Standard of care

This is the manner in which the PEC giver must act or behave. It depends on the level of training,

experience and circumstances around the scene. One has a moral and legal responsibility to

respond to legitimate calls for help, but should not act improperly to give treatment that is beyond

his/her scope of practice.

Allegations of negligence

Assault and improper conduct form the basis of most legal actions brought against emergency

care personnel by the public. Make sure that your actions are in the casualty’s best interest.

There is no need to neither hesitate nor be concerned about legal liability provided that:

PEC is not forced on a conscious adult or older child who refuses such help.

You give the help you would hope to receive if you were in a similar circumstance.

You use caution when giving PEC so that you do not aggravate or increase injury.

A casualty is not abandoned. When the offer of help is accepted it must be given and

continued until the casualty can be handed over to a more qualified person.

A common sense approach is adopted when giving PEC, if/when the casualty’s life is not

in danger.

Suspected child abuse

Be on the alert for signs of child abuse when giving PEC to children.

Unusually shaped bruises or burns, injuries that would not be normal for a child and

fractures in children and infants, where the cause is not readily apparent or is suspicious

in nature, should alert you to look for other signs. The child’s apparent fear of a parent or

babysitter should reinforce suspicions of child abuse.

Insist on medical attention for the child’s injuries, no matter how minor they may be, to permit

a full medical assessment. If the parent or babysitter refuses medical assistance, you have

a duty to notify local child welfare agencies or authorities (e.g. Child line or FAMSA). Do not

accuse anyone of child abuse, but for the child’s welfare do not hesitate to report suspected

cases.

Child line: 080 005 5555

FAMSA: 082 231 0370

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Confidentiality and Privacy

PEC giver shall maintain all confidential matters entrusted to him by the casualty without

divulging them to any unauthorised persons. He shall also respect the casualty’s privacy and

avoid exposing the casualty unnecessary when giving treatment.

Abandonment

Never abandon (leave) a casualty who is in your care. Once the casualty accepts your offer of

help, stay with her/him until you hand him over to medical help, another PEC giver, or she/he

no longer wants your help. This is when the problem is no longer an emergency and further

care is not needed.

Declaration of death

Only a qualified authorized health care practitioner can certify death.

4.3 EMERGENCY SCENE MANAGEMENT (PRIORITY ACTION APPROACH)

PEC is given safely in a proper sequence according to life threatening conditions. At times the

sequence might be changed depending on the patient’s condition. This is also called Priority

Action Approach.

Below are the five steps and related actions taken in Emergency Scene Management (ESM)

Step 1. Scene survey

Calmly approach the scene

Identify all the possible risks and hazards

Take charge in the absence of a person senior to you, if there is someone ask if they

can help

Quickly assess the situation accurately and decide on the priorities of action

Call out for help to attract attention of by standers

Assess and remove all hazards to make area safe for self, casualty and bystanders

Find out the history of the accident (what happened), how many casualties there

are and determine the mechanism of injury (how & where the injury occurred)

Identify self as PEC giver and offer to help so as to obtain consent

Assess responsiveness to determine level of consciousness (LOC), [AVPU i.e. If

casualty is alert, responds by making noise when spoken to, responds to painful

stimulus, no eye, voice or motor response on painful stimuli]

In adults a GCS is used whilst in newborns an APGAR score is used to assess LOC

Send for medical help

Don gloves

N.B Priorities of action means start treating the casualties according to this sequence:

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i. Manage life threatening bleeding

ii. Unconsciousness – no pulse start CPR immediately

iii. Airway- open, protect and maintain

iv. Breathing – ensure adequacy

v. Circulation – control minor bleeding

vi. Deformities- manage fractures

vii. Evaluation - continuous patient evaluation

N.B Making the scene safe means: in case of:

i. Police officers- to control traffic, switch off the ignition, watch out for petrol spillage

and ask people not to smoke

ii. Body fluids -wear appropriate personnel protective clothing (PPC) i.e. head

gear, rubber gloves, plastic goggles, protective closed shoes, mouth mask)

iii. Initiate preventive measures and alert the appropriate departments (SAPS, METRO, FIRE

and EMS)

Step 2. Primary survey (assessment)

Prioritise the casualty (P1, P2, P3, P4) by assessing life threatening conditions

Medical patient (conscious vs unconscious)

Assess the nature of the illness

Trauma patient (conscious vs unconscious)

Assess the mechanism of injury

Circulation

Control any life threatening bleeding

Palpate for circulation by feeling for the carotid artery on a unconscious adult, radial

artery on a conscious adult or brachial pulse on the infant for 5-10 seconds

If pulse is absent or unsure of pulse start chest compressions and attach AED

If pulse and breathing are present, check vital signs. Continue with treatment according

to clinical condition of casualty

Airway

For a medical casualty

Open the airway using Head tilt jaw lift manoeuvre

For a trauma casualty

Open the airway using the Jaw Thrust Manoeuvre

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Clear any obstructions that might be obstructing the movement of air

(Suction or use your smallest finger to remove the obstruction while visualizing it

Breathing

Assess breathing by placing your ear near the casualty’s mouth and nostrils. Look for

chest movement and feel for any signs of air movement

Position the casualty on his back on a firm flat surface (provided there are no

suspected head and spinal injuries, in case rather support his head in

alignment with his spine and continue with the next action

Step 3. Secondary survey (Focused assessment)

Focus on the chief complaint

Assess the nature or mechanism of the chief complaint

Assess the affected system as well as the related systems

Manage the chief complaint

After 15 minutes do perfusion assessment to unstable patient

After 15 minutes do perfusion assessment to stable patient

NB: Secondary assessment can be done only on condition the life of the casualty is not in danger.

It can only be done if medical help is delayed by more than 20 minutes.

Secondary survey has four sub-steps:

Obtain the history of condition or accident e.g. symptoms, allergy, medications, past medical

history, last meal, events leading to incident –from the casualty, bystander or relative

Assess and record the casualty’s vital signs- i.e. LOC , breathing, pulse, skin temperature

and colour

Conduct a head to toe examination without repositioning the casualty

Give first aid treatment for injuries or illness found e.g. wounds, fractures and

bleeding

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Step 4. Head to toe assessment

It is done to identify injuries that might have been missed, starting at the head of the casualty until

the planter of the foot using the palms of your hands to assess for any deformities, contusion,

abrasions, puncture wounds, burns, trauma, lacerations and swelling (DCAPBTLS)

Step 5. Ongoing casualty care

Once PEC for injuries and illnesses that are life threatening has been given, the

PEC giver will do the following:

Remain with the casualty until medical help arrives

Record the events of the situation including casualty’s condition and the PEC given

Continue to monitor vital signs

Check casualties CAB

Give nothing by mouth (NPO)to unconscious patient

Protect and take care of the casualty’s belongings

Step 6. Handing over of the casualty

Give full report to whoever is taking over from you

This includes the casualty’s particulars-name, address, telephone

number, etc.

History taken from the casualty (what happened, what kind of injuries are involved

and what PEC has been given)

Hand over all the casualty’s belongings and sign for such belongings

N.B Once the PEC giver has decided that assistance is required, it must be done

immediately. When calling the ambulance, police, fire brigade, the following information

must be conveyed by the caller:

* Telephone number from which the call is made and the caller’s name

* Address and location of the incident giving nearby road junctions or landmarks to assist the

paramedics to reach the scene as quickly as possible

* Circumstances of the incident and conditions of the casualties e.g. road traffic accident,

two cars involved, three people trapped

* Number of casualties involved

* Help that is being given

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5. PRACTICE OF PRIMARY EMERGENCY CARE (PEC)

5.1 ASPHYXIA

Learning outcomes

At the end of this lesson the student must be able to:

- Define asphyxia

- Discuss the causes of asphyxia

- Discuss the signs and symptoms of asphyxia

- State the aim of treatment of asphyxia

- Outline the assessment and treatment of asphyxia

Definition of asphyxia

Asphyxia is lack of oxygen to the tissues of the body

Causes of Asphyxia

G- Gas e.g. fumes, and smoke inhalation

O -obstruction e.g. choking, strangulation, drowning, suffocation.

N- nerve poisons e.g. bites of certain snakes, stings of spiders and scorpions, causing the tissues

of the throat to swell

E – electricity e.g. shock by electric current

N.B The tongue is the most common cause of choking leading to asphyxia

Signs and symptoms of asphyxia

- Difficulty in breathing

- Breathing may become noisy or snoring

- Breathing may stop (apnea)

- Possible frothing at the mouth

- Blueness of lips, finger tips, gums (cyanosis)

- Increase in rate and depth of breathing

- Anxiety and restlessness

- Confusion

- Possible unconsciousness

- Coughing

Aim of treatment

- To improve oxygen supply to the tissues

Assessment and treatment of Asphyxia

Assessment entails the first two steps that you take as outlined in ESM

Remove the cause of asphyxia and if possible remove the casualty from the cause

Open the casualty’s airway and remove any obvious obstructions

Assess the casualty’s breathing – look, listen and feel for 10 seconds

Do head -to-toe examination and place the casualty in the recovery position

Send for medical help

Treatment is administration of oxygen (O2)

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5.2 CHOKING

Learning outcomes

At the end of this lesson the student must be able to:

Define Choking

State the causes of Choking

List the signs and symptoms of Choking

Describe measures that can be implemented to prevent choking in the elderly and young

children

Describe step by step PEC of a choking adult who is:

- Conscious

-Unconscious

Describe step by step PEC of a choking infant who is:

-Conscious

-Unconscious

Definition of Choking

Choking is a life threatening emergency whereby the casualty’s airway is partly

or completely blocked and airflow to the lungs is reduced or cut off resulting in poor

gaseous exchange

NB : When air supply to the lungs is cut off, the person’s face immediately changes colour

If not corrected, the face becomes grey and lips and ears bluish = cyanosis

Causes of choking

Foreign bodies e.g. food and objects

- Adults: gulping drinks with food

- In children and infants: toys, button and coins

- In elderly: food and pills

Laryngeal oedema (swelling)

Unconscious casualties: the tongue falling back, saliva, blood or vomit pools in the throat

Laryngo-tracheal bronchitis in children

Injury: tracheal or throat

Illness causing swelling e.g. asthma, croup and allergic reactions

Signs and symptoms of choking

Noisy breathing (stridor)

Coughing, gaggling indicate difficulty in breathing

Restlessness

Vigorous use of accessory muscles of respiration

Cyanosis

Marked distension of the neck veins

Casualty may collapse

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Measures that can be implemented to prevent choking

Adults

- Cut food into smaller pieces that can be easily chewed

- Drink alcohol in moderation. Alcohol causes one to lose the coordination of the muscles

used in swallowing thus making it easier to choke

- Do not talk, laugh, or gulp drinks with food in your mouth

Children

- Supervise children when they are eating

- Do not feed children less than four years with nuts, popcorn, round sweets,

grapes

- Advice children not to run or move about when eating

- Supervise children when they are playing with balloons and marbles

Infants

- Keep small toys out of the baby’s cot

- Do not let infants play with balloons and marbles

- Only give small bite size pieces of food

- Check pacifiers (baby’s dummy) for small parts or worn nipples

Step by step PEC of a choking adult and child who is:

Conscious and has partial obstruction

Determine if the casualty is choking

Assess if he/she is able to cough talk or breath

Monitor vital signs

Encourage him/her to cough repeatedly

If the casualty cannot cough forcefully, cannot breath, makes a high pitched noise and

starts to turn blue, give (5) five back blows

If obstruction persists call for help

Stay with the casualty

Do abdominal thrusts (Heimlich manoeuvre)

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If victim is unable to cough, talk or breath, stand behind him and place arms around his

waist with your thumbs positioned just above his navel and well below ribcage

Perform sudden inward and upward abdominal thrusts

Repeat the abdominal thrusts until obstruction is relieved or until the casualty

becomes unconscious

Unconscious and has complete obstruction

NB: Lower the casualty to the ground and send for medical help and apply AED

* Determine if casualty is breathing

Remove any visible objects using hooked finger in small children and infants, and index

finger in adults

Lift chin up and tilt head backwards

Look , listen and feel for breathing with ear just above the mouth

If not breathing, ventilate using a face mask

NB Ensure that there is chest rise with each breath

If unsuccessful, reposition the head, check if the mask is fitting properly and ensure a good

seal then re-ventilate

Do chest compressions

Step by step PEC of a conscious infant with:

Partial obstruction

If the casualty can cough forcefully or breath, stand by and don’t interfere

Let the casualty try to cough up object

If a partial blockage lasts for more than a few minutes, get medical help

If the casualty cannot cough forcefully, cannot breath, makes a high pitched noise and

starts to turn blue, give (5) five back blows

For infant casualty

Pick the baby up and turn her/him over

Support the head and neck throughout the movement

Give five (5) back blows between the shoulder blades

Turn the baby face up and bring her close to you

Give five (5) chest thrusts to create an artificial cough

Open the mouth, remove any visible matter

Look, listen and feel for breathing

Ventilate the infant

Keep giving back blows and chest thrusts until either the airway is cleared or the baby

becomes unconscious

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Unconscious infant with complete obstruction

Repeat steps 1-7 of partial obstruction then:

Pick the baby up and turn her over

Support the head and neck throughout the movement

Give five (5) back blows between the shoulder blades

Turn the baby’s face up and bring her close to you

Give five (5) chest thrusts to create an artificial cough

Open the mouth and remove any visible matter

Look, listen and feel for breathing, ventilate the baby

Keep giving (5) back blows and (5) chest thrusts until either the airway is cleared or

medical help arrives

Commence CPR if necessary

5.3 ARTIFICIAL VENTILATION /RESPIRATION

Learning Outcomes

At the end of this lesson the student must be able to:

- Define Artificial Ventilation (AV)

- State indication for Artificial Ventilation

- List different techniques of AV

- Describe and demonstrate step by step administration of artificial

ventilation on an adult casualty

Definition of Artificial Ventilation

- Artificial Ventilation is a way in which air is supplied to the lungs of a

casualty who is breathing ineffectively or not breathing at all

Indication for AV

- No breathing

Different techniques of AV

- mouth to mouth

- mouth to nose

- mouth to mouth-and –nose

- bag valve mask ventilations

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Step by step administration of Artificial Ventilation

Adult casualty

Begin with scene survey

Assess responsiveness CAB

Assess breathing for up to 10 seconds

Call for help

Place the casualty face up, protecting the head and neck during movement

Establish a clear airway immediately using a finger sweep to remove

secretions

Open the airway using a head tilt-chin lift manoeuvre or jaw thrust in suspected neck and

spinal injury

Re -assess breathing

Ventilate the casualty twice (two rescue breaths), Blow for about two seconds or

enough air to make the chest rise adequately

If pulse is present ventilate the casualty – give one slow full breath every 5 seconds X

10 breaths until help comes

5.4 CARDIO PULMONARY RESUSCITATION

Learning Outcomes

At the end of this lesson the student must be able to:

- Describe the concept of Cardio Pulmonary Resuscitation (CPR)

- State and recognise the need for CPR

- Describe and perform all steps of CPR, in their correct sequence for an adult casualty

- List signs of successful CPR

Definition of Cardio Pulmonary Resuscitation

- CPR is two basic life support skills put together-artificial respiration and artificial circulation.

Artificial respiration provides oxygen to the lungs. Artificial circulation causes blood to flow

through the body, but flows only enough to give a person a chance for survival.

Purpose of CPR: is to circulate oxygenated blood to the brain and other organs until either the

heart starts beating, or medical help takes over.

Indications for CPR

- If a casualty has stopped breathing and absence of heartbeat

Signs of successful CPR / Recovery

Spontaneous breathing without series of gasping irregularities

Presence of pulse

Skin colour changes to normal

Pupils size will return to normal; both pupils will be equal and react to light

Level of consciousness will improve

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5.5 AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

Learning Outcomes

At the end of this lesson the student must be able to:

Define AED

Discuss the principles of defibrillation utilising an AED

Describe the safety precautions that form part of the safe use of the AED

Utilise the AED correctly and safely

Definition of AED

AED is the application of an electric shock to a heart that has stopped breathing using a portable

electronic device as part of the CPR protocol.

Principles of defibrillation

AED is able to automatically diagnose a potentially life threatening cardiac arrhythmia

(ventricular fibrillation and ventricular tachycardia) and advise the operator to deliver a shock.

The application of electrical therapy stops the arrhythmia, allowing the heart to re-

establish a perfusing rhythm.

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5.6 WOUNDS

Learning Outcomes

At the end of this lesson the student must be able to:

- Define a wound

- Name and classify wounds

- Name and recognise different types of wounds

- State the dangers of wounds

- Describe aim of treatment

- Describe general PEC of wounds

- Discuss the specific PEC of wounds with embedded or impacted object

Definition of a Wound

A wound is any break in the continuity of the tissue of the body, resulting in bleeding,

which can lead to shock. Germs also get a chance to enter the body resulting in

infection.

Types of wounds

Open

When there is a break in the outer layer of the skin resulting in bleeding

Closed

When there is no break in the outer layer of the skin with the possibility of internal bleeding

which may be severe

Burns wounds

Closed Open Burns

Classification of wounds

Incision = Clean cut caused by a knife

Laceration = Torn wound caused by machinery

Puncture = Wound caused by pointed instrument

Abrasion/scape = Open wound whereby the outer protective layer and tiny underlying

blood vessels are exposed e.g. in accidents

Gunshot = Bullet wound

Bruise = Caused by a fall or blow from something blunt

Contusion = Bruise caused by blunt violence

Avulsions = Wound with a large piece of skin torn away

Amputations = Complete or partial loss of a body part

Burn = Caused by heat, radiation, chemicals and electricity

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Complications of wounds

Bleeding

Infection

Shock

Aims of management

To stop or control hemorrhage

To prevent infection

To prevent or treat shock

General PEC of wounds

Safety

CAB

Expose and examine the wound for foreign objects

Apply direct pressure on the affected area using gauze swab

Clean around and away from the wound with a clean material and water

Apply a clean dressing

Assess for vital signs i.e. pulse, perfusion, temperature, colour and motor sensation

especially when the wound is on the limb

Treat for shock if necessary

Specific PEC of a wound with embedded object

Do not remove embedded foreign objects from the wound

Control serious bleeding by applying pressure around the object

Clean around and away from the object with a clean material and water

Place a clean dressing around the object without disturbing the object

Cover the object around with a ring pad that is large enough to cover the object

Bandage the ring pad in place with a bandage to stabilize the object

Do not apply pressure on the object

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5.7 BURNS

Learning outcomes

At the end of the lesson, the student must be able to:

Define the concept burns

Discuss classification of burns

List the causes of burns

Identify different types of burns

Discuss the management of burns

Definition of burn

They are injuries to a person’s body tissue that were caused by heat, chemicals or radiation.

Classification of burns

Causes and types of burns

Type of burn Causes

Dry

Wet

Chemical

Electrical

Cold

Radiation

Fire

Steam, hot oil or water

Acids, alkalis

Lightning and electricity

Compressed gas

X Rays and sunburn

Electrical Chemical Wet Dry

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PEC management of burns

NB: Never use ice to cool the burnt area as it will make the burn worse

Check the casualty’s SCAB ( Safety, Circulation, Airway, Breathing)

Maintain breathing and check vital signs every 5-10 minutes

Determine the level and depth of burn injury

Cover the burnt area with a clean wet dressing

Call for medical help if necessary

Treat the casualty for shock

5.8 BLEEDING

Learning Outcomes

At the end of this lesson the student must be able to:

Define the concept bleeding

Name and explain types of bleeding

Describe three classification of bleeding

List the signs and symptoms of bleeding

Describe and recognise different methods of controlling bleeding

Describe PEC for severe external bleeding

Describe PEC treatment for epistaxis (nose bleed)

Describe PEC treatment for - Partial Amputation

-Complete Amputation

Definition of bleeding

Bleeding is escape of blood from intravascular space to the extra vascular space.

Two major categories of bleeding

Internal bleeding

External bleeding

Three classifications of bleeding

Arterial - blood spurts out with each heart beat and is bright red

Venous - blood flows out more steadily and is dark red

Capillary - blood oozes out in minor wounds

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Signs and symptoms of bleeding

Pallor of the skin and mucous membrane

Cold clammy skin

Rapid pulse gradually becoming weaker

Rapid shallow respiration

Yawning and sighing

Gasping for air

Anxiety and restlessness

Thirst

Nausea

Fainting and dizziness

Possible unconsciousness

Methods of managing bleeding

Direct pressure with a bandage to the wound to stop blood flow and allow clots to

form(coagulation)

Indirect pressure by bandaging

Splint and elevate

PEC management for severe external bleeding

Scene survey : assess mechanism of injury

Do primary survey

Apply directed pressure to the wound as quick as possible

If the wound is large and wide open, you may have to bring the edges of the wound

together first

Elevate the injury while keeping pressure on the wound

Place the casualty at rest

Quickly apply clean dressing direct onto the wound

Check circulation below the injury

Bandage the dressing tight enough to stop bleeding and not to cut off circulation

Treat for shock if necessary

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PEC treatment for:

Partial amputation

Scene survey

Control and manage bleeding

Send for medical help

Reposition the partial amputated part as near to normal position as possible

Cover the area with sterile dressing gauze

Bandage in position

Splint

Complete amputation

Stop bleeding by applying direct pressure

Place the casualty at rest

Bandage the dressing in place

Care of the amputated part

It needs to be preserved

Do not try and clean the amputated part

Attach a record of date and time and send together with the casualty

Place the amputated part in clean watertight bag and seal the bag

Place the first bag in another bag with cold water or crushed ice if available

Keep it in a cool place and get both the casualty and the amputated part to the

medical help

Label amputated part with casualty’s particulars i.e. name, date and time of incident

Treat for shock

Reassure the casualty

5.9 NOSE BLEED

Definition of nose bleed

Nose bleed is a common condition of bleeding from rupture of blood vessels in the nostrils

Causes

A hit to the nose

Sneezing or blowing the nose

An infection e.g. cold or flu

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PEC management of nose bleed

Put on gloves and let the casualty sit upright with head well forward

Loosen any tight clothing around the neck and chest

Advice casualty to breathe through the mouth

Tell the casualty not to swallow, speak, cough or sniff as blood clotting will be

disturbed

Pinch soft part of the nose for a maximum of 10 minutes and release

If bleeding has not stopped, re-apply the pressure for another 10 minutes

Do not allow casualty to stoop over a basin or blow the nose

When the bleeding stops, with the casualty’s head still tilted forward, wipe around

the nose and mouth with a gauze

If bleeding continues for more than 30 minutes or bleeding re-starts, then medical

help is required

5.10 SHOCK

Learning outcomes

At the end of the lesson the student should be able to:

• Define the concept shock

• Discuss the types and causes of shock

• Recognise the signs and symptoms of shock

• Discuss the management of shock

Definition of shock

A state of acute circulatory insufficiency characterized by reduced circulating blood volume,

with inadequate tissue perfusion and resultant low oxygen in the tissues

In order to maintain an adequate circulation and blood pressure there must be:

1 an efficient pump

2 an adequate volume of circulating fluid

3 sufficient tone in the blood vessels to prevent excessive vasodilatation

Types and causes of shock

Types of shock Causes Clinical picture

Cardiogenic Ineffective pumping of the heart ↓cardiac output=hypotension

Hypovolemic Inadequate circulating blood

volume

Low urine output, low CVP

Septic Infections Rigor, oliguria, hypothermia

Neurogenic Drugs, spinal shock, painful

physical & emotional experiences

Hypotension

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Common presenting signs and symptoms of shock

Skin may be cold, pale and clammy

Cyanosis

Decreased urinary output

Tachypnoea

Decreased LOC

Diminished urinary output

Mental confusion and apprehension

Low SBP

Tachycardia

Hypothermia

PEC treatment for shock

• Reassure the casualty if he/she is conscious

• Keep the patient in a flat or semi-recumbent position or the position best suited for

his condition

• Remove the cause of shock if possible or treat the cause e.g. control bleeding

• Keep the casualty warm

• Give nothing by mouth if unconscious

• Maintain airway patency

• Administer supplementary oxygen

• Relieve or minimise the pain and anxiety

• Monitor vital signs

• Handle the casualty gently to avoid fluid shifts

• Seek for medical help

• Administer supplementary fluids guided by haematocrit, urinary output and blood

pressure

5.11 FRACTURES

Learning Outcomes

At the end of this lesson the student must be able to:

Define a fracture

State causes of fractures

Name the classification of fractures

List and describe the types of fractures

List the sign and symptoms of fractures

Describe PEC management for Closed and Open Fractures

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Definition of a fracture

A fracture is a break or crack in a bone

Causes of fractures

Directed impact

Transmitted impact

Classification of fractures

Closed fracture - the skin over the fracture is not broken

Open fracture - the skin over the fracture is broken and this can cause serious

Infection

Types of fractures

Oblique :bone is broken at a steep angle

Greenstick : bone is not broken right through

Comminuted : bone is crushed

Spiral : bone is broken by twisting

Depressed : skull is fractured inward

Complicated: broken bone has cause damage to internal organs

Transverse: bone is broken straight across

Signs and symptoms of a fracture

Pain and tenderness

Loss of movement

Mobility of limb at site of fracture

Deformity /shortening

Swelling

Discolouration (bruising)

Crepitus (grating)

Shock increases with severity of injury

Bleeding wound in open fractures

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PEC management for:

Closed fracture

Steady and support the fracture

Assess neurovascular function on affected part

Immobilise the fracture with a splint

Splints the fractured limb

Open fracture

N.B Add the following treatment to the above:

Stop bleeding if there is an open wound

Do not put pressure on the protruding bone

Clean the wound around and away from the protruding bone

Apply a clean dressing around the protruding bone

Or make a tent to cover the bone depending on the length of the protruding bone

Make a ring pad large enough to cover the protruding bone

Support the ring pad with bandages

Treat for shock

LIST OF REFERENCES

American Heart Association. 2001: BLS for Healthcare Providers. Fighting Heart Disease and

Stroke. Dallas. USA.

Bledsoe BE; Porter RS & Cherry RA. 2007.Essentials of Paramedic Care.2nd edition. New

Jersey.Pearson Prentice Hall.

SAMDC.1994. Curriculum for the basic ambulance course. The professional boards for

emergency care personnel. Doc 3. (Part 1, August).

St John Ambulance. 1992. Standard First Aid and Safety Orientated. Calvin & Sales. Cape

Town.

St. John Ambulance. 1999. First on the scene. The complete guide to first aid and CPR.

Canadian cataloguing in publication data. South Africa.