BLOCK 3 Bl-3/A MEDICAL ASPECTS of DISASTERS and EMERGENCY FIRST-AID PROVISION Bl-3/B EPIDEMIOLOGY and SANITARY ACTION

BLOCK 3 Bl-3/A MEDICAL ASPECTS OF DISASTERS AND EMERGENCY FIRST-AID PROVISION Bl-3/B EPIDEMIOLOGY AND SANITARY ACTION

RS • MAJO JEU R HA MA ZA ES RD U S Q A S I G

E D

M R

E O

N C

C T A

Conseil de l'Europe • Council of Europe SCHOOL OF CIVIL PROTECTION

MODULE Bl-3/A MEDICAL ASPECTS OF DISASTERS AND EMERGENCY FIRST-AID PROVISION

HANDBOOK

RS • MAJO JEU R HA MA ZA ES RD U S Q A S I G

E D

M R

E O

N C

C T A

Conseil de l'Europe • Council of Europe Authors

Mustapha DENIAL • Directeur Executif de l'Observatoire National des Droits de l'Enfant, sous la presidence de Son Altesse Royale La Princesse Lalla Meryem. • Coordinateur de la commission maghrebine de vaccination (Algerie, Libye, Maroc, Mauritanie et Tunisie) en charge de la reorganisation des services de vaccination et de la campagne d'eradication de la poliomyelite et du tetanos • Membre du Conseil Consultatif des Droits de l'Homme • Docteur en medecine, Universite de Montpellier I, 1986

Paola BIANCO Lecturer, University Nurse School, Turin, Italy In charge of the Infection Control Programme care, "San Giovanni Bosco" Hospital, Turin, Italy CEMEC (European Centre for Disaster Medicine, Republic of San Marino) consultant for implementation of emergency programmes in refugee camps Expert and consultant in different humanitarian missions: 2001 - Implementation of Emergency Project in Cibitoke hospital, Burundi; 2000 - EUR-OPA MHA Risk Assessment Mission in Kosovo; 1999 - Italian Health System (Valona refugee camp) Albania; 1995/1996 - International Red Cross (Goma refugee camp) Zaire; 1994/1995 - UNICEF/CUAMM (Nyamata Project for Orphan Care) Rwanda; 1993/1994 - Croix Rouge de Belgique, and Medicins sans Frontieres, (Ngenda, Mass refugee camp) Rwanda; 1988/1990 - Different Italian NGOs Italian cooperation project: primary health care - Camerun; 1983 - Zaire.

Mohamed NESH-NASH President of Tanjah Tebbiah Polyclinic, Tanger, Morocco Founder and the Board Member of the Moroccan Human Right Organisation (OMDH) Member of the Mohamed V Foundation in charge of migrants Former Vice-President of the health Commission of the International Federation of the Red Cross and Red Crescent (Geneva, Switzerland) Former Vice President of the Medical Organisation in Tanger, Morocco • Coordinator of Moroccan Medico-Social Mission in Mitrovica (Kosovo), 1999-2001 • Director of Relief and Assistance Operation for Migrants Spain & Morocco), 1978 - 1992 • Director of Moroccan Red Crescent Clinics (1980-1992) • Adviser of the Arab Secretariat of the Red Crescent and Red Cross (Jeddah) • Member of the Moroccan National Observatory of the right of children • Mission in El Salvador, Sudan, Palestine, Spain, Morocco • Medical Doctor & surgery, Madrid, Spain, 1962

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Table of contents page 1. The human body ...... 1 1.1 The skeleton ...... 1 1.2 Muscles ...... 1 1.3 The respiratory system ...... 3 1.4 Circulatory systems ...... 4 1.5 Physiology ...... 5 1.6 Effects of emergencies and disasters on health ...... 5 2. The general principles of first AID ...... 9 2.1 Examining a casualty ...... 9 2.2 Handling techniques ...... 12 2.3 Organisation of medical care ...... 18 3. Treatment of casualties ...... 21 3.1 Haemorrhages ...... 21 3.2 Fractures ...... 37 3.3 Wounds ...... 44 3.4 Breathing difficulties ...... 47 3.5 Burns ...... 64 4. Bandages ...... 67 4.1 Triangular bandages ...... 67 4.2 Tailed bandages ...... 70 4.3 Roller bandages ...... 73 Annex 1: Classification card ...... 78 Annex 2: Management of health relief supplies . . . 78 Annex 3: Medical care survey form ...... 81

BL - 3/A . Theskeleton Thehumanbody 1.1 1. . Muscles 1.2 Muscle contractionisthe resultofinteractionbetweenthetwo. allel tothemajoraxisofcell. These filaments areoftwotypes: cytoplasmcontainsmyocytes. numerouselongatedfilamentsThe latter’s (myofibrils)par- Muscle tissueiscomprisedofmusclefibreswhich inturnarecomposedofcellscalled Muscular system(Fig.2)isanorganwhichable tocontractandrelax. tively), theheartandlungs(protectedby ribs). marily thebrain,bonemarrow(locatedin skullandthevertebralcolumnrespec- also serveasacalciumstoreforthebody. Lastly, theskeletonprotects theviscera,pri- framework, attached towhichthemusclescanacteffectively and in co-ordination. They The bonesoftheskeletonplayanessentialroleinmovement,formingasolidandstable The skeletonhasaround200bonesandcomprisestwomainparts: of thevertebralcolumn. All togethertheyformthethorax,andskull(cranium),whichjoinsontoupperend The skeleton(Fig.1)ismadeupof: Together, allthebonesformsolidframeworkofhumanbody. with themusclestomakemovementpossible. moveable orsemi-moveablejoints, whichenabletheskeletal systemtoactinconjunction The parts oftheskeletonarejoinedtogethersometimesbysutures,butmostoften by long timeafter deathandinadryenvironmentthereisvirtuallynodecomposition. almost mineralhardness.Becauseoftheircomposition,bonesareconservedforavery formed bythedepositoftricalciumphosphate. This givesthebonestheirrigidityand The parts oftheskeletonaremadeupprimarilybonetissue,matrixwhichis ment ofthecharacteristicsskeleton. pology andcanbeusedtoidentifyrace,sex,etc.Morphometryistheprecisemeasure- the nose,chin,feet). These featuresareofparticular interesttothefieldofphysicalanthro- gives thebodynotonlyits generalshape,butalsonumerousindividualfeatures(shapeof Although surroundedbymuscleswhichinturnarecoveredskin,thehumanskeleton forming theframeworkofbody. Biologically speaking,humansarevertebratesand,assuch,haveaninternalskeleton thickfilaments madeofmyosine • thinfilaments, made ofactin • theappendicular, comprisingtheupperandlowerlimbstheiranchoring • theaxial,consistingofskull,vertebralcolumn, ribsandsternum, • theribs,joinedatbacktospinalcolumn andatthefronttosternum • thevertebralorspinalcolumn,composedof vertebrae • acentralcolumn, • points (theshoulderandhipgirdles). EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 1 Fig. 3 2 Fig. 1 The respiratorysystem The skeletonsystem EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Fig. 4 Fig. 2 The cardiovascular system The muscularsystem

BL - 3/A BL - 3/A .. Striatedmuscles 1.2.4 Disorders 1.2.3 Smoothmuscles 1.2.2 Cardiacmuscle 1.2.1 1.3 The respiratory system Therespiratory 1.3 blood throughthecardiovascularsystem. cles, butits contractionsarerhythmicalandinvoluntary. These contractionspumpthe The cardiacmuscleisalsocalledthemyocardium.Itsimilarinstructuretostriatedmus- a part inthefunctioning oftherespiratorysystem. and thelungs,enveloped inpleura. The thorax,withits ribcageandmuscles, alsoplays nasal cavity, themouth,pharynxandlarynx),windpipe (trachea),thebronchialtubes The respiratorysystemcomprisesthe tracts (i.e.theupperairpassages -the the energytheyrequire. ide-laden venousbloodintooxygen-bearingarterial blood)wherebycellsareprovidedwith piration, i.e.breathing(movementofairinthelungs) andhaematosis(turningcarbondiox- The respiratorysystem(Fig.3)isaoforgans involvedintheinitialstages ofres- of thebody(forearm,leg). ated inthatpart ofthebodyandextrinsicmuscleswhentheyarelocatedinanotherpart enable apart ofthebody(e.g.hand,foot)tomovearecalledintrinsicmuscleswhensitu- towards themid-lineofbody, abductorsmoveitawayfromthemid-line.Muscleswhich “opens” ajoint,flexormuscle“closes”it;adductormusclesmovelimborappendage nist ifitisaprimemover, antagonist ifitopposesagonistmovement. An extensormuscle muscleistermedago- Skeletal musclesareclassifiedinaccordancewithhowtheywork. A of calciumintheblood;whenitisverysevere,referredtoasspasticity. Hypertonia (pathological increaseinthemusculartonus)canbearesultoffalllevel reduction ofmusculartone)canresultfollowingafallinlevelpotassium intheblood. tained inaconstant state ofmoderate contraction:musculartone.Hypotonia(pathological which commandsitcomesintocontact) andproducesmotion. These musclesaremain- reactions, acts upontheend-plate(theareaofmusclecellwithwhichnervefibre certain neuronstotransmitthenerveimpulseothercells),whichviaachainofchemical the musclebyreleasingacetylcholine,achemicalneurotransmitter(substance secretedby connected toanerveendingwhichreceivessignalsfromthebrain. This signalstimulates possible. They contract voluntarily, underthecontrolofbrain.Eachmusclefibreis Also stripedorskeletal muscles,striatedmusclesjointhebonestogetherandmakemotion (spasms inwhichresulturineretention). biliary tractsphincter(spasms inwhichleadtobiliarycolic)andthevesicalsphincter upper respiratorytracts (glottis,larynx),andespeciallythesphincters:analsphincter, the the musclesofdigestivetube(oesophagus,pylorus,colon),urinarytracts, the Certain smoothmusclescanhavespasms (suddeninvoluntary contractions). These are tem whichisnotunderdirectconsciouscontrol. cles, theircontractionsareinvoluntary, beingtriggeredbytheself-stimulatingnervoussys- bronchial tubes,gallbladder, bloodvessels,etc). Although similartothoseofstriatedmus- Smooth musclesarepresentinthewallsofmanyorgans(theuterus,intestines, EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 3 4 .. Thecardiovascularsystem 1.4.1 systems Circulatory 1.4 blood ittransports is richinoxygen. the commontrunkofall the body’s arteries,withthe exceptionofthepulmonaryartery; ding lung. The bloodittransports ispoorinoxygen. The left ventricleleadsintotheaorta, divided intotwobranches,left andright,whichthenfurtherbranch outintothecorrespon- ventricle isthechamberfromwhichpulmonary arterycarriesbloodtothelungs;itis Leading fromeachventricleisalargevesselorartery withathickbutelasticwall. The right which bringoxygenatedbloodfromthelungs. The left atriumreceivesthefourpulmonaryveins,twoonrightandleft, blood fromallorgansexceptforthelungs. The upperandlowervenaecavaeleadintothe rightatriumbringingtheoxygen-depleted The atriareceivethebloodarrivingintoheart viatheveins,largethin-walledvessels. ed byavalvewhichchannelsthebloodfromatriumintoventricle. Each ofthesetwocompartments issubdividedintotheatriumandventricle,separat- reach thewholebody(systemiccirculation). purified ofcarbondioxide,whichitpumps toalltissuesalongthebloodvesselswhich The left-hand sideorhalfoftheheartcontains thebright-redarterialblood,richinoxygen, stone topulmonarycirculation,whichiswhollyencasedinthethorax. the lungs,organsresponsibleforrespirationandexhalation,isdynamickey- blood, poorinoxygenandrichcarbondioxide. This right-handsideisorientedtowards The right-handsideorhalfoftheheartcontains onlythedeep-red,almostblackvenous pendent sectors. into twohalvesbyapartition, whichsubdividesthecirculationofbloodintotwototally inde- As inallhighervertebrates,birdsandmammals,thehumanheartisdivided,frombirth, The heart sign thattheindividualhasdied. shut downthebrain,producingstraightlineonbrainmonitor(EEG),irreversible and evacuatethewasteproducts produced. The cardiacarrestof3minutesisenoughto The roleofbloodcirculationistoprovidetissuewiththeoxygenandnutrients itrequires prime importance asthecirculatorysystemiskeytolifeinhigheranimals. progress madeinstudyingthecardiovascularsystem.Researchthisfieldisclearlyof CPR), ShumwayandBarnardforhearttransplants, andmanyothersarekeyfiguresinthe machine, W.B. Kouwenhovenforexternalcardiacmassage(cardiopulmonaryresuscitation in thediameterofbloodvessels), André Thomas andC.Lilleheifortheartificial heart-lung illaries, ClaudeBernardandRenéLericheforvasomotricity(theabilitytoproducechange The namesofBartholin,forthelymphaticsystem,Malpighi(1661)andMagendiecap- Finally in1628,WilliamHarverydiscoveredbloodcirculation. 1553 thatServetusdescribedtheindependentrightandleft compartments oftheheart. vessels. Galenwasthefirsttorecognisepresenceofbloodthere,butitonlyin Hippocrates, believedthattheairfromlungswasconveyedthroughoutbodyby still perpetuatesthemistake madebytheauthorsofancientworldwho,alongwith The conceptof“circulatorysystem”isarelativelyrecentacquisitionsincetheterm“artery” culation, whereas theaorta and thevenaecavaeare the vehiclesforgreater orsys- From thearterytopulmonary veins,thebloodcompletessmall orpulmonarycir- Vessels EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Thelymphaticsystem 1.4.2 .. Types ofemergencies anddisasters 1.6.1 Effectsofemergenciesanddisasters onhealth 1.6 Physiology 1.5 gle venoustrunk,thecoronarysinus,whichleadsintorightatrium. ly formlargerbranches.Lastly, circulationbacktothemyocardiumpasses throughasin- almost imperceptibly. These venulescontinuefromthenetworkofcapillariesandgradual- diameter ofaredbloodcorpuscle. The transitionfrom capillariestovenulestakes place Capillaries areapproximately7-8micrometersindiameter, i.e.roughlythesameas of dissolvedsubstances betweenthebloodandvascularisedarea. capillary walls(1micrometerthick)isconducivetothediffusion ofgasesandthetransfer terised byastratifiedlayerofflattenedcells,theendothelium. The extremethinnessofthe ly becomesthinner. The finalbranchesofthearteriesbecomecapillaries, charac- Each coronaryarteryissubdividedintoeverfinerbranches;thewallofgradual- ply, dies. This iswhathappensinaheartattack (myocardialinfarction). blood toawholesectionoftheleft ventriclewallandthissection,havinglostallbloodsup- suddenblockageinonebranchoftheleft coronaryartery, forexample,stops theflow of A ly bere-established byanastomoses(bypass surgery). cated territoryandifthereisanyobstructionineitherone,thecirculationcannotgeneral- and areabout5mmindiameter, entertheheart.Eachofthesearterieshasits owndedi- or themyocardium. Two coronaryarteries,theleft andtheright,whichoriginateinaorta In describingthevasculationofanorgan,weshalllookatmuscularwallheart, is completelycontained: thecirculatorysystemis“closed’. sue levelviaavastnetworkofsmallcanals,thecapillaries,withresultthatblood temic circulation.Bloodispassed betweenthearteriesandcorrespondingveinsattis- ral andman-madeemergencies and/ordisasters. In thefollowingobserved areonlyafewofthebasicprinciplespertinent todifferent natu- ules. tions, andanumberofprevention guidelineswillbedetailed andpresented inothermod- Detail approachestobeadopted,theprecautionsundertaken duringrescueopera- equipment. asters, withoperationalplansbeingelaborated for interventionbyspecialisedteamsand longtechnicalstudyshouldbemadeof each ofthebellowlistedemergenciesand/ordis- A the varioussystemsofhealthylivingbeings. concerned withthephysicalandchemicalprocessesatworkincells,tissues,organs Physiology isthestudyoffunctionsandnormalfunctioninglivingorganisms.It corpuscles andisdrainedbythesystemofveins. small intestine.Lymphatic fluidiswhitish,richinwhitebloodcorpuscles, hasnoredblood clavical veinatthebaseofneck. The lymphatic systemdrainsdigestedfatfromthe racic duct,originatesintheabdomen,crossesthoraxandemptiesintoleft sub- nodes. The lymphaticcollectorscometogetherinlarger ducts. The mostimportant, thetho- multi-valved vessels,thelymphaticcanals. They are interspersed bynodes,thelymphatic spaces whichcontain lymphaticfluid. This fluidpenetratesasystemofsmall,irregular, The lymphaticsystemplaysaveryimportant role,drainingtheinterstitial,extra-cellular EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 5 6 extent on: The fateofthecasualtiesandactiontaken byreliefpersonnelwilldependtoalarge first witnessesintheminutesimmediatelyfollowing thedisaster. In manyseriousaccidents, theeffectiveness of reliefdependsuponthebehaviourof Road accidents and withradiationcontamination threat. tion products orcausticgases,withamechanicalaggressionsuchexplosionandcollapse The heataggressioncanbeassociatedwithatoxic threatsuchasinhalationofcombus- tions), etc. hotel anddiscothequefires,firescollateraltonaturaldisasters(earthquakes,volcanoerup- explosions, industrialandfactorytraffic accidents (bus,tanker truck,train), scene. These areclassifiedasseverefiresandexplosions duetoairplaneaccidents, mine Every yearabout100severeburndisastersoccur, eachwithmorethan20deathsatthe Fires Traumatic injuriescausedbyfloodingarefewandrequireonlylimited medicalattention. deaths fromvenomoussnakebiteshasbeenreported,butnotfullysubstantiated. slightincreasein Slow-onset floodingcauseslimitedimmediatemorbidityandmortality. A Floods the weakestmembersofpopulation. injured intheirwake.Deathsresultmainlyfromdrowningandaremostcommonamong Flash floodsandtidalwavesmaycausemanydeathsbutleaverelativelyfewseverely Flash floodsandtidalwaves injuries willberelativelyminor. Effective warningbeforesuchwindstormswilllimit morbidityandmortality, andmost deaths andinjuries. floods orseasurgesoften associatedwiththem,destructivewindscauserelativelyfew Unless theyarecomplicatedbysecondaryemergenciesand/ordisasterssuchasthe Destructive winds of referralsashumanitarian operationsinmoredistant areas becomeorganised. sisting ofcasualtiesfromtheimmediateareaaroundmedicalfacility, andthesecond surgery andotherintensivetreatment.Patients mayappearintwowaves,thefirstcon- simple fractures,andaminoritywithseriousmultiplefracturesorinternalinjuriesrequiring likely tobeamassofinjuredwithminorcuts andbruises,asmallergroupsuffering from from earthquakes,butregardlessofthenumbercasualties,broadpattern ofinjuryis Little informationisavailableaboutthekindsofinjuries(orinjuryepidemiology)resulting ulation) andinjurelargenumbersofpeople. The tolldependsmostlyonthreefactors: destructioninearthquakesmaycausemanydeaths(over10%ofthepop- The buildings’ Earthquakes theaccuracy oftheinformation provided • whetherthewarning isaddressedtotheappropriateheadquarters • thespeedwith whichthewarninghasbeengiven • thepopulationdensity. • thetimeofdayatwhichearthquakeoccurs,and • typology thebuildings’ • EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Principaleffectsonhumanhealth 1.6.2 .. Commonhealthproblems 1.6.3 vivors themselves cannotmeetontheir own. Additional resourcesshould, therefore,bedirectedtowardsmeetingthe needsthatsur- to transporttheinjured medicalposts. ties minutesafter an impact andwithinhoursmayhaveorganised themselvesintogroups achieve clearpersonalends. Earthquakesurvivorsoften beginsearch andrescueactivi- increases assurvivorsrapidlyrecoverfromtheir initialshockandsetaboutpurposefullyto alised panic orstunnedwaiting.Spontaneous yethighlyorganisedindividual action After amajornaturalemergencyordisaster, humanbehaviouronlyrarelyreachesgener- lowing keyissuesshouldbenoted: optimise themanagementofhealthhumanitarian assistance anduseofresources. The fol- ferent emergenciesanddisasters.Ifrecognised,thesecommonfactorscanbeusedto with distinctsocial,healthandeconomicconditions,therearestillsimilaritiesbetweendif- disasters areuniqueinthewaytheyaffect areaswithdifferent levelsofvulnerabilityand health andaboutthemosteffective waysofprovidinghumanitarian assistance. Though all ural disastershealthhasledtodifferent conclusions,bothabouttheireffects onhuman survivors entirelydependentonoutside relief.Systematicobservationoftheeffects ofnat- but alsomassivesocialdisruptionandoutbreaksofepidemicdiseasefamine,leaving In thepast, sudden-impact disasterswerebelievedtocausenotonlywidespreaddeath, Social reactions Unless theaccidentisofcatastrophic proportions,itispossibletobeeitherwitnessorvictim. Effective managementofhealthhumanitarian aiddependsonanticipating and • Disaster-createdneedsforfood,shelterand primaryhealthcareareusually • Theactualandpotentialhealthrisksafter adisasterdonotalloccuratthe • Someeffects areapotential,ratherthan aninevitable threattohealth.For • Thereisarelationshipbetweenthetypeofdisaster andits effects onhealth. • theinitialsteps taken • victim-preservationmeasurestaken • mum numbersofsuppliesandpersonneltodisaster areasislessessential. times andpoints wheretheyareneeded. The logisticalabilitytotransportmaxi- identifying problemsastheyarise,anddelivering specific materialsattheprecise other privatereliefactivities. and spontaneously engageinsearchandrescue,transportoftheinjured life. Furthermore,peoplegenerallyrecoverquicklyfromtheirimmediateshock not total. Evendisplacedpeopleoften salvagesomeofthebasicnecessities there isovercrowdingandstandards ofsanitation havedeclined. increased diseasetransmissiontake longertodevelopandaregreatestwhere and placeofimpact andrequireimmediatemedicalcare,whiletherisksof tance withinadisaster-affected area. Thus casualties occurmainlyatthetime same time.Instead,theytendtoariseatdifferent times andtovaryinimpor- result fromnaturaldisasters. increased riskofdiseasetransmission,althoughepidemicsdonotgenerally example, populationmovementandotherenvironmental changesmayleadto tidal wavescauserelativelyfew. ple, earthquakescausemanyinjuriesrequiringmedicalcare,whilefloodsand This isparticularly trueoftheimmediateimpact incausinginjuries.Forexam- EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 7 8 during theemergencyreliefphaseisstronglydiscouraged. and communitysocialstructures. The indiscriminate useofsedativesandtranquillisers with themtemporarily. Wherever possible,efforts shouldbemadetopreservethefamily ly followingdisasters,andfamilyneighboursinruralortraditionalsocietiescandeal Anxiety, neurosesanddepression arenotmajor, acutepublichealthproblemsimmediate- Mental health distribution systemsmaycurtail accesstofood. within thedisasterareamayreduceabsoluteamountoffoodavailable,ordisruption Food shortages intheimmediateaftermath mayariseintwoways.Foodstockdestruction Food andnutrition ments. It maybenecessarytoprovideshelterforreasonsotherthanprotectionagainsttheele- risk. The needtoprovideemergencysheltertherefore variesgreatlywithlocalconditions. clothed, andabletofindwindbreaks,deathfromexposuredoesnotappearbeamajor cies ordisastersintemperateclimates. As longasthepopulationisdry, reasonablywell The healthhazardsofexposuretotheelements arenotgreat,evenafter majoremergen- Climatic exposure lic servicescannotcope,andtheresultmaybeanincreaseinmorbiditymortality. provide humanitarian assistance iscreated.Peoplemaymovetourbanareaswherepub- When large,spontaneous ororganisedpopulationmovements occur, anurgentneedto Population displacements immediate post-disasterperiod. sewage, andthefailuretomaintain orrestorenormalpublichealthprogrammesinthe refugee camps), thedisruptionofpre-existingsanitation servicessuchaspipedwaterand tors increasethepressureonwaterandfoodsuppliesriskofcontamination (asin The riskofepidemicsisproportionaltopopulationdensityanddisplacement. These fac- tamination ofwaterandfood;hencesuchdiseasesaremainlyenteric. The mostfrequentlyobservedincreasesindiseaseincidencearecausedbyfaecalcon- Diseases EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Theinitialassessment 2.1.1 Examiningacasualty ThegeneralprinciplesoffirstAID 2.1 2. The pupilsmaybe: opened. This responseiscalledthe“pupilreflex”. darkness andshouldcontractwhenalightis shone onthemorwhentheeyelidsare The pupilsshouldberound,symmetricalandregular. Normally, theyaremoredilatedin Examination ofthetwopupils,byraisingeyelids, takes onlyafewtenthsofsecond. understood onlytoowell,byanapparently unconsciouscasualty. should betaken toavoidpointlesscomments whichcouldbemisunderstood,orindeed scious. However, it ispossiblethatheorshecanstillheareverything. Accordingly, care If thereisnoresponse,thefirst-aidermaylegitimatelyassumethatcasualtyuncon- should belookedfor. bally orvisually;aneyelidopeningahandmovingaresignsofconsciousnesswhich alone?”, “Whereareyougoing?”)thattheinjuredpersonwillbeabletorespond,eitherver- It isonlybyaskingquestions(e.g.“Whathappened?”,“Wheredoesithurt?”,“Areyou carried outintotal silenceyieldsfewresults. When approachingacasualty, thefirst-aidershouldspeaktohimorher. An examination Consciousness concerning thestate ofthecasualty: quick examinationandlisteningshouldprovideanswerstofourfundamental questions Except indangeroussituations(fire,riskoffurtheraccidents), afewwords,carefuland whether: of thecasualtybylooking,listeningandaskingquestions.Heorshewillbelookingfor In thetimeofjustafewseconds,first-aidershouldbeabletoassessvital functions medical knowledge. must alsopreventanyharmfulinterventionbybystanders whomayornothaveany the steps thatmustbeimmediatelytaken, butalsothose that mustbeavoided.Heorshe The first-aidertoapproachacasualtyhasanenormousresponsibility. Notonlyinviewof irregularorasymmetrical (onecontracted,theotherdilated),generally indica- • dilated,without anyresponsetolight. This generallyindicatesalack ofoxygen • contracted,whichisusual • isheorsheinastate ofsevereshock? • isthereanylossofblood? • doesheorshehavebreathingdifficulties ? • isheorsheconscious? • circulationisfunctioning normally thecasualty’s’ • thecasualtysuffers fromanybreathingdifficulties • thecasualtyisconsciousornot • tive ofdamagetothenervous system problem (state ofshock, cardiacarrest) to thebraincausedbyeither anairwayobstruction(asphyxia)oracirculatory EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 9 10 Look andlistenforsignsofbreathing. That maybe: Breathing impossible, toobtain atalaterstage. sciousness atanymomentandtheinformationrequiredwillbeallmoredifficult, ifnot ber ofclearandconcisequestionsshouldalsobeasked. The casualtymaylosecon- num- The sameexaminationshouldalsobecarriedoutonacasualtywhoisconscious. A should stillcarryoutarapidexamination: bent, eyesclosed,etc);however, despitetheurgentactionthisrequires,first-aider Unconsciousness maybeassumedfromthecasualty’s physicalstate (motionless,head the eyelids,shouldassumeafracturedskull,andkeepverycarefulwatch possible toexaminethepupils.Insuchcases,first-aidershouldnotattemptopen If thereisabloodclotontheeyeoreyes,ifseveredamagetoitnot These aspects areallpart andparcel oftheinitialassessmentandshouldbenoteddown. sheet followingthisinitialexamination. subsequently losesconsciousness.Theyshould benotedonanevacuation The answerstothesequestionscouldsave thecasualty’s lifeifheorshe rapidand superficial • wheezing • noisy • gasping • hardorimpossible toseeorhear • isheorsheinavisiblestate ofshock? • istherealossofblood? • isthecasualtybreathingnormally? • Doyouhaveanyotherallergies? • Doyouhaveanyallergiestoparticular medicines? • Areyoucarryinganymedicalcardshowing: • Areyouunderanymedication? • Areyoutaking anymedicationforyourheart?Fornerves?dia- • Doyouhaveanyproblemsbreathing? Take adeepbreath,breatheout • Wheredoesithurt? • betes? hard! You arebeingtreatedwithanticoagulants? • You aresuffering fromdiabetes? • You aresuffering fromhaemophilia? • Areyoutaking corticosteroids? • Areyoutaking anticoagulants? • Questions tobeaskedassoonpossible EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Firststeps 2.1.2 gaspingsoundisoften caused bythetonguefallingbackwardswhenheadisbent. A ties diefromthis. of mucus,bloodorvomitwhichcanobstructtheupperairpassages. Oneoutof7casual- With unconsciouscasualties,makesureyoulistenoutforgurglingscausedbyabuild-up have tobeidentified). casualtywhocomplainsofchokingshouldbebelieved(andthecausesthis scious). A It isessentialtolistenthecasualtyspeak(ifheorsheconscious)breatheuncon- The consequencesofbreathingdifficulties are: Chest andabdomenmovements maybe: ing ornotbreathing properly, thefirst-aider should: If thevictimisunconscious, isnotbleeding,inastate ofsevere shock,isnotbreath- ing, duringandafter evacuation. of severeshock,theexamination shouldbecontinuedandthecasualty monitoredpend- If thevictimisconscious, hasnobreathingdifficulties, isnotbleedingand notinastate and theappropriatesteps mustbetaken immediately. the personconcernedisnolongerbreathingor is gasping,therehasbeencardiacarrest Lastly, withanunconsciouscasualty, ifthereisnopulse,oritcannotbedetected,and the groin,aresignsthatcasualtyshouldnot beleft inasitting position. breathing and,especially, averyweakbutracingpulse(over110/min) taken attheneckor Indications arepaleness ofthelips, earsandtheface.Coldsweats, rapidandsuperficial With unconsciouscasualties,first-aidershave toassessthesituationthemselves. are anxiety, shiveringtrembling andthirst. be taken aresomewhatdifferent. Indicationsofastate ofshockinaconsciouscasualty tial thattheinitialexaminationshouldcheckforthis,sinceinsuchcasesmeasuresto Commonly theonlyindicationofinternalbleedingisastate ofshock.Itisthereforeessen- State ofshock However, asageneral rule,bloodstained clothingshouldimmediatelybevisible. under thesleeveanddrips off thehandontocarseat(inaroadaccidentforexample). trousers. The samecanbetrueofbleedingfromthe armorthearmpit,whichrunsdown often seenonlyonceitreachesthefoot,havingtravelleddownlegunderneath first-aider shouldbealerttothis.Bleedingfromthethigh,whetherarterialorvenous,is casualty andthepath followedbythebloodflowingbeneathclothescanmislead,and It isusuallyquiteclearwhenthereconsiderableexternalbleeding. The positionofthe Bleeding sweatingisoften asignofbuild-upcarbondioxideinthebody, aconse- • abluishhuetothelips, earsornails(cyanosis)indicatingalackofoxygenin • flutteringofthenose,indicatingadvancedbreathingdifficulties • theneckmusclestightenorahollowformsjustabovebelowster- • toofastorslow, asignofbreathingdeficiency • irregularorerratic,precedingrespiratoryarrest • non-existent,thisisrespiratoryarrest • quence ofbreathingdifficulties the body num, indicatingmajoreffort requiredtobreathe EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 11 12 .. Generalprinciples 2.2.1 Handlingtechniques 2.2 ficult tostraightenup.When bendingandstraighteningup,moveslowly andsmoothly. bent andthepelvistilted forward.Donotbendtoomuch,however, asitwouldthenbedif- form thelift. To usethispower toits bestadvantage, thebackshould bestraight,theknees as closepossibleto the body. Itisthepowerof leg muscleswhichisusedtoper- Lastly, thebackshouldbekeptstraight,withchintucked in,shouldersbackandelbows side oftheitemtobecarried,andshouldbend his orherhips and knees. The carriershouldthereforebeclosetotheobject, withonefootinfrontoftheother, either The individual’s centreofgravityislocatedmoreorlessatthepubis. moves outside thisbasesurfacearea,afallisinevitable. larger andthecentreofgravityisgenerallyperpendicular tothis.Ifthecentreofgravity in frontoftheother. Inthisway, thesurfaceareabetweenexternalsidesoffeetis position ofanddistance betweenthefeet,whichshouldneverbeparallel; oneshouldbe person’s balanceislinkedtothe Balance isessentialtoavoidanyinvoluntary movement. A as possible. To dothat,thekneesandhips shouldbebent. this canonlybedonebyadoptingaparticular position,withthefeetasclosetoload Reducing thelengthofleverarmalsoreducespressureonvertebrae.However, the tower, and500kg whenitis6metresaway. crane,forexample,canbear1tonnewhen thetrolleyis3metresfrom as practicable. A sible. The leverarm,i.e.thedistance betweentheloadandfulcrum,shouldbeasshort The centresofgravityboththebearerandloadshouldbeasclosetogetherpos- The positiontobeadopted casualties onstretchers(this,however, involvesteamwork). This generaladviceshouldbefollowedinallcasesofhandling,e.g.lifting andcarrying – willbeinevitable. this isnotdone,injuries–pain, lumbago,sciatica,backstrain,tornmuscles,sprains,etc The firstaidpersonnelmustbegiventraininginthecorrectuseofhandlingtechniques.If once steps havebeentaken toensurenofurtheraccidents couldoccur. sage andresuscitation, onceanyobstructiontotheairpassages havebeenremovedand If thevictimappearstobedead,aqualifiedfirst-aidershouldapplyexternalcardiacmas- her legsslightly. being extricated,toallowcirculationthebrain.Ifthereisnoseriousinjury, raisehisor for himorhertobeplacedinalyingposition(withthehead,neckandbodyaligned)before If thevictimisinaseverestate ofshockindicatingmajorinternalbleeding,itisessential Nomatterswhatthelocation(exceptwhereairistoxic)carryoutartificial • ifthevictimisinavehicle(roadaccident),ascarefullypossibletilthead • makesuretheupperairpassages areunobstructed • ual insufflators. should betaken overbyaqualifiedfirst-aiderassoonpossible,usingman- resuscitation (suchasmouth-to-nose)beforeandduringremoval. This task arrange foroxygentobeadministered(providedthereisnoriskoffire) tilt theheadtosideinrecoveryposition)and,whereappropriate, ticable, unfastenclothes,removeanydentures,insertaGuedel-typeairway(or well backsothatthehead,neckandtrunkareallaligned. As soonasisprac- EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Fig. 5 victims Examination ofconscious 13 14 Fig. 7 A Handling techniques(A-turinig avictim/patient ;B-Lifting avictim/patient) C O L L E AIGTESPOON THE MAKING C T I O EIA ASPECTSOFDISASTERS MEDICAL N

A N D

T R A N S P O R T FIRST-AID PROVISION FIRST-AID A T I O N AND EMERGENCY

Fig. 6 B victims Examination ofunconscious C O L L AIGTEBRIDGE THE MAKING E C T I O N

A N D

T R A N S P O R T A T I O N

BL - 3/A BL - 3/A .. Applicationofhandling principlestocasualties/patients 2.2.2 Pay attentiontothefollowing: Mistakes tobeavoided understand thegeneralprinciples beforetheycanbeapplied tospecificcases. more difficult tomanoeuvrethan cratesorbuckets. This iswhyitfirstofallessentialto personisveryheavyandmuch lift them,helpthem walk,turnthemover, washthemetc. A bers areoften required topullthembackupthetopofbed,sit themdownonabed, There aremanypatients orotherswhoareunabletomove by themselves.Familymem- straightening yourlegs. apart, bodybentforward,armsasfarbackpossible.Lift thewheelbarrowby The techniqueisverysimilartocarryingastretcher. Your feetshouldbeslightly Lifting awheelbarrow straight. Bendslightlyforward.Lift thebucketbystraightening your legs. Place yourfeeteithersideofthebucket,bendlegsandkeepshoulders Lifting abucket To lift, straightenyourlegs,keepingarmsstraightallthetime. You shouldbenddown,keepyourbackstraight andhaveyourfeetslightlyapart. Carrying astretcher your chestand,bystraighteninglegs,lift ittoontothetable. on yourthigh,take itinyourforearms,keepinglegsbent. Then place itagainst lifted bystraighteningyourlegs.Ifyouwishtoplaceitonatable, orifitisresting The boxshouldbeplacedatanangleandgrippedbyoppositecornersthen Carrying aboxwithouthandles thigh tosupporttheload. outstretched andlegsbent.Lift theobjectbystraighteningyourlegs,using Position theloadbetweenyourfeet,withonehandlefacingforwards,arms Carrying anobjectwithhandles tant thingstoretain. These techniquescanhelpavoidinjuries. This ispossibly oneofthemostimpor- These areafewexercisesforprovidingbetterunderstanding ofmovements. donotbendyourlegstoomuchotherwiseyouwillhavedifficulty straighteningup • donotforgettobendyourlegs;keepingthemstraightwillmakeyouarchback • donotarchyourbackorcurvethespinalcolumnasthiscoulddamage • beasclosepossibletotheloadlifted • makesureyourfeetarenottooclosetogetherorfarapart; thiswillupset • avoided atalltimes inter-vertebral disks;damagecanalsobecausedbytwistingthespine,to your balanceandcouldcausespinalinjuryorhernias EIA ASPECTSOFDISASTERS MEDICAL Examples/Exercises onmovements FIRST-AID PROVISION FIRST-AID AND EMERGENCY 15 16 structed, withplentyofroom. head andthetwosides)isimpossible,accessfromasingledirectionshouldbeunob- Access tothebedshouldbeasconvenientpossible.Ifaccessfromthreesides(the slip oryourkneesknockintosomething.Inshort,itisverylikelythatyoucouldfall. niture ispositionedtoocloselytogether, itisnotatalleasytomoveabout. Your feetcould First ofall,theroomshouldbetidied.Iffloorislitteredwithvariousobjects, orifthefur- position ortwistyour body Never archyourback tolift anything, nevercarryanythinginacrouched acquired inthemovement, forexamplewhenbreakingthefallofan object To reduce theeffortrequired,useweightof the bodyandspeed Use yourlegmusclestolift theloadandbecarefulnottotwist thespine as possible,backstraightandlegsbent Always stand closetotheload,feetapart, thetwocentresofgravityasclose turned toadvantage. ic energy, i.e.toacertain extent,yourownbodyweightcanalsoonoccasion be The directionofmovementcanalsobeutilised.Lastly, movementincreaseskinet- umn. them appropriately. Movinginthis wayalsohelps avoidsprainstothespinal col- way throughtheprocess). To thisend,donotkeepyourfeetinoneplace,butmove movements flowonfromeachother(butthisspeedshouldnotbereducedmid- The objectmaybemovedmoreeasilyasaresultofthespeeditacquiresthese leg. paravertebral muscles. The counterweightcouldbe,forexample,astraightened avoid becomingunbalanced. This willhelpyoulimit excessivecontractionofthe cranewithits weights andcounterweights givesagoodillustrationofhowto A raised), notafter breathingout. When exertingeffort, holdyourbreathafter breathingin(whenthediaphragmis absorbers”, formedbyairintheorgans. Pressure onthespinalcolumnshouldbedistributedbytryingtocreate“shock hold. of yourfingers,sothatitdoesnotslipandobligeyoutomakeextraeffort tokeep lifting. You shouldtake holdoftheloadwithpalms ofyourhandandnottheend these musclesreactquicklyandpreciselyprovideconsiderablepowerwhen serve asa“claw”butthearmmusclesarenotactuallyusedforlifting, eventhough Your armsshouldremainstraightwhenlifting. Infact,thearmsandhandsmerely there areanumberofothermovements tohelpreducefatigue. Once youareinapositionwhereyourbackisstraight,feetapart andkneesbent, EIA ASPECTSOFDISASTERS MEDICAL Principles tobeborneinmind FIRST-AID PROVISION FIRST-AID AND EMERGENCY Related movements

BL - 3/A BL - 3/A often beraised,making itmucheasiertoprovidecareapatient orelderlyperson. to afall.Lastly, whilebedswhicharetoohighdifficult toaccess,bedsatfloor levelcan what movements will bemadesothattheydonotanythingout offearwhichcouldlead It isessentialtoensurethat patients areawareofwhatisgoingtohappen. They mustbe told son hastodothelifting. Clearly, itismuchbetteriftherearetwopeople toperformthistask. It isoften moredifficult toarrangefortherightnumber ofcarriers,andfrequentlyjustoneper- ples caneaseeveryone’s task andpreventinjury. tion. Theydoillustrate,however, thatapplyinggoodhandlingprinci- These movements shouldnotbeundertaken withoutcarefulprepara- or herwrists andplaceyourarmsunderneathhisorherarmpits. head ofthebed.Wherethisispossible,stand behindthepatient, take holdof his It ismuchhardertodothistask onyourown,especiallyifyoucannotstand atthe body fromonelegtotheother. ing position. Then bendyourstraightleg.Here,you are shifting the weightofthe and handunderhimorher, bendonelegandkeeptheotherstraightinwait- easier iftherearetwoofyou.Stand eithersideofthepatient, placeyourforearm It isoften quitedifficult topullapatient backuptothetopofbed.Itismuch Pulling apatient backuptothetopofbed and beabletolift thepatient. steady thepatient’s legs.Byleaningbackwardsyouwillcreateacounterweight your kneesbentandonefootinfrontoftheother, take holdof the beltorsheetand to putadrawsheetorbeltaroundhisherwaist.Keepingyourbackstraight, To getapatient seatedontheedgeofbedintoastanding position,itisuseful Getting apatient seatedontheedgeofbedintoa standing position Complete themanoeuvrebybendingyourknees. opposite thigh. The patient canthenbeturnedroundwithouthavingtolifted. position. Placeyourarmaroundpatients backoftheneckandotheraround The principleinvolvedistopivotthepatient onceheorsheisinasemi-seated It isrelativelyeasytoseatapatient onthesideofbed. Seating apatient onthebedside This makesiteasytoturnthepatient round. pelvis andtheotherunderthorax.Pullhandaroundthoraxupwards. be turnedontotheirback. To dothis,placeonehandaroundthepatient’s thighsor patient withoutmucheffort. Occasionally, patients lyingontheirstomachhaveto around thecrotcharea.Bystraighteningyourlegs,youshouldbeabletoturn feet apart, placeoneofyourarmsunderthepatient’s shoulderandtheotherhand opposite totheonetowardswhichheorshewillbepivoted.Withyourkneesbent, To turnapatient overinbed,youshould,ifpossible,stand onthesideofbed Turning apatient overinbed EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Examples/Exercises 17 18 .. Searchandrescueunits 2.3.4 mobilehospitals Observation 2.3.3 First-aidmobilehospitals 2.3.2 Mobilehospitals 2.3.1 Organisationofmedicalcare 2.3 simply medicalsurveillanceornursingcare. by volunteers. They willtake inpatients whohavealreadybeentreatedandrequire These areunits withlimitedmedicalandparamedical staff resources,possiblyreinforced disaster area. sprains etc)andambulatorytreatmentforthenon-serious casualtiesandinhabitants ofthe first-aidmobilehospital isadaycentreprovidingfirst-aidcare(treatingbruises,cuts, A units intothegeneralframeworklaiddownbynationalplan. hospitals. These localauthoritiesshouldbeabletoincorporatetheactivitiesofmobile authorities shouldbegivenresponsibilityforco-ordinatingthetasks assignedtothemobile do nothavetodependonthealreadystretchedresourcesofcommunity. The local water, foodandother dailynecessitiesforbothcasualtiesandstaff, sothatthesehospitals equipment. Itisalsonecessarytoensurethatthereareadequatesuppliesofdrinking the appropriatemedicalandsurgicalfacilities,suppliesofmedicinesemergency ifications (medical,auxiliary, administrative andtechnical)numbers,thatthereare Before theyaresetup,itisessentialtoensurethatthereadequatestaff, intermsofqual- existing hospitals havebeendamagedorcannotfunction. The useofmobilehospitals asobservation,treatmentorfirst-aidcentresisjustifiablewhen The followingmustbecarriedout: inefficiency andchaos. Whatever thetypeofdisaster, anumberofbasicprincipleshavetobeobservedavoid and healthcentrestaff areresponsibleforemergencyassistance. organisations. Ifthedisasteroccursinaruralarea,awayfromtownorcity, dispensary istered byambulancestaff, firefighters,thepolice,RedCross,orotherhealthcare urgent caretheyneed.Whendisastersoccurinurbanareas,firstaidisgenerallyadmin- First aidisgenerallygivenatthedisastersiteitself inordertoprovidecasualtieswiththe aid. They should,inaddition, beabletotravelimmediatelythesceneof disaster. If theyaretobeeffective, rescue units shouldhaveteamswho been trainedinfirst contact shouldbemadewithregionalhospitals andtheiroutposts sothatthey • casualtiesshouldbegivenfirstaid(including maintenanceofvital functions, • anappropriatelocationhastobefoundfortheinitialtriageofcasualties,before • anassessmentmustbemadeofthescaledisaster, thenumberofcasu- • acommandpostmustbesetuptoco-ordinaterelief,monitortheuseof • can implementtheiremergencyplanstotake inthecasualties IV drips) stopping bleeding,clearingairpassages and,whererequired,transfusionsand they areevacuatedtomedicalcentres alties, wheretheyarelocatedandtheirimmediateneeds resources andpreventconflicts ofresponsibility EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Triage, identificationandclassificationofcasualties 2.3.5 care services. out inthehospital anditisatthispointthatdecisionsaretaken ontransfertothehealth- thirdorderofpriority(third-leveltriage)iscarried ter areaoruponadmissiontohospital. A secondorderofpriority(second-leveltriage) isdecideduponoutside thedisas- triage). A Triage isacontinualprocess.Initialprioritiesaredeterminedatthedisastersite(first-level triage. have tobeclassifiedonthebasisoflikelihoodtheirsurvival. This procedureiscalled When therearealargenumberofcasualtiesandmedicalresourceslimited,theinjured EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Fig. 8 Model triagetag /sorce: PAHO, ScientificpublicationN°443,1983/ 19 20 .. Evacuationpriorities 2.3.8 Identificationandclassification 2.3.7 Triage atthedisastersite 2.3.6 Table 2 Evacuation priorities(Table 2)aremadeinaccordance withtheinjurystatus ofthecasualty. Table 1 the evacuationpriority. putting acolour-codedtag onthecasualty(Table 1)thatindicatestheinjuryseverityand Wherever possible,casualtiesshouldbeidentifiedduringthetriageprocess. This involves out examinationstoconfirmdeath. All deathsshouldbecertifiedsothatmedicalstaff donotwasteanytimehavingtocarry ever theseverityoftheirinjuries. This doctorshouldtake careofthetriageoperations. Ideally, adoctorshouldbedispatched tothedisasterareaexamineallcasualtieswhat- Colour ofthetag Yellow The dead Casualties whohavebeentrappedorburied Casualties whoareneithertrappednorburied Green Black Red casualtieswithblacktags whoaretrapped • casualtieswithblacktags, neithertrappednor • buried Evacuation priorityaccordingtoinjurystatus ofthecasualty Tagging ofcasualties EIA ASPECTSOFDISASTERS MEDICAL Evacuation priority Injury status ofthecasualty Injury Second Highest Third FIRST-AID PROVISION FIRST-AID AND EMERGENCY their vital functions. impossible toapplythenecessarytechniquesmaintain pulse for20minutes,oriftheirsituationissuchthatit dead iftheyarenolongerbreathing,therehasbeen Placed onthedead,only. Casualtiesareconsideredtobe likely todieveryshortly. Used forcasualtieswhohaveminorinjuriesorare they arenotinalife-threateningsituation. Casualties fallingintothiscategorymustreceivecarebut Used onlyforcasualtiesrequiringimmediatecare. Casualty description to beevacuatedafter other Evacuation order yellow tags yellow tags green tags green tags casualties red tags red tags

BL - 3/A BL - 3/A .. Types ofhaemorrhage 3.1.1 Haemorrhages Treatment ofcasualties 3.1 3. the courseofaction. Nowadays itistheamount ofbleeding,ratherthanthistextbookpattern, thatdetermines For averylongtimethese different typesofhaemorrhageweredealtwithindifferent ways. dents, inthefamilyenvironment,duringleisureactivitiesandatwork. lary haemorrhages,i.e.mostofthehaemorrhages thatoccurasaresultofeverydayacci- are asfinehair. Herebloodoozesindroplets. Mostexternalhaemorrhagesarecapil- Capillary haemorrhageaffects theminuteblood vesselswecall“capillaries”becausethey haemorrhage Capillary cose veinisoneexampleofvenoushaemorrhage. arterial blood,asitispoorinoxygenandmuchricher incarbondioxide.Ruptureofavari- ing thebleeding. The woundbleedsinasteadystreamofdarkredblood,muchdarkerthan As veinshavethinner, softer walls,theseverededgestendtocollapse andclose,reduc- Venous haemorrhages rhythmic spurts, correspondingtoeachbeatoftheheart(left ventricle). As arterywallsarethick,thecutremainswideopenandbrightredbloodgushesoutin Arterial haemorrhages illary). are usuallydistinguished,dependingonthetypeofbloodvesselinvolved(artery, vein,cap- Three categoriesofexternalhaemorrhage: External haemorrhages Haemorrhages aretraditionallybrokendownintothreetypes: external, wherethereisanopenwound. or capillaryvesselisruptured. The bleedingmaybeinternal(insidethebodytissues)or Haemorrhage meansbleeding,adischargeofbloodfromthevesselswhenanartery, vein capillary • venous • arterial • internalhaemorrhagewithbleedingfrombody openings,wherethebloodflows • internalhaemorrhage,wherethebloodescapesfromnormalcirculatory • externalhaemorrhage,generallylinkedtoanaccidentandthecasualtyloses • or faceorifices(ears,nose,mouth)fromthegenito-urinarytractandanus body cavitiesconnectedtotheoutside: thecasualtymaybleedfromhead from thebodywithouttherebeinganyopenwounds;bleedingoccursinside mosis orbruisingarevisiblesignsoflessserioushaemorrhage toms shouldalerttherescuertopossibilityofserioushaemorrhage;ecchy- the factthatanaccidenthastaken placeandtheappearanceofcertain symp- channels, butremainsinsidethebodyandcannotbeseenfromoutside; blood fromanopenwound EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 21 22 tually disappearing.When bruisingfollowingaviolentbloworsprainisaccompanied bya that changescolourasthe daysgoby, turningblue,greenish thenyellowishbeforeeven- The firstsignofecchymosis orbruisingisareddishblackishdiscolouration oftheskin around anopenwound. ture ofcapillaryvessels; itmayalsooccurunderamucusmembrane (conjunctivitis)or Bruising isanaccumulationofvaryingamounts ofbloodundertheskinfollowingrup- Ecchymosis, orbruising diseases ofthebloodandmustbetreatedaccordingly. Some internalhaemorrhages,largeorsmall,very localormorewidespread,aresignsof Warning signsexistonthreelevels: There isalwaysapossibilityofseriousinternalhaemorrhageintheeventanaccident. Serious internalhaemorrhages Internal haemorrhagesmaybecausedby: The courseofactionvariesaccordingtothegravityinjury. (bruising) tothemostserious(ruptureofliverorspleen,ectopicpregnancy). The term“internalhaemorrhage”coversavarietyofaccidents, fromthemostharmless vessels, itcannotbeseenfromtheoutside. Itremainsinsidethebody. These arehaemorrhageswithnoopenwound. Although bloodescapesfromthe Internal haemorrhages muscle hasaregulatingeffect ontheexternalbleeding. misleading, forevenifamajorarteryhasbeensevereddeepinsidethebody, themassof by pitchforks,agriculturalequipmentandsoon)often bleedinasteadyflow, whichcanbe ruptured veinsorarteries.Somedeepwounds(bulletknifeinjuriescaused Bleeding wounds(whichareoften coveredbyclothing)aremoreoften thannotasignof exact typeofhaemorrhageatthesceneaccident. group ofcapillaries.Itisoften difficult, ifnotimpossible(evenforadoctor)todeterminethe Accidents areusuallycomplexevents thatrarelyaffect onlyonevein,arteryor thevictimlookspale anddrawn,isweak andfaint,iscoldshivering(cold • thegeneralappearanceofcasualty, wherethepreviouslydiscussedsigns • theaccidentitself, wherethevictimreceivedaviolentblowtoabdomen, • ectopicpregnancy;ruptureofthefallopiantube producesinternalbleedingthat • injurybyfirearmorforeignbody;herethere is anopenwoundbutoften onlya • ruptureortearofonemorebloodvessels bybrokenbonefragments • contusioninjuryfollowinganaccidenttothe chest, abdomen(ruptureofthe • asimpleknock,bloworeverydayaccident • or sheisdying thirst, buzzingintheears,blurredvisionand,above allfear, thefeelingthathe conscious, thecasualtycomplainsofbreathingdifficulties (suffocation), intense hands orfeet);thepulseisbarelyperceptible,weak, tenuous,irregular. Ifstill of astate ofshockareapparent back, skull,etc. requires urgentsurgery small one,obstructedbyaforeignbody;thebleedingremainsinsidebody liver orspleen),back,skull,etc. EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A of ablooddisorderthatfallsoutside thescopeoffirstaid. broken bone.Ifbruisingappearsspontaneously, withoutanyphysicaltrauma,itisasign very sharppain andfunctionaldisability, itisasignofmoreseriousinjury-fracturedor or duodenalulcer, haemorrhagicgastritis,etc. There arevariouspossible causes:rupturedvarices,veinsoroesophageal lining,gastric of bloodlostandthereal extentofthehaematemesis. blood, whichshouldbeconservedforsubsequent analysisinordertoevaluatetheamount Blood leaksorisvomitedfromthemouth. The victimvomits varyingquantitiesofverydark Haematemesis otorrhagia, itcanpointtofractureoftheskull. In theeventofanaccident,however, sometimesbutnotnecessarily inconjunctionwith Sometimes itisasignofblooddiseaseorhigh bloodpressure. case onlyasimpletreatmentisrequired. This isthescientificnamefornosebleed. The causeisoften simpleandlocal,inwhich Epistaxis origin ofthehaemorrhageisatrauma. may beasignoffracturedskull,andinparticular fractureofthepetrosalbone,when the sectionondivingandleisureaccidents, suffice ittosayherethatbleedingfromtheear Blood oraclearerfluidmaybesecretedfromtheear. As bursteardrumsaredealtwithin also occurinconnectionwithcertain eardisorders,suchasotitis. accident), orabursteardrumsustained inadivingaccident.Bleedingfromtheearmay This meansbleedingfromtheear. The originmaybeaccidental (fallonthehead,road Otorrhagia This isacaseofbleedinginbodycavitybeingevacuatedthroughnaturalorifice. the lowerabdomen.Sheispale andfaint,withsignsofinternalhaemorrhage. Tubal ruptureisaterribleandbrutal accident. The victimfeels asuddenstabbing pain in rity, sotwotypesofaccidentare tobefeared: implants itself inthefallopiantube. The tube isnotelasticenoughforittodevelopmatu- implants itself intheuterus.Sometimes,forsomeobscurereason,fertilisedegg In normalpregnancytheovum,fertilisedbyasperminouterthirdoffallopiantube, Ectopic (orextrauterine)pregnancy the brain)orintracerebral(insidebrainitself). the skull.Haematomasmayalsobesubdural(whentheyformbetweenduramaterand haemorrhage occursbetweentheoutermembranecoveringbrain(theduramater)and or anaccident.Forexample,extradural(epidural)haematomaisawhere Amongst themoreserioushaematomaarethoseformedinsideskullfollowingablow example) orinsideanorgan. more bloodanditformsaclotorcystinthebodytissue(subcutaneous haematoma,for The difference betweenanecchymosisandahaematomaisthatwiththere Haematoma tubalrupture,wherethefallopiantubebreaks, causingheavybleedinginthe • tubalabortion,wheretheovumisejectedinto theperitonealcavity • peritoneal cavity EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 23 24 .. Whattodointheeventofexternalhaemorrhage 3.1.2 waste timelooking forasterilebandage oracleanclothto placebetweenthehand and the haemorrhage,not wound,whichwillbeattendedtolaterinhospital. Itisvital notto loss canbedangerous for thecasualty. The mosturgentthing forthefirst-aidprovideris cient tostopthebleeding. Itisimportant tostopthebleedingassoon aspossible,blood chief, towel,foldedscarf, etc.)helddownfirmlyonthewound.Doneproperly, thisissuffi- must betaken very quickly, possiblywiththeaid of anyavailablepiececloth(handker- First aidisoften administeredbyabystander whohasnospecialequipment. This firststep Pressing downonthewound In justabouteverycasethefirstthingstodoare: Immediate actions against agrazedkneeorwindsitroundbleedingfinger, isdoingtherightthing. instinctively pressesaclothtobleedingforehead,childwhohandkerchief but, onthecontrary, aspontaneous, subconsciouslyrememberedreaction. Someonewho an arteryinthethighorarmrequiresimmediateaction,areflexwhichisnothingnew The mostimportant signfortherescuerisamountofbloodbeinglost. The sectionof opportunity. doctororgynaecologistshouldthereforebeconsultedattheearliest ed withoutdelay. A Like allmenstrualanomalies,metrorrhagiacanbeasignofdiseasethatshouldtreat- fallopian tubes,uterus). of atumour, anectopic pregnancy, inflammatorylesionsofthegenital apparatus (ovaries, This isalsovaginalbloodloss,butoutside thenormalmenstruationperiod.Itmaybeasign Metrorrhagia genital infections,etc. transfusion maybenecessary. Menorrhagiamaybecausedbycysts, tumours, fibromas, profuse andgivescauseforconcern,thepatient mustbetaken tohospital, asablood of bleedingorthedurationperiodshouldbereportedtoadoctor. Ifthebleedingis Menorrhagia isabnormalvaginalbleedingduringmenstruation. Any changeintheamount Menorrhagia neys, kidneystones,cancer, renaltuberculosis. Some ofthemostfrequentcausesrenalhaematuriaareacuteinflammationkid- a symptomofdiseasetheurinarytract. Following abloworshockitcanbesignoffracturedpelvis,butingeneralismerely much blooditcontains. Haematuria isthepresenceofbloodinurine. The colouroftheurinedependsonhow Haematuria terises manyheartdiseases. abscess, tuberculosis,etc.Cardiovascularoriginsincludethemitralstenosisthatcharac- pulmonary accidents isdisease:bronchiectasis (brochialdilatation), pneumonia,lung diovascular orbroncho-pulmonaryorigin.Moreoften thannottheoriginofthesebroncho- Haemoptysis isthespittingofblood,generallyaccompanied bycoughing.Itmaybeofcar- Haemoptysis ifnecessary, laythe casualty downinahorizontal positiontoprevent theonset • pressyourhanddirectlyonthewound • of shock EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A stop thebleeding. er unpleasantitmaybe,therescuermustpresshisorherhanddirectlyonwoundto the bleedingwound.Ifthereisnothingatalltohand,whichoften thecase,andhowev- depending onhowserious thehaemorrhageisandhowtightlyitcompressed (withabout a sponge.Whenplaced overthewoundandcompressed,itabsorbssome oftheblood, wrapped separately, isplacedoverthewound. The latexfoampad is airtight andacts as three parts: a compress,foampad andanelasticbandage. The sterilecompress, Supplied inaplasticsachet thatprotects itfromthelight,ready-to-use dressingisin This materialismoresophisticatedandveryeffective. Emergency haemostatic pad dressing cuts frombleeding. place. Separately wrappedandsterile,theyprotectthewoundeffectively stopordinary These areeasytouseandshouldalwaysbekept inthehome,carandatwork- Sticking plaster and heldinplacewithstrips ofgauze,canvasorelasticbandage. When first-aidequipmentisavailable,sterilecompressesshouldbeplacedonthewound Sterile compresses bandage withwhatevermaterialisavailable,inordertobefreedootherthings. Having topressonthewoundimmobilisesrescuer, sohe/shemusttrytomakeatight Make abandage two situations: carefully releasingthepressureofhandonwound. The rescuerwillobserveoneof After ashorttime(afewminutes)therescuershouldcheckoncasualty’s conditionby What todonext improvised bandagetostopthebleeding(usingascarf,forexample). by aclothwhenoneisavailable)andonlyreleasethepressureyouhavemadean So, whenfacedwithahaemorrhage,pressdownonthewoundhand(protected sure onthewound;thismustbeavoided. Too muchhastemaycausethecasualtytofallover, makingtherescuerreleasepres- compression ofthewound),tositononesideandfinallyliedown. alty tokneelandthen,stillsupportedbytherescuer(whoconstantly maintains manual The casualtymustbemadetoliedownwithgreatcare. The easiestwayistoaskthecasu- This servestwopurposes: it isimportant tomakehimorherliedown. rax orhead,however, thecasualtymaystillbeinastanding orsittingposition;inthiscase The casualtymayalreadybelyingdown.Intheeventofwoundstoupperlimbs,tho- thecasualtydown Laying thebleedingwillresumeasbadlybefore • thebleedingwillhavestoppedordecreased considerably • ithelps preventtheshockthatoften accompanies casesofseverehaemor- • itmakeseasiertoapplycompressionawoundthelowerlimbs,thorax • rhage or head EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 25 26 aged. without thedisadvantages ofthetourniquet.Its widedistribution anduseshouldbeencour- The emergencyhaemostatic pad stops bloodcirculation locally, intheinjuredvessels, but The emergencyhaemostatic pad shouldbeappliedasfollows: sure alreadyexertedbythepreviouslayers. tic, sorescuermustbecarefulnottopullittootightaseachextraturnaddsthepres- tening deviceusinghookswhichattach tothefinallayersofbandage.Itishighlyelas- The elasticbandageisbetween0.9and1.3metreslong,withagripononeendfas- bandage passes andunderwhichonecanslipone’s hand. or arteryandthepressureofpad. Itisheldinplacewithaslidingstrapunderwhichthe blood, thefoamexpands andabalanceisachievedbetweenthepressureinsidevein continues toseepthroughthebandage,however, itshouldbetiedtighter. As itfillswith 40% pressureitabsorbs50mlofblood). This absorptionofbloodisquitenormal.If tightened bytyinganotherstripofwhateverclothisavailablearoundit. worse. Ifthebleedingcontinues,bandageisnottightenough.Itshouldbe always dangerous,often servesnousefulpurposeandsometimesmakesthings The bandageshouldbemoderatelytight,butnotastightatourniquet,whichis be madewithascarf,tieortwistedstripofcloth. which replacesthepressurepreviouslyexertedbyrescuer. The bandage may case, theclothusedinitiallyshouldbeleft inplaceandheldtherebyabandage, When thereisnodomestic,carorfactoryfirst-aidkittohand,whichusuallythe Thetransitionfrommanualpressuretoapplicationofthehaemostatic pad • Therescuershouldnotreleasepressureonthewoundwhilepreparing thepad • Therescuershouldnotreleasepressureonthewoundinordertogoandfetch • applythepad andstart windingthebandage(thesidefacinginwardsis • slipthehandbetweenpad andthereversesideof bandage,under- • placethesterilecompressonwound • extremity towardstherootofmember. should beappliedintherecommendedmanner, windinginwards fromthe the pad isheldinplacebythefirstloopofbandage,restbandage ing thewoundmaybeleft inplaceinsteadofthesterilecompress. As soonas should take nomorethanasplitsecond.Ifnecessarytheclothalreadycover- (opening thewrapperandtaking outthecompress). the haemostatic pad fromthefirst-aid cabinetorkit. be taken toavoidcertain mistakes. compression andthosewhichresumebleedingasbadlybefore,caremust of haemorrhages,boththosewhichdecreaseconsiderablyafter localmanual side withthegreendottedline). Although thistypeofbandagecanstopallsorts neath theslidingstrap Improvising abandagewithwhateverisavailable EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A should bewashedlikeawoollengarmentandleft todryawayfromthelight. facing outwardsandapplyanewsterilecompress.Ifthelatexfoampad isbloodstained, it The haemostatic pad canbeusedmorethanonce.Justrollupthebandagewithhooks In allcasesthefollowingprecautionsshouldbetaken: located attheroots ofthelimbsaretaught. wound beinginflicted.In firstaidandoccupational safetytrainingonly the2pressurepoints is soprofusethatpressure onthearteryisonlyeffective ifexertedwithinsecondsofthe Statistically thecarotidpressurepoints areseldomused.Bleedingfromsevered carotids In practice2keypoints canbeusedtostopalmostallhaemorrhages thus: In allcasesthepressureshouldbeexertedasclose aspossibletothewound. are mostaccessible.6precisepressurepoints shouldberemembered: familiar withthepaths followedbythemainarteriesandpoints onthebodywherethey In ordertoapplypressureonthearterycorrectly, therescuerorfirst-aidprovidermustbe pick-up andtransportation tohospital, untiltrainedemergencystaff takes over. bone withthethumborfist. The pressureshouldbemaintained atalltimes,evenduring This isdonebyexertingpressureonthemainarterialtrunk,pressingarteryagainsta close tothewoundaspossible. In suchcasestherescuermuststopcirculationbetweenheartandwound,as a moredelicateapproachisneeded: While theabovemeasureswillstopmosthaemorrhages,therearesomerarecaseswhere pressure Applying non-local decrease thepressureinveinsandarteries. With thecasualtylyinghorizontally, raisetheinjuredlimbabovelevelofheartto Horizontally lyingcasualty bloodshouldcontinuetocirculatelowerdownthelimbfrombandage; • thebandageshouldnotturnredorleakblood-ifitdoeshasbeenapplied • thepressurepointinhollowofgroin,i.e.wherelegmeets thetrunk, • thesub-clavianpressurepoint(undercollarbone,bypressingartery • 1pointoneachcarotid(oneithersideofthe Adam’s apple) • 2points onthelowerlimbs(inmiddleofgroinandinside • 3points oneachupperlimb(behindtheclavicleorcollarbone,under • whentherescuercannotpressdirectlyon woundbecauseaforeignbody • whenthematerialavailableformakingacompress bandageisinsufficient and • ceptible; thecompressbandageisnotatourniquet extremity ofthelimbshouldnotturncoldorblue;pulsemustremainper- tightly enough for allhaemorrhagesofthelowerlimbs against thefirstrib)forallhaemorrhagesof upper body thigh, betweenthekneeandgroin) armpit andontheinsideofarmbetweenelbow is intheway(forexample,aknifeorbrokenglass) the bleedingcontinues EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 27 28

Fig. 11 Fig. 9 Behind the shoulder blade In thegroin the middle of thegroin inguinal-femoral artery in Pressure pointonthe the shoulderblade subclavian arterybehind Pressure pointonthe EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Fig. 12 Fig. 10 On thethigh on thethigh femoral artery Pressure pointonthe of theneck carotid arteryatthebase Pressure pointonthe

At the neck

BL - 3/A BL - 3/A When thisisdoneproperlythebleedingshouldstop. left thumb. The otherfingersusetheupperbackmusclesforleverage. If thehaemorrhageisonleft side,usetherightthumb;ifitisonside 9).Pressthethumbdownwardsintohollow. (Fig. The sub-clavianarteryisaccessiblebehindthecollarbone,atbaseofneck window whenovertaking orpassing tooclosetoavehiclecomingtheotherway). or thearmpit,whenawholelimbistornoff, inaroadaccident,forexample(armoutof 9)intheeventof serioushaemorrhageoftheshoulder This isthearterytocompress(Fig. the firstribtoirrigateupperlimbs. From theaorticarch,amajorarteryreachesoutofthoraxbetweencollarboneand The sub-clavianartery The upperlimbs the levelof groin. The aorta branches intothetwoiliacarteries,whichthenbecome thefemoralarteriesat The groin The lowerlimbs to benoemergencypressurepointbelowtheelbow. detriment ofthecasualty. Forpracticalpurposes,therefore,thereisgenerallyconsidered artery intotheradialandulnararteriescanleadto mistakes thatwasteprecioustimetothe accessible arteryandaboneagainstwhichtopress it.Butthebranchingofhumeral There arecountlesspossiblepressurepoints, evenontheforearm. All thatisneededan is recommended. keep upthepressureinthisposition,soother, moreaccuratemethod, usingthethumb, and applyingcounterpressurewiththethumbon theoutside of thearm.Itismoretiringto Another techniqueistoapplythepressurewith the fingers,seizingarmfromfront The otherfingersgriptheouterarmforpressure. biceps andpressesitagainstthehumerus(thearmbone). left side,theleft thumb. The rescuergrasps thearmfrombehind,slips thethumbround along theartery. Ifthewoundis ontherightside,thumbisused,andifit rial isavailableorwhenpressurecannotbeexertedlocally. Itisinfacta“pressureline” This pressurepointisusedforallmajorhaemorrhagesoftheupperlimbswhennomate- upper arm.Itforksintheforearmbelowelbow. The humeralarteryirrigatestheupperlimbsandisaccessibleinsidebiceps onthe The humeralartery dom usedbecauseit“neutralises”therescuer. In practice,althoughitismentionedinthemainfirst-aidmanuals,thispressurepointsel- As previously, thepressuremust bemaintained untilthecasualtycanbe got toahospital. top oftheother. The positionofthethumbsisimportant. They mustbesidebyside, not tiptooroneon armpit withboththumbsplacedsidebyside,flatteningthearteryagainstbone. must usebothhands,wrappingthemroundtheshouldermusclesandpressinginto Pressure isexertedherewhenthehaemorrhagelocatedinupperarm. The rescuer This leavesthetrunkandisaccessibleinhollowofarmpit. The axillaryartery EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 29 30 exceptional circumstances andincertain specificcaseswhen: body tissueandcomplicating anysurgerytheinjurymayrequire.Itshould beusedonlyin It stops allirrigation ofthelimbdownstreamapplicationpoint, crushingandinjuring be adangerousweapon. how touseitproperly, therefore,letusconsiderits disadvantages, forthetourniquetcan haemorrhage, soitisfoundinmostmanualsand schooltextbooks.Beforeconsidering This waslongconsideredastheeasiest,most effective meansofstoppinganexternal The tourniquet and transportation tohospital. wards againstthevertebrae. Again, thepressuremustbemaintained throughoutpick-up The otherfingerspressagainstthebackofneck. The carotidshouldbepressedback- (Fig. 10)iftheleft carotidisseveredandwiththeleft thumbiftherightcarotidissevered. is important nottoobstructbreathing.Pressureshouldbeappliedusingtherightthumb the woundandheart. The carotidarteriesrunalongbothsidesofthe Adam’s apple.It a knifeorbrokenglass,forexample). As usual,thepressureshouldbeexertedbetween should beusedasapressurepointtostopbleedingiswhensinglecarotidsevered(by Bleeding fromtheorificesisasignofinternalhaemorrhage.Soonlytimecarotid lowed byacompressbandage. Bleeding fromopenwoundstotheheadorfaceshouldbestoppedbymanualpressurefol- fective butitcanbedangerousforthecasualtyasdeprivesbrainofnecessaryblood. from facialwounds,nosebleedsorthevomitingspittingofblood. This isnotonlyinef- The rescuermaybetemptedtousethispressurepointintheeventofprofusebleeding chea, andsometimesleadtoinstant death. accident atwork. They areusuallyaccompanied byotherdamage,suchasaseveredtra- Severed carotidarteriesarearareoccurrence,generallycausedbyroadaccidentoran The carotid ground. Onceagain,aconstant pressuremustbekeptupuntilthecasualtyishospitalised. To makeiteasier, thecasualty’s legisslightlybentandplacedsidewaysagainstthe on thearterywithfist,armoutstretched, alwaysbetweenthewoundandheart. beside thecasualtywhereheorshecanwatchcasualty’s face,pressesverticallydown Like thehumeralartery, itisaccessible ontheinsideoflimb. The rescuer, positioned be stoppedusingabandagecompress. 12)forallhaemorrhagesofthelowerlimbsthatcannot It isusedasapressurepoint(Fig. fossa atthebackofknee. This arteryspiralsdowntheinsideofthighfrommiddlegrointopopliteal The femoralartery thumbs. weight, inwhichcaseitisvirtuallyimpossibletodepressthearteryusingoneorboth Effective pressurecanonlybeappliedwiththefist,especiallywhensubjectisover- firmly evenwhilethecasualtyispickedupandtransportedtohospital. tically onthemiddleofgroin.Difficult asthismaybe,pressuremustbeapplied casualty, watchinghisorherface,pressesdownwithclosedfistandoutstretched armver- essential forthisoperationthatthecasualtyshouldbelyingdown. The rescuer, besidethe 11) inthemiddleofgroin(themid-inguinalpoint).Itis The arteryisaccessible(Fig. upper thirdofthethigh. The femoralarteryinthegroinispressurepointeventofhaemorrhage EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A Taking theavailablematerialinfreehand,proceed asfollows: wound, andshouldcontinuetodosowhileapplyingthetourniquet. The first-aidprovidershouldalreadybeexertingpressure(haemostasis) onornearthe cannot beusedinthecircumstances. This isneverthefirstcourseofaction.Itshouldonlybedonewhenothermethodsfailor Applying animprovisedtourniquet The wordtourniquetmeansdifferent thingstodifferent people: In suchcases,whenalltheseconditionsarefulfilled,atourniquetcanbeimprovised. Even then,therescuershouldcheckthatfollowingfourconditionsarefulfilled: checkthatthe tourniquet issufficiently tight,i.e.thatthebleedinghas stopped • nowstopapplyingpressurewiththeotherhandandusebothhandstotiea • tightenthetourniquetbypullingtwoendsapart -thiscanbedonebyhold- • slipthehandthroughloop,grabtwolooseendsandpullthem • wrapitroundthelimb,withlooptowardsyou • foldthematerialdoubletomakealoop • finally, thereistheimprovisedtourniquet,weaponoflastresortformod- • thetourniquethastraumatisedgenerationsof accidentcasualties,notonly • foranurseitisvenoustourniquetmadewith arubberstrapandusedtofacil- • isthereenoughroomforthetourniquetbetweenheartandwound,i.e. • isitnotpossibletouseacompressbandage? • hasamajorarteryinthearmorlegbeensevered? • isthetourniquetreallynecessary? • awholelimbhasbeensevered(handorarmsawnoff byacircular sawor • therescuercannotcontinuetoapplymanualpressure(forexamplewhile • therescuerisaloneandthereareothercasualtiesinneedofurgentattention • therescuerisaloneandhastoleavescenefetchhelp • tight flatknotonthesideoflimbopposite loop ing oneendbetweentheteeth the loop ern-day first-aidprovider ond strap)butbecauseitisoften asourceofskinandtissuelesions because oftheequipmentneeded(astraporcuff, a stick,sometimessec- concern totherescueratanaccidentscene it isthereforeameansofstoppingvenous(orreturn)circulationandno itate thetaking ofbloodsamplesortheadministrationintravenousinjections; between thewoundandrootoflimb(armpitorgroin)? sheet metal or the wheelofarailwaytruckorcarriage) chopped off byaguillotineorothercuttingmachine,legseveredfalling casualty isdisengagedfromavehiclefollowingroadaccident) and firstaid EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 31 32 sible: handling ofemergencycases.Sothenoteshould providethefollowinginformationifpos- Also, inmajordisasters,thearrivaloflargenumbers ofcasualtiescancausedelaysinthe in theinjuredlimb. casualty inhospital. The doctorneedstoknowhowlongthecirculationhasbeenstopped first-aid providershouldprepare anoteforthedoctororsurgeonwhowillbereceiving tial steps havebeentaken (dressingthewound,warmingandcomfortingcasualty), his/her ownwatchoronthatofthecasualty, orpreferablyboth;then,assoontheessen- The first-aidprovidershouldnotethetimeatwhichtourniquetwasapplied,eitheron Write anotefortheemergencyservices The dressedwoundandtourniquetshouldbekeptvisible. cover himorherforwarmth,andcomforthim/her. To preventthisthefirst-aidprovidershouldlaycasualty downinahorizontal position, Blood loss(sometimessubstantial) andpain cantriggersevereshock. Preventing shock After applyingthetourniquet,rescuermust: What todonext pass oneendofthematerialthroughloop,pullittightandtietootherend. al maybetooshorttomakeatourniquetasdescribedabove.Inthiscase,just The improvisedtourniquetisusuallyappliedtothethigh,andavailablemateri- other circumstances. Elastic tourniquets (madeofflatrubberbands)arenotimprovisedandusedin and shouldbeavoidedatallcosts. Narrower materials,likestring,wire,shoelacescutintotheskin folded diagonally, astripofcloth,stocking,etc.canallgiveexcellentresults. tourniquetcanbeimprovisedusingvariousmaterials:atie,canvasbelt,scarf A thetimeatwhich thetourniquetwasapplied(24-hoursystem,i.e.17.15, not • theword“tourniquet” inahighlyvisibleposition • thecasualty’s name • keepaconstant watchonthecasualtywhileawaitingambulanceanddur- • alerttheemergencyservices • carefullynotethetimeatwhichtourniquet wasapplied • preventthecasualtyfromgoingintoshock • 5.15) ing transport EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Material used Special cases

BL - 3/A BL - 3/A .. Whattodointheeventofinternalhaemorrhage 3.1.3 head withlipstick orwhateverelseisavailable. “tourniquet” oralarge“T”andthetimeofapplication)canbewrittenoncasualty’s fore- If thereisnopaper, penorpenciltohand,themostimportant pieceofinformation(theword by increasingthehaemorrhage. and certainly notanything likealcohol,teaorcoffee, whichstimulatetheheartbeat,there- If thecasualtyisconscious andasksforsomethingtodrink,donotgive anyliquidatall, In bothcases,trytokeep thecasualtywarm. tion fromdeteriorating: roleislimitedtopreventingthesitua- As nolocalactionispossible,thefirst-aidprovider’s Constant supervision shortest possibletimeandsurgerycanbeperformedwithoutunnecessarydelay. alerted swiftly, clearlyandaccurately, sothattheambulancecanarriveatscenein rations mustbemadewithminimumdelay. The emergency servicesshouldthereforebe The evacuationofacasualtywearingtourniquetisanemergency. The requisiteprepa- Alerting theemergencyservices Serious internalhaemorrhages must beproscribed. still recommendedinsomemanualsisanobsoleteanddangerouspracticethat to evacuatethecasualty. The carefullooseningofthetourniquetevery20minutes tory arrest. The first-aidprovider cannottake thatrisk,nomatterhow longittakes to bloodloss,removingatourniquetcanresultinsuddenrespiratoryandcircula- take preventiveactionorcorrectivemeasuresifanythinggoeswrong.Inaddition Doctors aloneareawareoftherisksinvolvedinremovingtourniquets andableto ened exceptbyadoctor! Once atourniquethasbeenapplieditmustneverberemovedorloos- anunconscious casualtyshouldbelaidonhis/hersideintherecovery position • aconsciouscasualtyshouldbelaiddownflat,withthelegsslightlyelevated • thisobservationmustbekeptupduringtransport, eitherbytheambulance • circulation(checkpulseregularly) • state ofconsciousness(placethecasualtyonhisorhersideinrecovery • breathing(applymouth-to-mouthartificialrespirationifstops) • Thefirst-aidprovidermustcheckthecasualty’s generalcondition,especially • a stretcher used. Inanyeventthecasualtymustbetransportedlyingdown,preferablyon crew orbythefirst-aidproviderwherealessappropriatevehiclehastobe position ifunconscious) the following: EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Important warning 33 34 Epistaxis will neitherhelpnorharmthecasualty. transported inthatposition,underobservation.Whichsideupisofnoconsequenceand The casualtyshouldbeplacedintherecoveryposition(onhis/herside)andpickedup Otorrhagia Internal haemorrhagesthatbleedthroughbodyorifices preceded bylossofverydarkblood,severeabdominalpain andfainting. This typeofaccidentcanoccurduringthefirst6weekspregnancyandissometimes car, inthesameposition asforordinaryinternalhaemorrhage(recoveryposition). ly aspossible.Failingthis,he/sheshouldtransportthecasualtytonearesthospital by save thecasualty. There isnothingtherescuercandoexceptcallanambulanceasquick- Where profuseintraperitonealbleedingoccurs,onlyanemergencysurgicaloperationcan Ectopic (orextrauterine)pregnancy ous damageandadoctorshouldbeconsulted. However, bumps ontheheadandserioushaematomascanbeexternalsignsofmoreseri- ple, often usedonbumps. warm, saltycompresses.Certain anticoagulantointments alsohelp:arnicaisoneexam- In simplecases,followinganot-too-severeblow, haematomascanbeheldincheckwith Haematomas casualty inacleanenvironment. infection, hencetheimportance ofimmediatefirstaid,todisinfectthewoundandplace Bruising inthepresenceofanopenwoundcanfosterdevelopmentmicrobesand treatment toadminister. alcohol. Ifindoubt,ortheeventofextensivebruising,leaveittoadoctordecidewhat Ordinary ecchymosisorbruisingistreatedbyapplyingacompressbandagesoakedin Ecchymosis and somepeoplereactbadlytothis. Tilting thehead backwardsdoesstopthebleeding,itistrue,butbloodrunsdownthroat ple “miracle”drug. Women wholosealotofblood duringmenstruationareadvisedtoavoidthis sim- static. Onthecontrary, itincreasesbleedingand shouldthereforenotbeused. The drug preventthesubjectfromcoughingorblowinghis/hernoseforafewminutes • pressagainstthebleedingnostrilwithafinger • keepthesubject’s headupandslightlytiltedforward;sittingsubjects maysup- • Thesimplenosebleedisafrequentaccident inchildhood(falls,roughgames). • after thebleedingstops port theirheadonhand,withelbowthetable ward: Numerous traditionalremediesexist,buttheproceduretofollowisstraightfor- antipyrine EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID is frequentlyconfusedwith AND EMERGENCY Important warning aspirin . Aspirin isnothaemo-

BL - 3/A BL - 3/A tion toahospital andplacedunderobservation. In allcasescautionisrequiredandthecasualtyshouldbeevacuatedinrecoveryposi- ble externalsignofafracturedskull. plications; evenifthereisnosimultaneous bleedingfromtheear, anosebleedispossi- (violent blowtothenose,roadaccident,fall,etc.)shouldalertrescuerpossiblecom- ous problem.Whenanosebleedoccursfollowingblowtotheskullorfall,accident Recurrent nosebleedsshouldbereportedtoadoctorastheymaysignofmoreseri- may cauterisethenostril. If pluggingthenostrilfailstostopbleeding,subjectshouldbeseenbyadoctor, who If thebleedingpersists, thenostrilcaneasilybeplugged: sive damage,afracture or whenitisimpossibletoapplyahaemostatic pad properly. application ofatourniquet (looselyatfirst)shouldbeenvisagedonlyinthe eventofexten- a compressbandageor, betterstill,anemergency haemostatic pad attheready. The occur atanytime. The first-aid providerorambulancecrewmustremainvigilant andkeep If thewoundisdeepand likelytohaveseveredamajorbloodvessel,haemorrhage may dence asexplainedearlier, stating thetimeofapplication. just abovethewound,tightened,evenifthereis nohaemorrhage,andanoteleft inevi- If thewholememberhasbeensevered,atourniquet maybeapplied.Itshouldplaced be taken. There aretwopossibilities. Delayed externalhaemorrhagecancausedeath withinseconds.Preventiveactionmust den life-threateninghaemorrhagemaybetriggered, soextremevigilanceiscalledfor. When thesubjectismoved,however, duringpick-uportransportation tohospital, asud- There isnohaemorrhageassuch,althoughthe woundisbloody. such asapieceofboneormuscle. blood vesselhasbeenseveredbutistemporarilycrushedorobstructedbyaforeignbody, When amemberissevered,crushedorseriouslydamaged,itpossiblethatmajor openwounds Non-bleeding Special cases ject shouldbetaken tohospital withtheutmosturgency. Whatever thecause,adoctorshouldbecalled,andinparticularly alarmingcasesthesub- Haemoptysis canbecausedbythoracictrauma. or coughdrinkanything. in bed,asemi-recliningposition,theairwaysunobstructed. The subjectshouldnottalk The brightredfrothybloodejectedshouldbekeptforanalysis. The subjectshouldremain Haemoptysis blood bytransfusionand/orperformsurgery. In theeventofprofusebleeding,immediatehospitalisation isnecessary, to replacethelost worse, refrainfromgivingthesubjecticetosuckorahotwaterbottlehug. must noteatordrinkanything. To avoidmaskingthesymptomsandmakingbleeding reclining positionorlyingonthesidesothatairwaysareunobstructed. The subject If thebleedingisnottooserious,calladoctorandmakesubjectstay inbedasemi- Haematemesis insertitintothenostril,leavingoneendprotruding • imbibeitwithoxygenatedwateroraspecialhaemostatic substance • rollasmallpieceofgauzeintocylindricalplug • EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 35 36 was firstcutoff. of applicationnotedshouldbethe(approximate)timeaccident,whencirculation noteshouldbemadeoftheexistencetourniquet,asusual,butinthiscasetime A ther upthelimbbeforeremovingload. One meansofdoingsoinsuchexceptionalcircumstances istoapplyatighttourniquetfur- orrhage orworse,sothismustbeavoided. Could theloadbeactingasatourniquet?Ifso,lifting itoff suddenly couldtriggerahaem- tree trunk,carchassis,etc.)itshouldnotbefreedwithoutduereflectionandprecaution. Where alimbhasbeencrushedorcompressedforlongtimeunderheavyload(beam, Crushed limbs tourniquet totightenit. denly starts tobleedprofusely, thebleedingcanbestoppedbypullingtwoendsof The woundmustthenbekeptundercarefulobservationduringtransport.Ifthesud- is noheavybleeding)beforethefracturesplinted. tourniquetmaybesetinpositionbetweenthewoundandheart(andleft looseifthere A to stopthebleeding. splint orotherapparatus maymakeitdifficult orimpossibletopressonnearthewound signs ofshock.Ifthefractureisopen,bloodwillspurtfromwound. The presenceofa If thefractureisclosed,therelikelytobeinternalhaemorrhage,withalargebruiseand arterial haemorrhage. can movethesplinteredbone,causingittoperforatefemoralarteryandtriggerprofuse Even after immobilisationofthelimb,contractionlargemuscularmassesthigh It shouldberememberedthatthebrokenbonesmightstillmoveevenafter theaccident. “shock-inducing” fracture,soitisimportant topreventthecasualtyfromgoingintoshock. and swelling,soitisonlynaturaltomentioninthissectiononhaemorrhages.Ita largest bonesinthehumanbody. Itisalwaysaccompanied byprofusebleeding,bruising Fracture ofthefemurisonemostseriousfracturesallas Compound (open)fractureofthefemurorthighbone but tourniquets can bedangerousandshouldavoidedifpossible Only inexceptionalcircumstances andasalastresortshouldtourniquet beused, the heart. ly tothewound,compressapressurepointon an arterybetweenthewoundand a bandagetighteneduntilthebleedingstops. Ifpressurecannotbeapplieddirect- ly onthewoundwithhand,then,after afewminutes,replacethismeasurewith As aruleonesimplestepisenoughtostopanexternal haemorrhage:pressdirect- very muchthesame: responseisgenerally In spiteofthewidevarietyhaemorrhages,rescuer’s evacuatethecasualtywhilekeepinghim/herunderconstant observation • avoidaggravatingthesituation • EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Conclusion .

BL - 3/A BL - 3/A . Fractures 3.2 .. Types offracture 3.2.1 possible causes: fractureoccurswhenaboneispartially orcompletelybroken. There area number of A trol organs(brain,cerebellum,medullaoblongata). the spinalcolumn. The skull, orcranium,formstheprotectiveenvelopeofnoblecon- The head out ofplaceandcanevencrackinoldersubjects. placed underexcesspressureorundergoesunduetorsion. The disciscrushed,orslips nucleus calledthepulposus. The discsare thefirsttosuffer whenthespineis Each disciscomposedofafibrocartilagenousring(annulusfibrosus)aroundsofter shocks, connecttheadjacentvertebrae,withexceptionoffirstcervicalvertebrae. protective canalforthespinalcord. The intervertebraldiscs,whosepurposeistocushion cygeal vertebrae,isthe“backbone”ofhumanbody. The columnofvertebraeformsa The spine parts oftheskeletondeservespecialattention: The namesofallthebonesinbodyarelittleinteresttoprovidersfirstaid,buttwo and wehavesummarisedthemainfunctionsperformedbyskeletoninhumanbody. Add thefactthatredbloodcorpusclesaregeneratedbymarrowoflongbones grouped intothreemaincategories: Composed ofproteinsandminerals,includingcalciumphosphorus,thebonescanbe heart andlungs,theskullprotects thebrain,andsoon). muscles, whichimpart motion,andtheyprotectthevital organs (theribcageprotects the Bones arelivingtissuewhichgrowsandneedsirrigation. They provideanchorageforthe The skeleton,composedof208bones,formsthesupportingframeworkforbody. The skeleton,joints andmusclestogetherformwhatwecallthemusculoskeletal system. between threetypesoffracture: The signsofafracturediffer dependingonits location. Traditionally adistinctionismade • • • theskull • thespine • shortbones,likethevertebrae,tarsi andthecarpi • flatbones,liketheskullandshoulderblades • longbones,likethoseofthelimbsandribs • openor compound fractures • simpledisplaced fractures • simplenon-displaced fractures • spontaneous fracture: arm causedbyafallfrombicycle,evenwhenonly thehandstrikesground) tion (fractureofthespinefollowingafallonheels, fractureofthearmorfore- indirect blows: blow fromtheboomwhensailing,etc. falling ontheunprotectedhead,aleghitbycar bumperinaroadaccident, direct blows: , madeupof32or33vertebrae,dependingonwhetheronecounts 3or4coc- is madeupof14facialbonesand8skullbones.Itrests onandisattached to EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID a bloworshocktothebone(occupational accident),anobject these fracturesaretheeffect ofcountercoupormuscularcontrac- AND EMERGENCY through decalcification,forexample. 37 38 .. Whattodointheeventoffracture 3.2.3 Howfracturesheal 3.2.2 put pressureontheinjured limbagainprematurely. lem seemstoariseseveralmonthsafter thefracture,whenpersonstarts to moveor If thenewbonetissuedoesnothardenenough, thebonewillsetabnormally. This prob- problems. Sometimes thecallusistoolarge,causingdiscomfort, unsightlydeformityorfunctional mends. callusformsandhardensuntilthebone cium issupplied.Bonetissuegenerated. A pocketofbloodformsroundthefracturepointandphosphocalcic changesoccurascal- A always bearinmindthatwhenanaccidentoccursthereisthepossibilityofafracture. It israretocomeacrossallthesesignsatonce,butoneenough. The rescuershould There arefivemainpointerstoapossiblefracture: impact. example). They cracklikeacarwindscreen,buttheir shaperemainsthesameafter the Flat bones,ontheotherhand,areoften brokenwithoutbeingdeformed(theskull,for “cracked likenuts”. The shortbones(vertebrae,carpi,tarsi, metatarsi, metacarpi) areoften crushedand ing. To simplifymatters,fracturesofthelongbonesareoften compared withabranchbreak- recognise signsofoverlapping,bentortwistedfractures. displaced invariouswaysandtovaryingdegrees,therescuershouldbeable Only anX-raycanconfirmthediagnosis.Inothercasesbrokenbonemayhavebeen The bonesmostfrequentlyfracturedarethelongbones,sometimeswithnodisplacement. blood vesselsandnerves. If thecasualtyismovedthereaddedriskoftearingmusclesorperforatingsevering caused bythebrokenbone,inwhichcaseitisoutward-facing. may becausedbythecausalagent(andisthereforeaninward-facingwound)orit therefore ariskofinfectioninadditiontothegeneraldangersfractures. The openwound The lasttypeiscompoundbecauseaswellthefracturethereanopenwound,and in ordertobe ableto: to establish theexact circumstances oftheaccidentandascertain exactlywhathappened, numberofprinciples guidetherescuer, whoshould,whenexaminingthecasualty, seek A sometimesthecasualtywillhaveheardbone crack;undernocircum- • soonerorlaterothersigns appear-swelling,oedema,ecchymosis, • deformitycausedbybonedisplacement(limb atabnormalanglethefracture • inabilitytousetheinjuredlimbwhichisnotdue toparalysis oranerveprob- • highlylocalisedpain thatintensifiesattheslightestmovement • bones tolistenforacrackingsound stances shouldtherescuerexpecttohearanycrackingorattemptmove haematoma, signsofbleedingfromrupturedbloodvessels knee; transversaldisplacement) “ski-type” rotation oftheleg,wherefootisnotatproperanglewith point; limbshortenedwheretwoboneparts haveoverlappedorcompacted; lem EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A some padding. Proceedasfollows: mity ofthefracturedarm. The magazinetechniquerequiresamagazine,threethongsand curled intoaU-shapedtubeormalleablemetal splintthatwillaccommodateanydefor- such casesthefracturedarmandnearestjoints maybeimmobilised usingamagazine above isinsufficient, asthethorax,againstwhichfracturedforearmrests, isnotflat.In Sometimes thebrokenboneisdisplacedand thetemporaryimmobilisationdescribed or twistandtucktheendinbetweensling theelbow. To block theelbowproperly, take theoverlappingapexofslingandsecure itwithapin should bewellsupported. site shoulder. The fingersshouldbeleft protrudingfromtheedgeofslingandwrist should preferablybemaintained inahorizontal positionortiltedslightlytowardstheoppo- over theinjuredarmandtwoendsaretiedtogetherroundneck. The forearm shoulder onthesameside,withapextowardselbow;othercornerisfoldedup corner ofthetriangleispassed undertheinjuredforearmandupoverchestto the elbow. The trianglehasalongbaseendingintwocorners,andsummitorapex.One Where atriangleofclothisavailableitcanbeusedtomakeanevenbetterslingthatblocks it withthearmcradledinside,orsupportinginaslingtiedroundneck. Temporary immobilisationalsobeachievedbyturning up theflapofajacketandpinning to theotherend. of clothinginwhichthearmisresting,thenbackupfrontandroundnecktobetied rest init. This isthenheldinplacebyasling,oneend ofwhichispassed undertheitem a cardigan,thebottomofgarmentshouldberolledupwardsuntilfracturedlimbcan least temporarily, usingthecasualty’s ownclothes.Ifthecasualtyiswearingapulloveror should beimmobilisedwithwhatevermaterialisavailable;thiscanusuallydone,at thing byholdingthefracturedforearmwithotherforearm. The wristandelbowjoints If thefractureisasimple,singlefracture,injuredpersonwilloften naturallydotheright Fractures oftheforearm bilise afracturedlimb. Always useafastandsimplesplintrequiringminimummaterial.Itisnotdifficult toimmo- To avoidpain anddisplacement,blockthejoints aboveandbelowthefracture. Fractured limbs placethe padding between themagazineand fractured limb,filling inthe • formacradlefor theforearmbylooselytyingtwoendsofmiddle thong • placetheforearmalong themiddleofmagazineoraskcasualtyto do so • slipthethreethongs crosswiseunderthemagazineatequaldistances • arrangeforpropertransportunderobservation • immobilisethefracturedlimbor, wherespinalinjuryissuspected,the • intheeventofacompoundfracture,coverwoundcarefully • alleviatepain, therebyreducingtheriskofshock • avoidallmovementbeforethefracturehasbeenproperlyimmobilised • avoidmakingmattersworsebyanyinappropriatemanipulation • identifyrelatedlesions,particularly inroadaccidents • preservethevital functions,whichareanabsolutepriority, withoutaggravating • together head/neck/trunk system obvious orsuspectedfractures EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 39 40 with onehandunderthe heelandtheotheroverinstep. Qualified first-aiderswill generallycarefullyexertgentletractiononthelimb, alongits axis, position itisin,nomatter howbadlymisshapenitmaybe. For thecasualfirst-aidprovider theruleisonceagaintoimmobilise broken limbinthe Professional emergencyserviceswilluse: are available: Broken legsrequiremoreequipment.Chancefirst-aidproviderswillusewhatevermeans Fractures ofthelowerlimbs ed andtuckedin.Boththeelbowshoulderarenowimmobilised. As withanormalsling,theapexoftriangle(atelbow)shouldonceagainbetwist- second slingisappliedasfollows: forearm) toblocktheelbow. Next,toimmobilisetheshoulderandfracturedbones,a Two triangularslings areused.First,anordinaryslingisapplied(asforfracturesofthe material. the elbowandshoulder. Onceagain,thecasualty’s clothingmayprovidethenecessary The principleisthesameasbefore-immobilisejoints oneithersideofthefracture,i.e. Fractures oftheupperarm described above. now beimmobilisedveryeasilybyplacingthesplintedforearminatriangularslingas procedure isnowhalfcompleteasonlythewristhasbeenimmobilised. The elbowcan on theforearmthatcouldcauseaconstrictionineventoftighteningorswelling. The Prior toallthis,therescuershouldtake off anywatchorbraceletthecasualtyiswearing Having padded thearmtoimmobilisefracture,rescuershouldthen: areducedairpressure orvacuumsplint • splint aThomas • aready-mademetal tubesplintoramalleable metal wireoraluminiumsplint • amalleablemetal sidesplint(wiremesh splint,Kramersplint) • makeaU-splintusingblanketandtwopiecesofwood • improvisealateralsplintoutofwood(astickorslatwood) • usetheuninjuredlimbasasplint • tietheendstogetherunderoppositearmpit, ifpossiblewithoutcoveringthe • placethemiddleofslingagainsttop of theshoulder • withtheapexoftrianglefacingdownwards towardstheelbow • checkthatthemagazinecausesnodiscomforttoelbow • tightenthemiddlethong • tieupthetwoendthongs:onebythumbshouldbefoldeddoubleand • (SAM splint) hand enough toaccommodateanysubsequentswelling area aroundthedeformedfracturepointandmakingasortofcushionsoft the thumbthatcouldcauseaconstriction) passed acrossthepalm ofthehand(taking carenottomakeanoosearound one endpassed abovethethumb,leavingthumbfree,whileotheris EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A age coversthesiteoffracture. jured limbbywrappingseveralwidebandagesaroundbothlegs,taking carethatnoband- with theaidofafigure-of-8-shapedbandage. The fracturedlimbisthenboundtotheunin- Padding isplacedbetweenthelegsandfeetaremaintained perpendiculartothelegs Using theuninjuredlegasasplint limbs, theyshouldreally beusedonlyforfracturesoftheankleorlower leg.Inthighfrac- Although thesearesupposedly foruseintheeventoffractureupper orthelower Pneumatic orinflatablesplints a spiralbandagearound legandsplint. placed ratherlikeonan improvised splint.Heretoothesplintisheldinplace withstraps or These arelikemeshcasts padded andwrappedincotton,onwhichthefracturedlegis Malleable metalU-splints place with3straps perlimbsegment,withextraimmobilisationaroundthejoints. and protectitduringpick-uptransportation. Likewoodensidesplints, theyareheldin to sizeandadjustedthedeformation. They fitsnuglyroundtheangleofbrokenlimb These aresidesplints madeofwiremeshandknownasKramersplints, whichcanbecut Malleable metalsplints Specialized equipment or aspiralbandage. The footismaintained perpendiculartotheleg. fractured limbifthereareenoughhelpers. The improvisedsplintisthenheldtightbystraps pulling gentlyonthefootandraisinglegorbymakinga“cushionofhands”under position. This isthemostdelicatepart oftheoperation.Itshouldbedoneeitherwhile each edgeofitroundastick.Carefullyraisethelegjusthighenoughtoslidesplintinto Place animprovised“stretcher”orU-splintunderthefracturedleg:take ablanketandroll injury. around thekneeandanklewherevercontact withthewoodcouldcausediscomfortor between thesplintandlegshouldbepadded, andpadding shouldbepositioned immobilised byawidestrap,however, andthefootheldperpendiculartoleg.Gaps bilised. There isnoneedforstraps aroundthechest,waistandhip. The kneemustbe The outside splintstops atmid-thigh.Onlythekneeandanklejoints needtobeimmo- Fracture ofthelowerleg knee shouldbeimmobilisedwithawidebandage. The splintisthenfinished. Wherever thefractureislocated,shoeshouldfirstbeunlacedbutnotremoved. The tight andthefootisblockedperpendiculartolegusingafigure-of-8bandage. to thegaps andthehollowsleft bythedeformedlimb. The remainingstraps arethentied is positioned. The threestraps arethentiedtopositionthesplints, andpadding is added top oftrunk)shouldbewoundonceroundthesplints toholdtheminplacewhilepadding straps firstandtolaythesplints ontopofthem. The “end”straps (ankle,topofthigh and ciple threestraps perlimbsegmentandthreeroundthetrunk).Itiseasiertoposition cially aroundthegroinandarmpit. They willbeheldinplacewithstraps orthongs(inprin- armpit. The otherisplacedalongtheinsideleg,fromfoottogroin.Botharepadded, espe- One splintisplacedalongtheoutside ofthebody, fromthebottomoffoottounder Fracture ofthethigh dle etc.,andcuttosuitthesizeofinjuredpersonlocationfracture. Improvised splints canbemadeusinganystrong,narrowstick,stripofwood,broomhan- Side splints EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 41 42 There areseveraltypesofchestinjury: ers thrownagainstthesteeringwheel. Almost 25%oftheinjuriessustained inroadaccidents arechestinjuriessustained bydriv- Chest injuries to-transport stretcher. that espousetheshapeofbodyandimmobiliseit. The mattressbecomesarigid,easy- mattress andtheairisemptiedfromenvelope,whichcontains smallpolystyreneballs Vacuum mattressesareuseful forimmobilisingthespine. The casualtyisplacedonthe Vacuum splintsandmattresses long inflatable cushionsreplacingthebandagesandstraps toholdthelimbstill. 10–exists, withaframethatispermeabletoX-rays, and Another version–the ATLAIR IT which isattached tothedentinframeatlevelofinstep. The tractionexertedbythefirstrescuerismaintained bythecanvasringroundankle, cular tothelegwithabandagetiedsiderings. The limbisimmobilisedusingabandageorstraps. Ifpossible,thefootisheldperpendi- released. inside legjoinsthetrunkandfinallyappliessplintwithouttractiononbeing round theankle,withstrongbondsoneachside,thenplacesthickpadding wherethe gently onthefootalonglineofleg,whileotherfirsttiesacanvasringloosely It takes twopeopletoapplythissplint-oneraisethelimboff thegroundwhilepulling This isacomplexpieceofequipmentcomprisingthefollowing: The Thomassplint Inflatable splints canbeleft onthecasualtywhileX-raysaretaken. compartments withspaces betweenthem. der thecirculation. This islessofaproblemwhenthesplintmadeupparallel tubular inflated bymouth.Itshouldnotbeblownuptoohardastheresultingpressurecouldhin- should beraisedverycarefully, exertingaslighttractiononthefoot.Itisthenfastenedand “stretcher-type” U-splints, theuninflatedsplintisplacedunderinjuredlimb,which can befoldedintoatubeshape).Buttonsareeasiertoclosethanzipfasteners.Like of pneumaticsplints (themostfrequentlyusedaremadeoflongtubularcompartments and tures theydonotimmobilisethehip,andthisisunacceptable. There areseveralmodels inthecaseofa blowingwounditisessentialtoclosetheimmediately. • asimplefracture oftheribisusuallynoproblemandinjuryheals well • injurieswherethecasualtyhasdifficulty breathing because severalribsare • visibleinjurieswithanopenwound • tworingsontheside,foruseinraisinglimb off theground • twoarticulatedhoops attheupperendofinsidebranch,whichwraparound • abandageformingseveralfigures-of-8,troughorbed • anelongatedU-shapedmetal framewithadentinthecurvedpart forfasten- • strips ofoverlapping adhesivecloth,tofacilitate evacuation. emergency stepcansubsequently bereplacedbyatriangularbandage or This isdonebypressing apieceofclothontothewoundwithhand. This broken the thighandclipintoupperendofoutside branch ing athongtoimmobilisetheinstep EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A or take adeepbreath. no injuryisobviousatfirstglance,pain mayberevealedbyaskingthecasualtytocough erly orcoughingupthemucusobstructinglungs(whichcanacceleratesuffocation). If which maybeeasytodetect,forexamplewhenthecasualtyhasdifficulty breathingprop- In conclusion,roadaccidentcasualtiesshouldalwaysbeexaminedforchestinjuries, gen -sweatingisasignofcarbondioxidepoisoning. An adverseeffect ispossible. If necessary, artificialrespiration shouldbeadministered.Caretaken withoxy- ing shouldbekeptundercloseobservation: sudden accelerationordecelerationthatmightaggravatehishercondition. The follow- The casualtymustbeevacuatedasamatterofurgency, withoutanyshaking,bumpingor No bodybandageshouldbeused. which givesleastdiscomfort),makingsurethattheairwaysarecompletelyunobstructed. dents. Ingeneral,therefore,thecasualtyistransportedinrecoveryposition(onside not beusedifthereisanysuspicionofspinalinjury, whichthereusuallyisinroadacci- If thewoundisslight,casualtyplacedinasemi-sittingposition,butthispositionmust breathe, whichcanresultinrealsuffocation, withthecasualtyturningblue,sweating,etc. sharper whenthecasualtycoughsorbreathesdeeply. The casualtybarelydaresto When thereisnoopenwoundthecasualty’s pain shouldalerttherescuer. The pain is lowed bymassagetreatment whenthecastisremoved. Where ligaments have beentornthejointmustbeimmobilisedina plastercast. This isfol- Remember thatoneofthe purposesofthebandageistoholdfootperpendicular totheleg. of cottonsoakedinalcohol. usually helps. Itisadvisabletobandagetheanklewithamedium-tightoverstrip or evenafracture).Localapplicationofsoothing ointmenttwiceadayforseveraldays or twistedjointshouldbeX-rayedtomakesurethere isnomoreseriousinjury(dislocation then thepain subsidesandmovementbecomespossible.Swellingoccurs. Any sprained dent. The subjectimmediatelyfeelsasearingpain andcannotmoveforafewminutes, affect thewristandelbow. They maybecausedbyafall,trippingorsporting acci- The ligaments arepulledortorn.Sprains generallyaffect theankleorkneebutcanalso Sprains actually pulledapart oroutofjoint,wecallitdislocationluxation. ple sprain,ortorn,resultinginamoreseriousinjury. Whenthetwoparts ofthejointare These arestraininjuries. The ligaments maysimplybestretched,as inthecaseofasim- Injuries tothejoints alty shouldbeplacedintherecoveryposition,mouthopenandtongueprotruding. obstructions (clottedblood,foreignbodiessuchasteeth,dentures,glass,etc.). The casu- If thewholefaceisinjured,thistakes priorityandtheairwaysmustbeclearedofany the lowerjawagainstupper(the(remaining)teethteeth). the lowerjawshouldbeheldinplacebyasling,mainpurposeofwhichistomaintain These mayoccurasaresultofblowtothechinorwholeface.Simplefractures Fractures ofthejaw state ofconsciousness • pulse(thenormalrateisbetween60and80beats perminute) • colouringoflips andnails • breathing(frequencyshouldremainalmostnormal,between12and20breaths • per minute) EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 43 44 .. Types ofwound 3.3.1 Wounds 3.3 tion. may leadtoasphyxia,especiallyifthecasualty is lyingdownwiththeheadinalowposi- perforatingwound,orawoundcombinedwithfractured rib, greater orlesserextent. A Depending ontheirseriousness,thesewounds canaffect acasualty’s breathingtoa Wounds tothethorax face andeyes Certain woundscanbelife-threatening;theseincludetothethorax,abdomen, Specific wounds Severe woundsmay: It issolelyforadoctortodecidewhattreatmentshouldbegiven. Severe wounds tion lessthanfiveyearsago). the casualtyis,inprinciple,properlyvaccinatedagainsttetanus (i.e.hadaboosterinjec- ly healnormally. Insuchcases bleedingisminimal,therelittleornoriskofinfection,and These aresuperficialgrazes,scratchesandclean-edgedcuts orincisions,whichgeneral- X-ray beforethejointisputbackinplace. ing itandtuckinginbesidetheelbow. The patient shouldthenbetaken tohospital foran elbow isblockedinplacebysecuringtheapexofslingwitha(safety)pinortwist- should protrudefromtheedgeofslingsothatcirculationcanbeobserved. The ing behindtheback,twoendsbeingtiedtogetheronhealthyshoulder. The fingers round thefrontofarmandoverneckonuninjuredsideotherendpass- The slingshouldbeplacedwiththeapexoftriangleonelbowside,oneend the armoninjuredsideacrosschestandsupportitwithaidofasling. ing, forexample,betweenthearmandthoraxtoholdawayfrombody. Fold event ofadislocatedshoulder(themostfrequentcase),placecushion,madecloth- aid providersmustleavethejointastheyfinditandnottrytoputbackinplace.In use theinjuredlimboreventomoveit,asjointisblockedinanabnormalposition.first- Dislocation occurswhenthetwobonesofjointareseparated. The personisunableto Dislocations The holloworgans(stomach, intestines),coveredbytheperitoneum(the membranewhich ture wound,entails ariskofdamagetoanintra-abdominalorgan. Apart fromobviously superficialgrazing,anywoundtotheabdomen, evenasmallpunc- Wounds to theabdomen Minor wounds becomplicatedbyafracture,haemorrhage,etc. • becontused,inwhichcasethecrushed tissueisconducivetoinfection • havealargeforeignobjectlodgedinthem oronethatisdifficult tospotand • beverydirty/highlycontaminated • godeep • belarge(possiblyrequiringstitchesor askingraft) • remove EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Howtodealwithawound 3.3.2 the symptomsofshock. tures underthepressureandcasualtysuffers aviolentinternalhaemorrhage,withall bleeding insidetheorgan. As thebloodbuildsup,fairlyinflexibleoutermembranerup- dent casualties.Followinganimpact, theexternalmembraneremainsintact butthereis Rupturing maybeeitherimmediateordelayed,asisfrequentlythecasewithroadacci- The solidorgans(liver, spleen,etc.)mayrupture,causinganinternalhaemorrhage. related shock. also formstheliningofabdominalcavity),maybeperforated,resultinginaperitonitis- Three rulesmustbefollowed: Severe wounds skin. non-allergic, adhesiveplaster, attaching theedgesofcompresstosurrounding allow thewoundtobreathe. The dressingshouldbekeptinplacewithstrips of,preferably ing willconsistofoneortwocompressessterilegauze,whichformadustbarrierbut wound isoozingfluidorthereariskofdirtgettingintoit,itmustbecovered. The dress- Wherever possible,aminorwoundshouldnotbedressedbutleft uncovered.Ifthe Protecting thewound debris backontothepart ofthewoundwhichhasalreadybeencleaned. onto thesurroundinghealthyskin.Nevergooversameareatwicetoavoidtransferring The compressisusedtocleanthewound,movingoutwardsfromcentreofwound cleaningofthewound Actual should behandledinthesameway. compressremovedfromametal box and removethecompress,holdingitbyonecorner. A aging byholdingonecorner. Ifitisinanindividualwrapper, tearoneedgeofthewrapper Without therightequipment,i.e.tweezers,acompressshouldberemovedfromits pack- Handling acompress gen peroxideandsoapgivegoodresults. ommended forreasonsalreadyexplained;alcoholisanirritant andcausesstinging;hydro- idly, butwithoutusingsubstances whichmaycausetissuenecrosis.Use of etherisnotrec- or variouskindsofdebris,andsometimesoilgrease.Itmustthereforebecleanedrap- woundisoften contaminated throughcontact withthegroundandmaycontain dirt,dust A Debriding (cleaning)thewound are verypainful. Facial woundsusuallybleedheavily. Wounds totheeyesoften causeshock,becausethey Wounds tothefaceandeyes Minor wounds evacuatethecasualty undersupervision • preventdeteriorationofthesituation • protectthewound • The goldenrule: EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Do nottouchthe wound! 45 46 encing breathingdifficulties. throughout transport,and, ifavailable,oxygenshouldbeadministeredto apersonexperi- and tiltedbacktofacilitate breathing. The casualty mustbekeptunderclosesurveillance An unconsciouspersonshouldbetransportedlying ononeside,withtheheadproppedup discomfort. injured side. The casualtywillinfactautomaticallyadoptthepositionwhichcausesleast she shouldbekeptinahalf-sittingposition,sometimes leaningoverslightlyontothe Wounds tothethoraxnecessitate emergencyevacuation. Ifthepersonisconscious,heor Positioning thecasualtywhilewaitingforevacuationand duringtransport Several techniquesarepossible,dependingontheequipmentavailable: an airtightdressing. wound”). Wherethisisthecase,woundmustbe“sealed”asquicklypossiblewith diately bechecked,i.e.whetherairisleakingoutfromthelungsviawound(“blowing With awoundtothethorax(chestorupperback),presenceofair“bubbles”mustimme- Specific wounds cumstances oftheinjuryandanyotherpotentiallyusefulinformation. It isadvisabletoprepare aninformationsheet,givingthecasualty’s name,thetimeandcir- ported lyingdown. severely woundedpersonmustbetrans- injuries thanamerelocalmedicalpractice. A The casualtyshouldbeevacuatedtoahospital, whichisbetterequippedtotreatserious Evacuation Preventing deteriorationofthesituation the casualtyistaken inchargebytheemergencyservices. ly. Antiseptics andotherproducts shouldnotbeused. The woundshouldbeleft asitisuntil rescuerdoesnothaveappropriatemeansofcleaninganddisinfectingawoundproper- A Protecting thewound should thereforealwaysbekeptlyingdownandwarmcomforted. Some particularly severe,large,deepwoundshaveatraumatisingeffect. The casualty or acleanpieceofcloth(ahandkerchief,napkin,towel,etc.). Depending onits size,thewoundshouldbecoveredwithasteriledressing(compresses) ifalittleequipmentisavailable,thewoundshould becoveredwithseverallay- • apad ofclothmaybekeptinplacewithanimprovisedtriangularbandage,tied • inarealemergency, therescuershouldpresseitherahandorclean,thick • thecasualty, whomayshowsymptomsofshock • thewounditself, whichmaybecomeinfected • Deteriorationofthesituationmayconcern: • compresses andhalfcoversthepreviouspiece of plaster sive plaster, arrangedsothateachpieceofplasteroverlaps theedgeof ers ofgauzecompressesandkeptairtightwithapatchwork ofpiecesadhe- son’s shoulderandsecuredwithastripofcloth around thethorax,withuppercornerofbandagepassing overtheper- pad ofclothdirectlyontothewound EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Generalobservations 3.4.1 Breathingdifficulties 3.4 Blood servesasavehicle foroxygen.Oxygenistransportedintwoways: to allthecellsinbody. ering system(thepulmonaryveins)toasecond pump(theleft ventricle),whichdeliversit pulmonary arteries)toanexchangesystem(the capillaries);itthenflowsthroughagath- level. The bloodisevacuatedbyapump(therightventricle)alongtransport system(the has asurfaceareaofabout70m along thearteriestofinetubes(capillaries)surrounding thealveoli. The capillary network dioxide. This circulatorysystemacts asapumpwhichevacuatesbloodfromtheheart remarkable chemical,haemoglobin,whichcancarry largequantitiesofoxygenandcarbon exchange, andtransports allessentialsubstances toandfromthecellsbymeansofa The circulatorysystemtakes upoxygenfromthealveoli,releasingcarbondioxidein system Role ofthecirculatory oli. The respiratorysystemhastwoseparate parts: tact withair. Itisanair-pumpwhichcarriesairthroughtheairways tothepulmonaryalve- The respiratorysystemisthemechanismwhichbringslargequantitiesofbloodintocon- system Role oftherespiratory properly: If oxygenistoreachthecells,twofundamental bodysystemsmustbefunctioning release ofcarbondioxideintotheatmosphere. mechanics ofbreathing,ventilationensurestheintake ofoxygenintothelungsand This isthemovementofairinandoutlungs,measuredlitresperminute.In Ventilation very smallquantitiesofraregasesandtracescarbonmonoxide). use ofoxygenpresentintheair(whichismadeup20.93%oxygen,79.03%nitrogen, Respiration consists ofallthephenomenalinkedtoabsorption,circulationandcellular Respiration a personexperiencingbreathingdifficulties. doomed. This showshowimportant itisforarescuertotake rapidactionwhenfacedwith quences maybeirreversibleandanyeffort toresuscitate thecasualtymaybeirrevocably cannot goshortofoxygenformorethanthreeminutes,beyondwhichtimetheconse- the typeoforganconcerned. The mostvulnerableorganisthenervoussystem. The brain Death ofanorgandeprivedoxygenoccursafter avariableperiodoftime,dependingon carbon dioxidewillfirstceasefunctioningandthendie. cellreceivinginsufficient oxygenandtoomuch Oxygen isabsolutelyvital tohumanlife. A combinedwith thehaemoglobincontained intheredbloodcells • dissolvedinthe plasma • thealveoliwhereoxygenisexchangedforcarbon dioxideathighspeed • asystemofairwaysinwhichvirtuallynoexchange ofgasestakes place • thecirculatorysystem,whichcarriesbloodaround thebody • therespiratorysystem,whichbringsinair • EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 2 , whichexplainsthespeedofgaseousexchanges atthis 47 48 .. Asphyxia 3.4.2 Table 3 described (Table 3)maylastseveralhoursordays. Hypercapnia develops moreslowlythanhypoxia,andthefourstages traditionally Hypercapnia can bedistinguished,dependingonwhetherhypoxiaorhypercapniapredominates. numberofstages Most ofthesymptomsobservedarerespiratory, circulatoryorcerebral. A patient’s condition. dioxide, andofthepHblood,makesitpossibletodetermineseriousnessa In amedicalenvironment,measurementofthepartial pressuresinoxygenandcarbon Asphyxia alwaysinvolves: difficulties Signs ofrespiratory often combinedinpersonsexperiencingbreathingdifficulties andresultincelldeath. An increaseincarbondioxideisknownas“hypercapnia”.Hypercapniaandhypoxiaare ia”, andits completelack“anoxia”(whichisexceptional). deficiencyofoxygenisknownas“hypox- cause, iswhatreallydefinesrespiratoryfailure. A Lack ofoxygenorexcesscarbondioxideinthecells,tissuesandorgans,whatever i.e. anyoneexperiencingrespiratorydifficulties evenifventilationhadnotceasedentirely. cial resuscitation oftherespiratoryfunctionwasconsideredtobesuffering fromasphyxia, ually cametomeanlackofventilation. Then, anyonewhoseconditionnecessitated artifi- The termasphyxiawasoriginallyappliedtoapersonwithnodetectable pulse,butitgrad- four stages (Table 4),each lastingafewminutes. Irrespective ofits cause, hypoxiaisadeficiencyofoxygenreaching thelungs.Itinvolves Hypoxia Three Stage Four One Two h yposdet h aiu atra n ubr ev eetr’reaction thesymptomsduetovarious(arterialand bulbar)nervereceptors’ • thesymptomsofhypoxiaandhypercapniathemselves,whetherseparate or • thesymptomsofcausalillnessoraccident • to thehypoxiaorhypercapnia combined Three stages of hypercapnia Cessation ofbreathing Cardiac arrest Deep comawithtotal lossofreflexes Slight cyanosis High bloodpressure Rapid pulse Partial airwayobstruction Sweating Difficulty inbreathing EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Description

BL - 3/A BL - 3/A Table 4 Resuscitation ispossibleonly through artificialventilation andopeningoftheairways. ia andmakeitnecessarytostart resuscitation: It isabovealltherhythmandqualityofbreathing thatsymptomatizetheonsetofasphyx- ning ofhypercapnia. pulsewhichisfastandtoomarkedmayindicatethebegin- third stages ofhypercapnia. A Cyanosis ofthefingernails,lips andearlobesisasignofhypoxiaorthesecond to knowhowlookandlistenforthesymptoms. the casualty. To recogniseacaseofasphyxiabeforethisstage isreached,itnecessary tion, commencedwithinthenextfewseconds,isclearlysolemeansofresuscitating have stoppedmovingandbreathinghasceased,atwhichpointeffective artificialventila- to considerthatacasualtyissuffering fromasphyxiaonlyoncethechestandabdomen the speed,strengthandregularityofbreathingmayvary. Itisthereforenolongerpossible stages ofhypoxiaandthefirstthreestages ofhypercapniaventilationcontinues,although asphyxia doesnotalwaysceasebreathing. As wehavejustseen,duringthefirsttwo varying accordingtothecause.Itisimportant tobeawarethatapersonsuffering from The symptomsareusuallyacombinationofthehypercapniaandhypoxia, The signsofasphyxia Three Stage Four One Two troubled,noisy (gurgling)breathing,showinganobstructionoftheairways due • breathingwhich istooslow-fiveorsixbreathsperminuteshortlybefore res- • breathingwhichistoofast-beyondfortybreathsperminutebutweak, • sign ofexcesscarbondioxide (hypercapnia)atallstages to anaccumulationofsecretions inthethroat,tracheaandbronchi;this isa piratory arrest scarcely causinganymovementoftheribs EIA ASPECTSOFDISASTERS MEDICAL Four stages ofhypoxia massage, maybetheonlymeansofrestarting breathingandheartmovement. cardiopulmonary resuscitation, combiningartificialventilationandheart ventilation alonedoesnotalwayssuffice toresuscitate thecasualty, and his orherpupilsshowexcessivedilation(mydriasis).Atthisstage artificial Circulation stops duetocardiacarrest. The personisnolongerbreathing,and convulsions arefrequent,andthepupilsusuallydilated. and, aboveall,cessationofbreathing(apnoea).Bloodpressurefalls, Only afewminuteslaterthepersonfallsintocoma,withtotal lossofreflexes successful. stage; thepupilsareoften alreadydilated. Attempts atresuscitation arealways The heartbeatspeedsupconsiderably;cyanosisisparticularly evidentatthis state isbrief,andtherelittletimetoact.Breathingalwaysstrongfast. The personfallsunconscious,often suddenly, butwithnolossofreflexes. This high. may reachandexceed150perminute;atthisinitialstage, bloodpressureisnot taken atthewristorcarotid,isfast,often morethan100beats perminute;it absorb asmuchairpossible-thisisknownpolypnoea.Thepulse,whether The persontakes stronger, quickerandbreaths,strainingtheribcageto FIRST-AID PROVISION FIRST-AID AND EMERGENCY Description 49 50 .. Carbonmonoxidepoisoning 3.4.2 Partial orcompleteobstructionoftheairways: The presenceoftoxicgasesintheairbreathedin,preventinghaematosis The causesofasphyxiainclude: The causesofasphyxia all thevital functions.However, inmostcasesitmustbecombinedwithheartmassage. ing forair, andhasnodiscerniblepulse,artificialventilationsometimessuffices torestart When apersonispale, unconscious,hasdilatedpupils,isnolongerbreathingorgasp- tion iscontinuing.Onthecontrary, artificialventilationshouldbecommencedimmediately. When apersonisinhalingharshly, orgaspingforair, itshouldnotbeassumed thatventila- ing appliance. Poisoning maybedueto asuicideattemptormaybecausedaccidentally byafuel-burn- Carbon monoxidepoisoning isafrequentphenomenon,especiallyin towns andcities. • obstructionofthetracheaandbronchi:Smallforeign bodies(peas,parts oftoys, • hanging • strangulation • spasms oftheglottis-theseoccurineventsuddenstimulation • presenceofmucus • swellingofthemucousmembranesthroat • obstructionwithblood-inthenoseor mouth ofapersonlyingonhisor • obstructionwiththetongue-whenaperson is unconsciousandlyingonhisor • thefrontandbackofthroat • themouthandnose • lackofbreathableoxygen intheatmosphere A • Stale air • Decreasedoxygencombinedwithanon-toxicgas • fallinpartial pressureinoxygen,alone A • changeinthemixofgases breathedin A • with waterprevents oxygenfromreachingthealveoliandpassing intotheblood. Drowning -inthelaststages ofdrowning,floodingthebronchopulmonarysystem a matterofurgency, inordertoremovetheforeignbodyusingbronchoscopy. will bebreathingnormally. However, specialistmedicalhelpmustbeobtained as obstruction. Itmayinfactobstructonlyoneofthe bronchi,inwhichcasethechild cease, thisdoesnotalwaysmeanthattheforeign bodyisnolongercausingan hours. Itisnecessarytobeawarethat,although thebreathingdifficulties may and theresultingoedemamaycompletelyobstruct thewindpipe inamatterof tal, asthemucousmembraneoftracheaswellsupinreaction totheirritation, ist medicalhelpisavailable.However, notimemustbelostingettingtoahospi- and artificialventilation(mouth-to-mouth)remainsperfectlyeffective untilspecial- tis andenterthetrachea. They nevercauseacompleteobstructiontobeginwith, peanuts) whichareswallowed,particularly bychildren,maygetpast theepiglot- diver orapersonwhoisdrowningbyviolentblowtothethroat. entrance tothetrachea. They maybetriggeredby cold waterswallowedbya her backwillflowdownintothethroat,whereitcoagulates her backthetonguefallsdownofthroat. EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A and agitation, whichmaygivetheimpressionthatpersonisdrunk. lapsing. Lossofconsciousnessissometimesprecededbyaperiodmental confusion usually attempttostand upinordertoopenawindowandtake afewsteps beforecol- sion ofunease,followedbygradualparalysis, beginningwiththeextremities.Casualties pain, dizziness,lossofhearing,confusion,somnolenceand,aboveall,ageneralimpres- icated whileasleep.However, itwouldseemthatthefirstsignsareheadache,abdominal The initialsymptomsofacutepoisoningarenotwellknown,ascasualtiesoften intox- poisoning Acute Symptoms ofcarbonmonoxidepoisoning Parkinsonism, fits of dizzinessorparalysis. may besubjecttostuporous states orpseudo-dementia, convulsions,pseudo- The long-termeffects are mainlyneurologicalandmental. Evenafter recovery, casualties poisoning isalwaysfatal. Despitetreatment,variouscomplicationsmaybeobserved: The subsequenteffects ofcarbonmonoxidepoisoning arevariable.Ifleft untreated,acute Subsequent effects health. Poisoningmaybe centration intheairinhaled,durationofexposureandcasualty’s priorstate of quickly itbuildsupintheorganism.Symptomsdependoncarbonmonoxidecon- The effects varydependingonthequantityofcarbonmonoxideabsorbedandhow ity withallmolecularstructuresthatusuallyfixoxygen. It doesnothaveadirecttoxiceffect. The damagewhichitcausesisduetoits affin- 3%. Inacountrydwellerthequantityistiny. In anon-smokerarterialbloodcontains 2.2%carbonmonoxide,andinasmoker All townandcitydwellershavesmallquantitiesofcarbonmonoxideintheirblood. Concentrations of1/200ormore(onelitrefor200litresair)resultinrapiddeath. not onlyofchronicpoisoning,butalsoacutepoisoningwithcoma. reaches 1/500(onelitreofcarbonmonoxidefor500litresair),thereisadanger one litreofcarbonmonoxidefortencubicmetresair).Oncetheconcentration Carbon monoxideisconsidereddangerousfromaconcentrationof1/10,000(i.e. bustion causesaviolentexplosion.Itissufficiently toxictoharmtheorganism. formed intocarbondioxide.Incertain conditions(presenceofoxygen),its com- easily mixeswithair. Onburning,carbonmonoxideemits intenseheatandistrans- Carbon monoxideisacolourless,odourless,tasteless gas.Itislighterthanand renal(renalinsufficiency, uraemia) • vascular(state ofshock) • cardiac(irregularheartbeat,pseudo-infarction) • pulmonary(lunginfections) • How doescarbonmonoxideaffecttheorganism? EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY What iscarbonmonoxide? acute , non-acute or chronic . 51 52 Table 5 Different solutionscanbeenvisageddependingonthecasualty’s state (Table 5). Examine thecasualty son’s mouthandthroatwithtwofingerswrappedinapieceofcloth. First, ensurethattheairwaysareunobstructedbylooseningclothingandclearingper- The treatmenttobegivenisthesameasforanypersonsuffering fromasphyxia. Before doinganything,itisessentialtoseekhelp. rescuermusttake extremecarewhenattemptingtosaveacasualty. There aretwomainrisks: A How todealwithcarbonmonoxidepoisoning Three must bedealtwithasfollows: sometimes toallotherpeoplepresentinthebuilding. An asphyxiated casualty cuers mustcontact thefiredepartment becauseoftherisktothemselvesand Casualties showanabnormalrosycolouring.Before taking any furthersteps, res- this formofpoisoningisallthemoreinsidioussince carbonmonoxideisodourless. one isfoundasphyxiatedinakitchenorbathroom. Itmustbeborneinmindthat own lifeisindanger. Carbonmonoxidepoisoningmustbesuspected whereany- Rescuers mustbeawareoftheriskandapproachanycasualtywithcare,astheir stands thecausescanavoidbytaking simplepreventivemeasures. Carbon monoxidepoisoningisafrequentoccurrence,whichanyonewhounder- State One Two theslightestspark orflamemaytriggeranexplosion • thegasishighlytoxic,andrescuermaybepoisonedinturn • beforegoingtothecasualty’s assistance rescuersmustprotectthemselvesandothers • nevercauseaspark andopen allwindowstoairthepremisesandreduce risk • ifbreathinghasstoppedbeginartificialventilation (mouth-to-mouth)immediately • ensurethattheairwaysarekeptunobstructedbytiltingback person’s headand, • of explosion if he/sheisbreathing,placinghim/heronhis/herside heart massagecombinedwithartificialventilation. mouth ornosethreetimes,take thepulseagain.Ifthereisnopulse,begin Immediately start artificialventilation! After breathing intotheperson’s The casualtyisnolongerbreathing,andapulsecannotbefelt. Immediately start artificialventilation! can befelt. The casualtyisnolongerbreathingortooslowlyandirregularly;apulse Lay thecasualtyonhis/herside,andmonitorpulsebreathing! The casualtyisunconsciousbutstillbreathingandhasadetectable pulse. Three states ofcarbonmonoxidecasualty EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Conclusion Description

BL - 3/A BL - 3/A .. Carbondioxidepoisoning 3.4.3 tory failure. bon dioxideproducedbytheorganism(internalcause),whichariseinallcasesofrespira- excess concentrationincarbondioxide(externalcause)orbyproblemseliminatingcar- Carbon dioxidepoisoning(hypercapnia)maybecausedeitherbybreathingairwithan broken. To dothis: Where thepersonisbreathing, theviciouscircleofreciprocalcauseand effect mustbe How todealwithcarbondioxide poisoning The airwaysareseverely obstructed,andbreathingisnoisy. and sometimesirregular. There areclearsignsofcyanosis,particularly ofthefingernails. deep coma.Breathingisweakandsometimesirregular, withinterruptions. The pulseisfast gernails, theearlobesorlips maybenoted. At stage three,thecasualtyfallsintoa shows obvioussignsofobstructiontheairways. Slightcyanosisofthebasefin- ing canbeobservedatthelevelofforehead, armpits andchest,thecasualty often agitated butmayalreadyshow signs ofunusualtorpororsomnolence.Heavysweat- Subsequently, atthesecondstage, breathingisfastandweak(oligopnoea).Casualtiesare aggressive. Casualties areoften agitated, lackcoordination, andtheirspeechbecomesincoherentor rience alltheusualformsofbreathingdifficulties. noises whenbreathing. At thesametime,ventilationspeedsup,andpersonmayexpe- Obstruction oftheairwaysisfrequentandoften discerniblethroughgurglingorsnorting sweating withnophysicaleffort. Bloodpressurealso risesatthisstage. Initial symptomsofhypercapniaareafastpulse,slightreddeningthecomplexionand Symptoms ofhypercapnia respiratory arrest(apnoea). Beyond 10%,adecreaseinbreathingcapacity (oligopnoea)isnoted,followedby breathing) inapersonatrest.10%isthetolerancelimitconsciousperson. 4%concentrationinalveolarairproducesastate ofpolypnoea(deep,rapid A concentration inalveolarairisincreasedby0.2%,ventilationperminutedoubles. gases containing aknownpercentage ofcarbondioxide.Whenthedioxide Experiments havebeenconductedinwhichapersonwasadministeredmixof Carbon dioxide(CO ing out,carbondioxideisemittedalongwithwatervapourandnitrogen). (wine andciderfermentation tanks) andhumananimalrespiration(onbreath- The usualsourcesofcarbondioxidearecombustion(fires,ovens),fermentation flame andprevents combustion. water). Itisheavierthanairandinitiallybuildsupatgroundlevel.willputouta How doescarbondioxideaffecttheorganism? EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID 2 ) isanodourless,colourlessgas,withafaintacidtaste (soda AND EMERGENCY What iscarbondioxide? 53 54 .. Electrocution 3.4.4 threatened. The personfeels numb. minute andmayreach180 to200perminuteincases,whichcasethe casualty’s lifeis Breathing israpid,sometimes panting orweak. The pulserateexceeds120beats per gard anddazed,withbulging, wildeyes. The complexion ispale andblue-greyincolour. tact withtheconductor. Foranumber of secondsorminutestheyremainimmobile,hag- Casualties areprojectedoveradistance ofseveralmetresassoontheycomeintocon- ia. Itisgenerallyduetoastrongflowofcurrent of severalamperes. Electric shockcanbeobservedincaseswhere there isneithercardiacarrestnorasphyx- Electric shock The mainrisksandlesionscaused appliances) –butcanbeavoidedthroughaminimum ofcareandattention. can beconducivetonegligence(imprudence,poor maintenanceofelectricalwiringand nature ofelectricityitself –electricityisnotvisibleonthesurfaceofaconductor, andthis part ofthecasualtyorhisherentourage.Electricalaccidents areaconsequenceofthe ic damagethroughburning. This typeofaccidentis, above all,duetocarelessnessonthe as renalfailure,whichmayprovefatal inthelongrun.Casualtiesmayalsosuffer cosmet- been resuscitated, orwhoshowednosignsofasphyxia,maydevelopafter-effects, such casualtywhohas Electrocution causesover200deathsperyearinFrance,forexample. A should becommencedimmediately. mouth andthroatwithtwofingerswrappedinapieceofcloth,mouth-to-noseresuscitation Where thepersonisnolongerbreathing,after rapidlylooseningclothingandclearingthe Respiratory arrestnecessitates immediateartificialventilation. side intherecoveryposition. to breathenormallyand,intheeventofcoma,positionpersononhis/her It isimportant tocleartheairways,stimulatepersonsothathe/shebegins ry andcardiacarrest. culty breathing,showssignsofcyanosisorisinacoma.Itmayleadtorespirato- Hypercapnia shouldbesuspectedwhenthepersonissweating,experiencesdiffi- duced bythebody. the gasinaconfinedareaorbyaninabilitytoeliminatecarbondioxidepro- Carbon dioxidepoisoningismostlycausedbyinhalingstale air, byabuild-upof take caretopreventatoosuddenintake ofoxygen,whichmay, paradoxically, • thecasualtyshouldbemadetoliedownwithupperhalfofbody • theairwaysshouldbeopenedupbylooseninganyclothingorotherobjectthat • secretionsshouldberemovedwithamucosityaspirator, ifavailable • thecasualtyshouldbebroughtoutofstate oftorporbybeingshakenor • cause respiratoryarrest tioned onhis/herside(intherecoveryposition) propped upandtheheadtiltedback;anunconsciouscasualtyshouldbeposi- may hamperbreathing pinched, andmustbemadetobreatheheavilycough EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Conclusion

BL - 3/A BL - 3/A state ofshockmustbemonitoredandtreatedassuch. After anaccidentofthistypethecasualtymustthereforeundergoafullexamination. The Others maybetheresultofelectricalcurrentitself (tornmuscles,seriousburns). son waspropelledthroughtheair(brokenlimbs,severewounding,cranialtraumatism). time tostopracing(severalhours).Seriousinjuriesmayhavebeencausedwhentheper- to normal,andthepersonfeelscalmerrecoverssomecolour. The pulseoften takes After anumberofminutesorhoursnumbnessgiveswaytomuscleache,breathingreturns necessary treatment. arrange fortransfertoa hospital forsurveillance,administrationof an alkalinedripandany son fromstanding up, talk toandreassurehim/her. Keephim/herwarm,bycovering, and her side(intherecovery position),after theairwayshavebeencleared. Preventtheper- pulse. The casualtymustbetreatedforshockandleft lyingdown,ifunconsciousonhisor brief examinationshouldbemadetoverifybreathingand the effects ofelectricshock. A The personhasbeenprojectedsomedistance awayfromtheconductorandusuallyshows The casualtyisnotincontactwiththeconductor ductor andwhethertheaccidentoccursindoors oroutdoors. The approachvariesdependingonwhetherthe casualtyisstillincontact withthecon- How todealwithelectrocution sary. Healing isextremelyslowbecauseofthevascular changes,andsurgeryisoften neces- ceased intheburntarea,whichistrulynecrotised,consistingofdead,erodedtissue. They donotbleedwhenprobedwithaninstrument,evenatsomedepth. All circulationhas edges, whicharegreyishorpurplishincolour;theirsurfaceishard,toughandflexible. lying musclesandbones. The areamaybecompletelycharred. These burnshavesmooth times evenamerepinpoint,orlarge.However, theyarealwaysdeep,reachingtheunder- appearance. Their shapevaries:round,linear, ormap-like. They maybeverysmall,some- Visible burnsexistonlywherethecurrententeredand left thebody. They aredistinctivein of internallesions. mere visualexaminationrevealsonlytheentryandexitpoints ofthecurrent,notextent vary inseriousness,butarealwaysmoreseverethanisapparent tothenakedeye,asa cles ofmoltenmetal (jewellery),orbythecurrentitself passing throughthebody. Burns These maybecausedbyanelectricalarc(spark) betweentwoliveconductors,byparti- Burns no longerfillsandempties;circulationceases. (ventricular fibrillation).Bloodisnolongerevacuatedintothecirculatorysystem;heart The heartnolongerfunctionsasapump;underthehanditfeelslikemassofearthworms body, resultingincontractionof theventriclesandofallfibresmyocardium. is usuallygiven). The currentproducegenuineshort-circuits insidethe figure of100mA Circulatory arrest: passes. Chestmovementisparalysed, andthepersoncan neitherexhalenorinhale. constant contractionofthediaphragmandintercostal muscles foraslongthecurrent Respiratory arrest: lar fibrillation(nocarotidpulse). due tomusclecontraction(detectable carotidpulse),orcirculatoryarrest,duetoventricu- Depending onthestrengthofcurrent,thismaytake theformofrespiratoryarrestalone, Asphyxia EIA ASPECTSOFDISASTERS MEDICAL hsocr ihacreto ewe 0m andseveralamperes(a This occurswithacurrentofbetween80mA This occurswithacurrentofbetween20and80mA.Itisresult FIRST-AID PROVISION FIRST-AID AND EMERGENCY 55 56 breaking thecircuit,as deviceusedtodosomaynotbesufficiently insulated. has beenelectrocutedand needshelp.Noattemptshouldbemadetocut off thepowerby off thearea,preventingpeople fromapproachingthepowerline,evenifsomeone nearit travelling throughtheground. The onlysolutionis tocalltheelectricitycompany andseal very highrisk,andmaybedangerousevenatsome distance because ofresidualcurrent Despite theconsiderablesafetysystemsincorporated inpowergrids,suchalineposes high-voltage powerlinebroughtdownbyastormandlying onthegroundisacaseapart. A ment itself. been testedtoguaranteethatitprotects theuseruptoagivenvoltage notedontheequip- with aninsulatedhandleandaspecialstool.Each ofthesepiecesequipmentmusthave ment (anelectricalemergencieskit),includingrubber boots and gloves,wirecutters,apole themselves ensuredthatthepowersupplyisoff oriftheyhavespecialinsulatingequip- In thiscasethetypeofcurrentisunknown,and rescuers cantake actiononlyiftheyhave Electrocution outdoors so theycantake chargeofthecasualtyandtransferhimorhertohospital. Always ensurethathelpisbeingsoughtandtheemergencyserviceshavebeencalled point artificialventilationaloneisnecessary. five chestcompressionswithonebreath(insufflation) untilapulseisdetected,fromwhich arms straight,sothatitiscompressedbyabout4cm. The rescuershouldthenalternate ning with5or10chestcompressions,givenbypressingonthelowersternumboth ue artificialventilation.Ifthereisstillnopulse,heartmassagemustbecommenced,begin- times, thencheckthecarotidpulse.Ifapulsecannowbefelt,rescuershouldcontin- airways andtiltingtheheadback,rescuershouldbreatheintomouthornosethree unconscious, showsablue-greycolouringandhasbothpupilsdilated,after clearingthe If thepersonisinadeath-likestate, i.e.hasnocarotidpulse,stoppedbreathing,is they areusuallysuccessful. The casualtyshouldthen beevacuatedtoahospital. again ontheirownandregainsconsciousness.Ifthesemeasuresaretaken withoutdelay, nose resuscitation mustbeadministeredimmediately, untilthepersonbeginstobreathe son hasstoppedbreathingbutadetectable carotidpulse,mouth-to-mouthormouth-to- clearing themouthandthroat,removinganydenturestiltingheadback.Ifper- ensure thathisorherairwaysarekeptclearbylooseningclothingattheneckandwaist, remove allrisk. After removingthecasualtyfromelectricalsource,rescuermust when dealingwithahouseholdelectricitysupply, aremerelyfall-backsolutionsanddonot or adrybottletotouchtheelectricalsource. These measures,whichshouldbeappliedonly stepladder, possiblyplacedonglass)andusingadrypieceofwood,e.g.broom-handle, should protectthemselvesbystanding oninsulatingmaterial(awoodenchair, stoolor the wireorotherelectricalsourcecanbepulledawayfromcasualty. To dothis,rescuers someone else.Ifitisdifficult toswitchoff theelectricitysupply, orthatwouldtake toolong, touching theperson,becausepowercanalwaysbeswitchedonagainaccidentally by appliance (anelectricrazor, forexample)maysimplybeunplugged.Removeanywire be turnedoff (atthemasterswitch)beforetouchingcasualty. Ifneedbe,thedefective The currentmaybeconductedbyapoolofwater, inwhichcasetheelectricitysupplymust The casualtyisstillincontactwiththeconductor have beenmade. turned off untilthecauseofaccidenthasbeenestablished andanynecessaryrepairs one accidenthasoccurred,theremaybeariskofothers. The electricitysupplymustbe rounding airwithatemporary, steriledressing.Lastly, therescuer mustbearinmindthatif Serious burnsareparticularly subjecttoinfection. They mustbeisolatedfromthesur- EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Howtodealwith breathingdifficulties 3.4.5 be. Itmayentail: eliminate thecauseofasphyxia. The earlierthismeasureistaken, themoreeffective itwill Without riskinghisorherownlife,arescuermust firstmovethecasualtyawayfromor Eliminate thecauseofasphyxia First steps action, andtimelostmayprovefatal. about whattodoordiginhishermemory. There areonlyafewsecondsinwhichtotake rescuermustnotneedtothink Success orfailureoften dependsonspeedofaction. A important itistocalltheemergencyservices. according tothenatureofproblem,mustbeobtained veryrapidly. This showshow It alwaysfallstoachancerescueradministerfirstaid,butspecialistmedicalassistance, "every secondcounts"! "every professional, mustobeyoneobvious,basicrule: Each steptakenbyarescuer, whetheramateuror removing thecasualtyfrompowersourceandadministeringfirstaid. to danger, byturningoff (orhavingsomeoneelseturnoff) thepowersupply, before must alwayscallforhelpfirst,thenensurethattheythemselveswillnotbeexposed must thinkfastandexercisethegreatestpossiblecaution.Inallcases,rescuers When comingtotheassistance ofapersonwhohasbeenelectrocuted,therescuer all onthekidneys. Long-term damagemainlyresults fromtheinternaleffects ofelectrocution,above ing externalheartmassage. piratory orcirculatoryfailure,necessitating artificialresuscitation, possiblyinclud- Immediate injuriesconsistofburnsandastate ofshock. The greatestriskisofres- occur. They causemanydifferent kindsoflesion. Electrocution canalwaysbeavoided,andsuchaccidents shouldthereforenever complexaction, involvingmoreorlesssophisticatedtechniques,the basic • asimpleaction,suchasturningoff theelectricitysupply atthemasterswitch • exposure todanger principles ofwhichshould befamiliartoeveryone,ifonlyavoidunnecessary then removinganywire still incontact with thecasualty EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Conclusion 57 58 Clearing theairways using blankets oritemsofclothingplacedbetweenthekneesandbehindhisherback. shoulder, againsttheperson’s check. The casualty shouldthenbewedgedinposition cushion (afoldedpulloverorjacket),ofathickness equivalenttohalfthewidth ofthe tain head,neckandthoraxalignment,itispreferabletohavefirstplacedanimprovised avoid anybendingorrotation oftheneckandtokeepspinalcolumnaligned. To main- keeps theheadextendedandfollowsrotating movement.Inthiswayitispossibleto caused aspinalfracture),thesecondplaceshis orherhandsonthecasualty’s cheeks, Where tworescuersarepresent(whichisdesirable after anyaccidentwhichmayhave towards thegroundorbed-surface. the knee,toserveasaprop. The headistiltedback andthemouthopenedturned The personisrolledtowardstherescuerinasinglemovement. The upperlegisbentat knee) and,withtheotherhand,lowerhalfoffartherupperarm(nearelbow). level. Withonehand,graspthelowerpart oftheperson’s farther thigh(justabovethe dent casualties.Iftherescuerisalone,heorsheshouldkneelbesidecasualtyatchest Placing thepersoninthispositionissimple,butmustbedonewithcarecaseofacci- through thenoseormouthfacialinjury. unconsciousness, lossofnormalcoughingorswallowingreflexes,vomiting,bloodrunning of theupperairways,particularly intheeventofaggravatingcircumstances, suchas throat. This positionmustbeusedwheneverbreathing maybehamperedbyobstruction tating theevacuationofmucus,vomitorbloodandpreventingtonguefromblocking The recoverypositionkeeps theupperairwaysofanunconsciouspersonclear, byfacili- ing thebackofthroat,orsuddenasphyxia,causedbyinhalationgastricsecretions. with thecause.Deathissimplyduetogradualasphyxia,causedbytongueobstruct- The wayaccidentcasualtiesorpersonswhofallintoacomadieoften hasnothingtodo At present,anincalculablenumberofunconsciouscasualtiesdieasphyxiaeachday. position The recovery Preventing asphyxia ing helppromptlyandprovidingpreciseinformationtotheemergencyservices. entirely ontherapidarrivalofmedicalassistance. This showsthevital importance ofseek- basic lifesupportbutwillbelimitedinscope,andthechancesofsuccessthereforedepend In anycase,thefirststeps taken byanamateurrescuer areaimedatprovidingeffective casualty’s state ofconsciousnessandwhetherheorsheisstillbreathinghasapulse. decides thefirststeps tobetaken. There arefourpossibilities(Table 6),accordingtoa The rescuermustquicklyexaminethecasualtytoassesshisorhercondition,which Examination andinitialaction life supportwhilewaitingforspecialistassistance. rescuers. However, thelattershouldbefamiliarwitheffective methodsof providingbasic Medical reanimationtechniquesareoften verycomplexandcannotbetaught toamateur Alert thepublicemergencyservices casualty’s chancesofsurvivalandforsubsequentrescueaction. thought-out. Ensuringone’s ownsafetyisabasicrule,withdirectconsequencesforthe Although thereisaneedforspeed,themeasurestaken byanyrescuermustbewell After loosening tightclothing(collar, tie,belt),anumber ofactionsshouldbe taken. and makesanyresuscitation attemptineffective. partial obstructionworsensrespiratory problems,hastensasphyxia mouth tothelungs. A This entails ensuring unhamperedrespiratorymovementanda goodairwayfromthe EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A Table 6 ed atthethroatorgroin. weak); apulsecanbedetect- ineffective (tooslow, toofast, breathing hasstoppedoris The casualtyisunconscious; Third possibility fast, toosloworhampered. breathing islaboured,too The casualtyisconsciousbut Second possibility pulsecanbefelt. difficulty. A and isstillbreathing,butwith The casualtyisunconscious First possibility arrest. cy, combinedwithrespiratory circulatory arrest,ordeficien- like state. Itcorrespondsto times referredtoasadeath- often dilated. This issome- throat orgroin;pupilsare pulse canbedetectedatthe breathing hasstopped,no The casualtyisunconscious; Fourth possibility Casualty's state EIA ASPECTSOFDISASTERS MEDICAL breathing andapulseconditions Possibilities accordingtoacasualty'sstate ofconsciousness, FIRST-AID PROVISION FIRST-AID AND EMERGENCY cial ventilation circulation bymeansofexternalcardiacmassage,alternating withartifi- If, after threeinsufflations, thereisstillnodetectable pulse,beginartificial begin mouth-to-mouthormouth-to-noseresuscitation immediately clear theairways it possibletocommenceartificialventilationimmediately. factor. Onlymouth-to-mouthandmouth-to-noseresuscitation infactmake The speedwithwhichthemethodcanbeimplementedisakeysuccess mouth, mouth-to-nose)ormanual(SilvesterNielsen)resuscitation remove denturesandimmediatelybeginamethodoforal(mouth-to- clear themouthandthroat loosen theclothing administer oxygenwithcare place theheadincorrectposition,slightlytiltedback remove dentures encourage thecasualtytocoughandbreatheslowly loosen anyclothingwhichmayhamperbreathing(collar, tie,belt) ting-up leave thecasualtyinpositionwherebreathingiseasiest,often halfsit- reassure andcalmthecasualty, whoexperiencesasuffocating feeling to thecasualty) one handonthecarotidpulse),recoveryofconsciousness(keeptalking (rhythm, strength,respiratoryfailure),circulation(therescuershouldkeep appearance ofcyanosis,integuments turningpinkagain),breathing do notleavethepersonalonebutstay nearandmonitorskincolour(dis- respiratory arrestinapersonsuffering fromhypercapnia) administer oxygen,carefullytobeginwith(arushofoxygenmaycause ery position the airwayswithvomit)bylyingcasualtyonhis/hersideinrecov- prevent theasphyxiafromworsening(forinstance, duetoobstructionof insert aGuedel-typeartificialairway, ifavailable secretions withamucosityaspirator, ifavailable mouth andthroatwithtwofingers,usingahookingmotion.Remove (collar, tie,belt),removingdentures,tiltingtheheadbackandclearing open theairwaysbylooseninganyclothingwhichmayhamperbreathing First stepstobetaken 59 60 exhales soasnottobreatheinthetoxicairreleased. must becarefultoremovehislips completelyfromthecasualty’s facewhenthelatter lungs (trichlorethylene,carbontetrachloride,methyl bromide).Insuchcases,therescuer to acasualtyintoxicatedwithcertain poisonoussubstances thatareeliminatedviathe cuers shouldbeawareoftheslight,butreal,risk thatexists when oralventilationisgiven or wherethecasualtyhasundergoneatracheotomy orhasatrachealwound. Amateur res- where thereisextensivefacialinjuryandthemouth andnosearenolongerrecognisable, artificial ventilationtechnique. The onlycircumstances inwhichtheycannotbeusedare The oralmethods,whichcanbeimplementedrapidly inanylocation,constitutethebasic the casualty’s alveoli. has ahighcarbondioxidecontent,infactservestopushproperlyoxygenatedairtowards mouth,throat,bronchiandtrachea. The alveolarairexhaledbytherescuer,cuer’s which The airreachingthealveoliofasphyxiatedpersonisinfactthatcontained intheres- has highoxygencontent. Their unquestionableeffectiveness isduetothefact thattheairsuppliedbyrescuer Oral methods ty, areusedasafollow-upmeasure toemergencyresuscitation. In amedicalenvironmentmechanicalartificialventilators,ofvaryingdegreescomplexi- always afollow-upsolutiontomouth-to-mouth. nected toaface-mask. This typeofequipmentisfast andeasytouseeffective, butis spot. Typical apparatus consists ofamanualventilator, ofbellowsorbag-valvetype,con- intended asafollow-upmeasuretooralormanualresuscitation begunimmediatelyonthe lengthy period.Nomatterhowsimpletheapparatus used,thesemethodsarealways Relay methods,usingapparatus, makeitpossibletomaintain artificialventilationfora amount ofequipment(theEvemethod). ods (Hederer, Chauveau, Binet)aremorecomplextoimplementorrequireasignificant Nielsen andSilvestermethods.Onlythelasttwoaredescribedhere.Otherknownmeth- There aremanyclosed-chestmanualmethods,themostwellknownbeingSchafer, differ accordingtothetechniqueused. The twomaincategoriestobedistinguishedare: ratus canbeusedforfirst-aidpurposes;theirmeansofaction,andthereforeeffectiveness, numberofmethodsnotrequiringappa- There aretwomaintypesofartificialventilation. A Artificial ventilation which isgentlytiltedup. hands areplacedontheperson’s cheeks,withthefingershookedroundlowerjaw, of thethroat,andthusopensupperairways.Itcanbedoneasfollows:rescuer’s Whatever thecasualty’s position,thisactiontips thetongueforward,awayfromback Tilt theheadback With acasualtylyingon his orherback,therescuertakes uppositionalongsidehimor her ried outanywhere:inabed, aboat,car, onrocksoreveninwater. More often thannot, thecasualtywillbelyingonground,butthis methodcanbecar- Mouth-to-mouth closed-chestmanualmethods,whichentail causingmovements oftheribcage • expiredairresuscitation methods,whichentail breathingairintotheasphyxiat- • to refillwithairpassively, bywideningtheribcagetofacilitate inhaling so thattheaircontained inthelungsisexpelled,andthenallowing ed person’s airways;thesearetheoralmethods(mouth-to-mouth;mouth-to-nose) EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A to avoidhyperventilating,whichwouldmakehimorherdizzyandthuslessefficient. in anadultis15to20breathsperminute. The rescuershouldnotbreathetoofast,soas The volumeofairinsufflated shouldbeneithertoomuchnotlittle.Optimalfrequency tive ischestmovementinthecasualtyasairentersandleaveslungs. casualty’s chesttofall,whiletaking anotherbreathes. The signthatthismethodiseffec- alty’s mouthquitefast. The rescuerthanremoveshisorhermouthandwatchesforthe seal. Then, withoutcompletelyemptyinghisorherlungs,therescuerblowsintocasu- normal, therescuerplaceshisorherlips aroundthecasualty’s mouth,ensuringagood air oninsufflation, toclosethecasualty’s nose. After taking aslightlydeeperbreaththan ty’s forehead.Itisalsopossiblefortherescuertousehisorherowncheek,whichfillswith is closedbypinchingitwiththeindexfingerandthumbofhandrestingoncasual- The nose,thoughwhichasignificantamountoftheairinsufflated wouldotherwiseescape, placing asupportunderthecasualty’s shoulders. casualty’s forehead.Othertechniquesarepossible,suchaslifting thecasualty’s chinor placing onehandorforearmunderthebackofcasualty’s neckandtheotheron and, after openingtheairways(looseningclothing,clearingmouth),tilts theheadback, All ofthesemethodsbegin withamovementtoexpelairfromthecasualty’s lungs (expiration). same timeshouldbefirm andnotsinkorcompresswhentherescuerapplies pressure. resistant topressure,thesurfaceonwhich thecasualtyisplacedtobepresseddownat the ownweight, but,asthechestisquite the principleofchestcompression usingtherescuer’s surface, soastopermit proper compressionoftheribcage. These methodsarebasedon To ensure maximumeffectiveness, itisessentialthatthecasualty shouldbelyingonafirm the casualty’s collarandbelt,thenopeningclearingthemouththroat. As withanyotherartificialventilationmethod,the airwaysmustbeopenedbyloosening serious consequences. Immediate actionisessential. Time lostplacing thecasualtyinrightpositionmayhave cautions arethesameasforanyartificialventilation method. used whentheoralmethods(mouth-to-mouth,mouth-to-nose) proveimpossible. The pre- There aremanymanualmethods,whichalways afall-backsolutionandmustonlybe Manual methods precautions. despite therescuer’s stomach oneortwotimesperminute,toevacuateanyairthathasenteredthe may withtimehamperventilation.Moreover, therescuershouldpressgentlyonchild’s monitor thechild’s chestmovement.Givingtoomuch airinflatesthechild’s stomach,which sufficient toraisethecasualty’s chest. This showshowimportant itisfortherescuerto an adultandmorefrequently, about 25to30perminute. The volumeofairneededisthat around thecasualty’s mouthandnose. The rescuershouldgiveweakerbreathsthanfor This techniqueisappliedtoinfants orsmallchildren. The rescuerplaceshisorherlips Mouth-to-mouth-and-nose ty’s chesttofall. The insufflation rateshouldbeabout15to20breathsperminute. and blowsintoitquitefast,beforeremovinghisorhermouthwatchingforthecasual- the casualty’s forehead. The rescuersealshisorhermoutharoundthecasualty’s nose mouth topreventtheinsufflated airfromescaping. The otherhandpressesdowngentlyon head back,bylifting thechinwithpalm ofhisorherhand,andclosesthecasualty’s cuer arethesameasformouth-to-mouthresuscitation. The rescuertilts thecasualty’s This methodcanbeeasierincertain situations. The positionsofthe casualtyandtheres- Mouth-to-nose EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 61 62 Before commencingcardio-pulmonary resuscitation ensure: pressions andtwelvebreaths (insufflations) shouldbeadministered. In thecourseofabout one minuteofthiscompressions-breathingcycle, 60chestcom- first caseandtwointhesecond. or tentimesinsixseconds,alternatingwithone inflationofthelungs(insufflation) inthe administered bytherescueriscompressionand releasefivetimesinaboutthreeseconds, spray resumingits initialshapeafter being compressed. The normalrateofmassagetobe When pressureonthesternumisreleased, heart fillsspontaneously, likethebulbofa heart againstthespine,causingbloodcontained inittoflow outintothearteries. flaccid likethebulbofaspray. Bypressingonthesternumitispossibleto squeezethe and thenpasses viatheaorta tothe organsandtissue.Whenthehearthasstoppeditis ry veins,andisevacuatedviathepulmonaryarteries tothelungs,whereitisoxygenated, the lungsoneitherside.Bloodarrivesatheartviapulmonaryandmajorcirculato- of thethoraxbetweentwobonesurfaces,sternuminfrontandspinebehind,with cle, whichcanbecompared tothepear-shapedbulbofaspray. Itislocated inthemiddle The principleofexternalheartmassageisbasedonthefactthatahollowmus- may haveveryseriousconsequences. circumstances thatanamateurrescuershould,asalastresort,take thisinitiativewhich rescuer mustbeconvincedthat,ifnothingisdone,thecasualtywilldie.Itonlyinthese son whohasmerelyfainted.Beforetaking thisaction,a be worsethanadministeringchestcompressionstoaper- breaths, beforebeginningheartmassage.Nothingcould checked severaltimes,after administeringseveralrescue ing suchadangerousprocedure. The pulsemust be that thecasualtyisinadeath-likestate, beforecommenc- does nothaveadequatetrainingmustbeabsolutelycertain spleen, stomach,heart). This meansthatsomeone who sternum, withdamagetotheunderlyingviscera(liver, heart massagedoesentail ariskoffracturingtheribsor there isabsolutelynoriskwithartificialventilation,external However, attentionmust bedrawntothefactthat,although citate thecasualty. tion isnotproperlyprovided,itwillbeimpossibletoresus- ventilation. Ifeitherartificialcirculationorventila- massage mustbecommenced,combinedwithartificial pulse isstillabsent,artificialcirculationbyexternalheart rescue breaths(mouth-to-mouthormouth-to-nose),the become detectable. If,after threeproperlyadministered sary toadministereffective artificialventilation,asaresultofwhichthepulsewilloften pupils areusuallydilated(mydriasis). The casualtyisinadeath-likestate. Itisfirstneces- The casualtyisusuallypale andhasceasedbreathing. There isnodetectable pulse. The (properly checked)pulseinthethroatorgroin. During evaluationofanasphyxiatedcasualty, thesignofcardiacfailureisabsencea matter whentheheartisnolongerbeatingorineffectively. ventilation, sothatthebloodincirculationisoxygenated,enough.Itaquitedifferent When thecasualtyisnolongerbreathingbutapulsecanbefelt,administeringartificial Heart massage EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY massage (reanimation) Cardio-pulmonary Fig. 13

BL - 3/A BL - 3/A chest) onthispart ofthesternum,withaxishandperpendicularto chest. The rescuerthenplacestheheelofhisorherhand(fingerslifted off thecasualty’s rescuer locatesthelowerthirdofsternum,whichisflatboneinmiddle knees touchingthecasualty’s arm. After thefirstthreebreaths,ifthereisstillnopulse, To dothis,therescuershouldkneeldownbesidecasualty’s shoulderwithhisorher sions withtwoinsufflations. administered bythemouth-to-mouthormouth-to-nosemethod,tencardiaccompres- It isthennecessarytoalternatefiveexternalcardiaccompressionswithoneinsufflation the pulseagain. The rescuershouldbeginbyadministeringthreeeffective rescuebreathsandthencheck out thepropermeasures willresultindeath. only incaseswhereadeath-like state persists. Insuchcasesaninabilitytocarry gerous andallowsofno error. Itcanhavetragic consequencesandshouldbeused ate artificialventilationwith externalheartmassage. This techniquecanbe dan- the commencementofeffective artificialventilation,arescuermayneedtoassoci- It isimportant tobeawarethatifcirculatoryarrest(nocarotidpulse)continuesafter he orshecanputintopracticewithouthavingto thinkfirst. It isimportant forarescuertobefamiliarwithartificialventilationmethods,which etc). tion, nomatterwherethepersonislocated(bed, roadside,rocks,boat,water, car, It isimportant toreactfastandgivemouth-to-mouthormouth-to-noseresuscita- must alsobegiveneffective artificialventilationwithoutdelay. one whoisbreathingtoofastorslowly, strugglingtobreatheorgaspingfor air often ceasesventilating(lackofmovementthechestandabdomen),butsome- It isimportant toknowhowrecogniserespiratoryfailure. An asphyxiating person These areessentialsteps, whichoften suffice toavoidasphyxia. entails rapidly: scious orexperiencingbreathingdifficulties byopening theupperairways. This is important toknowhowavoidrespiratoryfailureinapersonwhoisuncon- taught bynationalandinternationalrelieforganisations,suchastheRedCross.It they donotknowthebasicsteps tobetaken, asdescribedinmanymanualsand From amoralstandpoint, nooneshouldletanotherpersondiesimplybecause taken immediately. Respiratory failureisfrequentandcausesmanydeathsiftherightactionnot thatthepersonislyingonhisorherbackafirmsurface(e.g.ground) • thatthecasualtyshowsallsignsofadeath-likestate (unconsciousness, • clearingthemouthandthroat • prudentlytiltingbacktheperson'shead • layingapersonwhoisvomiting,bleeding fromthemouthorunconsciouson • looseningclothing • pulse, mydriasisofthepupils,whichnolongerreacttolight) blue orgreycolouring,respiratoryfailure,absenceofacarotidfemoral his/her side EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Conclusion 63 64 .. Classificationof burns 3.5.1 Burns 3.5 sub-cutaneous tissue, musclesorevenbones. involves blistering;athird-degree burnaffects merely reddenstheskin; asecond-degreeburn first-degreeburn tion ofthehealingprocess. A Depth. 1% isaddedforthegenitals. stomach andthebuttocksallcountfor9%, each thigh,arm,thechest,back, into percentages. The head,eachlowerleg, Wallace’s “ruleofnines”,whichdividesthebody it islifethreatening.Itcanbecalculatedusing Extent. Burns areclassifiedaccordingtotheir: chemicals. branes causedbyheat,fire,electricityorcaustic burnisdamagetotheskinormucousmem- A begins tobreatheagainspontaneously andregainsconsciousness. pulse, whichshouldbecheckedbetweenchestcompressions,restarts), thecasualty Resuscitation shouldcontinueuntilspontaneous circulationresumes(inthiscasethe checked byanotherrescuer). face, areductionindilationofthepupils,andresumptionpulsegroin(tobe The effectiveness ofheartmassagecanbeseenfrom thereturnofnormalcolourto to riseoninflationofthelungs. The effectiveness ofartificialventilationcanbeverifiedbywatchingforthecasualty’s chest ways, headtiltedback,etc.). tilation (removalofthecausebreathingproblem,ifaccidental, openingoftheair- as precisepossible,andtoobeyalltherulesnecessaryensureeffective artificialven- ried outbyanamateur. However, itisvital toseekhelppromptly, givinginformationthatis Although dangerousifperformedimproperly, thistechniquecansavelives,evenwhencar- three secondsorteninsix). The rhythmisslightlylessthanonecompressioneveryhalf-second(fivemovements in of fracturingtheribs.Iftheyareplacedtoolow, themassagewillbeineffective. the handsarepositionedcorrectly. Iftheyareplacedtoohighortotheside,thereisarisk the chestmustbecompressedby3to5centimetres. This involveslittlerisk,providedthat suddenly released,againwithasmooth,sharpmovement.Forthemassagetobeeffective, her bodytopressdown,withasmooth,sharpmovement,onthesternum.Pressureisthen exert pressure.Withelbowslockedandarmsstraight,therescuerusesweightofhisor sions. The otherhandisplacedontopofthefirst;itthiswhichmainlyusedto sternum. This handisforpositioningpurposesandmostremaininplacefivecompres- cause • location • depth • extent • The depthofaburndetermines thedura- The extentofaburndetermineswhether EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 1% forthehand Fig. 14 9% ofwhich 18% 18% 18% 1% fortheface 1% 9% ofwhich burns extent Calculation of

BL - 3/A BL - 3/A .. Themaintypesofburnsandrelatedrisks 3.5.2 burns whichgrowworseiftheareaisnotimmediatelyrinsedwithwater. and therespiratorysystem.Electricitycausesseriousinternalinjuries.Chemicalscause Cause. serious. Burnstothefaceentail ariskofdamagetothemucousmembranesandairways. Location. Table 7 (Table 7): Depending onthecause,location,extent,depthorpossiblecomplications,aburnmaybe nal injuries(haemolysis,renalinsufficiency, etc.). In thecaseofaburnbyelectrocutionvisible damageisnoguidetotheextentofinter- which pain isfelt. They mustalwaysberinsedwith largequantitiesofwater. Chemical burnsarealwaysserious. They take placeintentofifteen seconds,following Very severe Severe Minor verysevere,necessitating emergencyadmissiontohospital withoutwaitingfor • severe,necessitating medicalassistance • minor, notrequiringmedicalattention • Burn Fire causesburnswhichdonotcontinuetodevelop.Steam penetratesclothing a medicalopinion Burns tothegenitals, trunk,bodilyorifices,joints andextremitiesarethemost EIA ASPECTSOFDISASTERS MEDICAL The maintypesofburnsandrelatedrisks the followingfourtypes: First, secondorthirddegreeburnsof the followingthreetypes: First, secondorthirddegreeburnsof on ajoint,bodilyorificeortheface. square centimetres)andarenotlocated small insize(nomorethanafew First orseconddegreeburns,whichare caused bychemicalsorelectrocution affecting bodilyaperturesorjoints condition orwhoiselderly suffered byapersonwithdiabetesorheart 10% inachildand8%aninfant covering morethan20%ofthebodyinanadult, affecting ajointor bodilyorifice condition orwhoiselderly suffered byaperson withdiabetesoraheart less than8%inaninfant body inanadult,lessthan10%achildand extensive, butcoveringlessthan20%ofthe FIRST-AID PROVISION FIRST-AID AND EMERGENCY Description Asphyxia Infection Shock blistering ornecrosis infection, intheeventof extensive rednessoftheskin heatstroke, intheeventof shock, inallcases blistering infection, intheeventof redness oftheskin heatstroke, intheeventof Risks 65 66 .. Howtodealwithaburns 3.5.3 istered. The casualtymustthenbeevacuatedtothenearest hospital, whereadripcanbeadmin- Treat thecasualtyforshock,by: severeburns Very The followingsteps shouldbetaken: Severe burns The followingsteps shouldbetaken: Minor burns ing ofthemouthorthroat. thing todrink? Yes, iftheburnissevere;no,casualtyunconsciousorthereburn- is duetoaflameandclothingnolongerburning.Shouldthecasualtybegivensome- ing isstillburningoriftheburnduetoacausticchemical(acidalkaline);no, the burnwascausedbyaflame.Shouldwaterbepouredovercasualty? Yes, ifcloth- steam oracausticliquidifclothingisstillburning;no,nolongerburningand Should thecasualty’s clothingberemoved? The answerisyes,iftheburncausedby General precautions lift bothofthecasualty’s legs • wrapthecasualtyinacleansheet • givingbicarbonatedwatertodrinkifhe orsheisconsciousandfeelsthirsty • coveringhim/her • givingreassurance • lyinghim/herdown,onhis/hersideifunconscious • seekmedicalassistance • covertheburnwithasteriledressingor cleancloth • givebicarbonatedwatertodrink • treatcasualtiesforshock,bymakingthem liedown,reassuringthemandcov- • chemicalburnsshouldberinsedwithlargequantities ofwater • blistersshouldneverbebroken;applyanantisepticandcarefullycoverthe • someonewhoissuffering fromsunburnshouldbekeptintheshade • ering themiftheyfeelcold area withasteriledressing EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Generalobservations Triangular bandages 4.1.1 4.1 Bandages 4. tape isnotavailable. clean pieceofcloth,inplaceonaninjury(woundorburn),whenadhesiveplaster (joints, limbs,etc.)asanimprovisedmeansofkeepingasteriledressing,orfailingthat age. These different typesofbandagearemostoften usedonthesameparts ofthebody Depending onthebandage’s shape,itisreferredtoasatriangular, tailed orrollerband- expense andtroublebyusingbandagingtechniques. help fromthenearestchemist,nurseorevendoctor. Yet itiseasytosavetimeandavoid a minorwoundtothepalm ofthehand…allmayfindyouunequippedandobligedtoseek soreeyethatneedscovering,aboilinthe armpit, asprainedankle, first-aidkit. camper’s A side, mayoften beuntreatable withthelimitedequipmentavailableinahome,caror after fallingoff abicycle,forinstance), or which islocatedonajoint,particularly the inner Moreover, awoundwhichisfairlyextensive,evenifonlysuperficial(scratchesorgrazing when adhesiveplasterortape isunavailableorforimmobilisingajoint. addition totheusualequipment,asameanseitherforkeepingsteriledressinginplace For treatingminorwoundsorburnsandcertain jointinjuries,bandagesareanecessary ages: fewsimplerulesshouldbefollowedbyrescuerstoensurecorrectuseoftriangular band- A Triangular bandageshavemanyadvantages: towel oranysquarepieceoffabric)foldedintoatriangle.Examplesare: An improvisedtriangularbandageconsists ofalargepiececloth(handkerchief,napkin, theknotis,inprinciple, positionedontheoppositesidetoinjury; the two • whenbandaging limbs(themostcommonuse)thetipisalwaysplaced towards • theyareextremelyeasytoimprovise • theystay inplacewell,withouthampering movement;aproperlypositioned • theyareaneasymeansofkeepinginplaceadressing,orcleanpiececloth, • theycanbeappliedveryrapidly • theycanbeusedonanypart ofthebody • bandagesproducedbyrelieforganisations frompiecesofwovenorunwoven • luggage piecesoffabricfoundinatraveller’s • householdlinen,preferablyfreshlylaundered • used tohold thebandageinplace reefknotisthen corners aretiedtogether andthetipisthenfoldeddown. A the shoulderorhip bandage doesnotslipormoveoutofplace is tiedorwhenitremoved positioned directlyonawound,withoutcausing pain eitherwhen thebandage angles asthecorners. is referredtoasthebase,vertextiporpoint,andtwobase sides arebetween90cmand1mlong. To facilitate manipulation,thelongside of fabric,buttheidealbandageisanisoscelestriangle,inwhichtwoequal and individuallywrapped.Frequentlytheirsizeisdeterminedbytheinitialpiece angles offabricarefoldedsoastotake upaslittlespace aspossible,sterilised first-aidkits; thesetri- fabric, whichareincreasinglytobefoundinmembers’ EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 67 68 .. Placingtriangularbandages 4.1.2 above thejointsoasto secure thetip,whichisfoldedback. ners arecrossedoverat thebackofkneeorinhollowelbow, thenknotted the tiplyingonupper armorthethighpointingtowardsshoulder thehip. The cor- the elboworkneehalfbent. The triangleispositioned ontheoutersurfaceofjointwith the elbow),inwhichmovement mustbemaintained. The bandageshould beappliedwith Wounds aremostoften locatedontheoutersurface ofthejoint(thekneecaportip Elbow orknee passing itbetweenthelegs. The principleisthesame,butinsteadofpassing overashoulder, thetipissecured after Abdomen ing awoundtothethoraxthroughwhichairisleaking (a“blowing”wound). triangularbandage canbeusedinthiswaytokeepplaceathickpad ofmaterialseal- A middle ofthebandagebeforeitistightened. piece ofclothmustnaturallybepositionedbetweenthecasualty’s chest(orback)andthe steriledressingorclean the twocorners(alreadytiedtogether)ortocasualty’s belt. A stripofmaterial,suchasaclothbelt,isthenknottedtothetipand over oneshoulder. A The baseofthetriangleistiedaroundthoraxparallel tothewaist. The tipispassed The techniqueisthesamewhetherchestorupperbackbeingbandaged. Thorax knot withtheresultingrollofcloth. improved byfoldingthebaseoftriangleupoverafewcentimetresandconcealing woman tiesaroundherheadtoprotecthairwhendoingthehousework,canbe The appearanceofthesetwotypesbandage,whichcanbecompared tothescarfa Since theknotcannotbetiedonwound,bandagemustturnedround,asfollows: solution. lems, butadults aresometimesmorereticent,inwhichcaseuseofabandageisgood essary toshavetheareasurroundingwound.Childrenwillacceptthiswithoutprob- With awoundtothehairlineorscalp,useoftraditionaladhesiveplastermakesitnec- For example,whenbandagingaboilonthebackofneckproceedasfollows: or scalp-thebandagemustbeturnedround. Depending onthelocationofwound-backneckor, conversely, theforehead Head thetwocornersarewrappedaroundhead, withoutcoveringtheears(which • thebaseoftriangleispositionedonforehead, anditisthetipwhich • thetwocornersarewrappedaroundhead,preferablywithoutcovering • thetipisplacedonforehead • thebaseoftriangleispositionedonbackneck,holdingdress- • asteriledressingorcleanpieceofclothisplacedontheboilitself • with areefknot support thebandage)andtiedinasimpleknot;bandageisthensecured placed atthebackofneck tip, whichisitself thenfoldedbackandheldinplacewithareefknot ears toomuch,andarethenknottedinthemiddleofforehead,securing ing inplace EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A As forthethoraxorabdomen,tipiskeptinplacewithastripofbandagecloth. Shoulder orhip described above. corners arecrossedover atthefrontofankle,holdingtipinplace, thenknottedas towards theankle,and the baseiswrappedaroundfoot,covering the heel. The two ple) orthebandagemay beplacedontopofthefoot.Inlattercase, thetippoints The footmayeitherbeplacedflatonthetriangular bandage(restingonachair, forexam- Foot before beingknottedontheoppositesideto wound. material inplace,andthetwocornersarewound aroundthelimb,inoppositedirections, the tipisplacedunderupperjoint. The bandagemaintains thedressingorpieceof The principleisthesame.Oneofequalsides isleft parallel totheaxisoflimb,and Forearm, upperarmandthigh person moves. satisfactory, asthebandagemay becomeloosemoreeasilyandslipoutofplacewhenthe The secondtechnique,whichmakesitpossibletouseasmallersizeofbandage,isless Depending onthecircumstances: above theankle,iswoundinoppositedirection,movingupleg. ond sideiswoundaroundthelegtosecuretipofbandage. The firstside,positioned of theleg;thisleavesothersidepositionedhorizontally parallel totheground. This sec- The tipispositionedundertheknee,andoneofequalsidesplacedalongaxis Lower leg covered. The bandageshouldstopatthejoints (oneithersideofthewound),whichshouldnotbe bandage isturnedinsuchawaythatoneoftheequalsidesliesalongaxislimb. The rulethatthetipshouldalwayspointtowardsshoulderorhipisfollowed,but Parts oflimbs of theleg. ty’s belt,andthecornersaretiedhorizontally aroundthethigh,withknotonoutside The tipofthetriangleisrolledaroundstripbandageorclothcasual- is possibletocovereitherthehipitself orthefrontbackofpelvis. The principleisthesameasforshoulder. Dependingonthelocationofwound,it Hip cause discomfortwhenthecasualtywasseated). in frontonthechest,soasnottohamperarmmovement(ifitwastiedbackwould the triangleisthenpassed undertheoppositearmpitandtiedthere,orpreferablyslightly es overtheshoulder, withthebaseoftrianglefacingout. The stripsecuring thetipof The tipisrolledaroundastripofbandageorcloth,whichthenpositionedsothatitpass- Shoulder eachcornerisslippedseparately underonesideofthebandage,already • eitherthetwocornersareknottedtogetherhalf wayuptheleg,usingareef • wound aroundtheleg knot ontheoppositesidetowound EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 69 70 .. Placingtailedbandages 4.2.2 Generalobservations 4.2.1 Tailed bandages 4.2 can betiedtogetheroneithersideoftheareacovered bythebandage. ends ofthestripclotharetorntoformtwoor threestraps, known asthe“tails”, which tain aprotectivedressingorcleanpieceofclothinplaceonwoundburn. Then, the The principleisthatthecentralportionofstrip offabricisleft intact, tobeusedmain- tered inpractice: able width, dependingontheintendeduse,althoughthreewidths aregenerallyencoun- etc), fromwhichastripshouldbetorn. This stripofclothwillbeabout1mlongandvari- tailed bandageismadeoutofapiececloth(towel, serviette,oldshirt,pieceofsheet, A very usefulforstoppinghaemorrhages,whichrequirecompressionbandaging. suitable equipment(ahaemostatic pad orindividualdressing)isnotavailable,theycanbe kits, sometimesmadeoutofelasticisedmaterialandindividuallywrapped.Wheremore As withtriangularbandages,pre-cuttailed bandagesareproducedforinclusioninfirst-aid Their namecomesfromtheirshape. of clothonawound,whenanadhesiveplasterorstripisunavailable. These arealsoanimprovisedmeansofholdinginplaceasteriledressingorcleanpiece bandages, asaprotectionagainstdirtandinfection. sequent medicalexamination. The resultingmaskis a goodexampleoftheprimaryuse the bandagetoallowcasualtybreathe,andpossiblyalsosee,orpermitsub- of severeburnsordamagetothebonesface.Inthiscase,holesshouldbemadein Less frequently, atriangularbandagecanbeusedtocovercasualty’s face,intheevent Face the tipinplaceafter ithasbeenfoldedback. around thewrist;theyaresecuredfirstwithasimpleknot,thenreefholding wrist. The baseisfoldedoverthefingers,thencornersarecrossedandwrapped piece offabric. The handispositionedinthemiddleoftriangle,withtiptowards gers shouldbeseparated fromeachotherwithsteriledressings,oranaccordion-folded or burnsmayalsobepositionedbetweenthefingers. As aprecautionarymeasure,thefin- woundmaybelocatedinthepalm oronthebackofhand.Insomecases,wounds A Hand foot, securingthebaseinplace,thenwrappedaroundankleandknottedatfront. The baseiswrappedaroundtheheel,andtwocornersarecrossedoverontopof towards theankle. triangle withthetoestowardstip. The tipisthenimmediatelyfoldedback,topoint The footmayalsobeplacedontopofthebandage.Positioninmiddle at thebackofknee), thebandageistiedsomewhatdifferently. Depending ontheposition ofthecentralpiecematerial(onkneecap, orconversely Knee 20to30cmforthethoraxorabdomen • 15to18cmfortheforehead,backofneckorarmpit • 8to12cmforthenose,chin,eyeorear • EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A the backofkneeandtiedaroundthigh. lower leg(withtheknottofrontoroutside). The lowertails arealsocrossedaround upper tails, atthighlevel,arecrossedaroundthebackofkneethentied is alwaystiedwiththejointinabentposition. The centrekeeps thedressinginplace. The This isabump-shapedpart ofthebody. As withatriangularbandage,thetailed bandage Kneecap and overthescalp),asfollows: splint. The bandage’s roleisthat ofasupportwrappedaroundthehead(under thechin The firststepisthereforetopressthelowerjaw againsttheupperjaw, whichservesasa be studiedwithcare.Ifcapable, thecasualtyshouldhimselfhold thebrokenjawinplace. In thelattercase,sequenceofactionsinapplying thebandageisimportant andmust dressing inplaceonthechin,samedoesnot applyintheeventofafracturedjaw. Although animproperlytiedbandageentails littleriskwhenitisamatterofkeeping This bandageisfrequentlyusedforeitherchinwounds orfracturesofthelowerjaw. Chin pass overtheears,beforealsobeingtiedbehindhead. The lowertails, sometimesfoldedslightlytoformapocketofmaterial,arebackand upper tails arepassed aroundthehead,underears,thentiedatbackofneck. nor themouth. The centreofthebandagekeeps thedressinginplace onthenose. The thinstripofmaterialshouldbeprepared, sothatthebandagecoversneithereyes A Nose then knottedatthebackofhead. eyes, arepassed overtheupperones,thussecuringbandageattemples. They are tails (thosenearesttheears)aretiedunderchin. The lowertails, positionedabovethe a fairlywidebandage(about15cm). The bandageisplacedontheforehead. The upper This isoneofthemostdifficult bandagestotiebecause ofthehair. Itisadvisabletouse therefore becrossedovereachother. The foreheadisregardedasabump-shapedpart ofthebody. The twosets oftails should Forehead forehead. The lowertails aretiedaroundtheneck,butnottootightly. passed aroundtheheadoverears(whichserveasasupport),thentiedacross the neckisaflatpart ofthebody. The centresecuresthedressing. The uppertails are This typeofbandageisoften usedtoholdadressinginplaceorcoverboil. The backof Back oftheneck Head is inplace. arm benthorizontal, andmovementofthejointmustnotbehamperedwhenbandage The techniqueisthesameasforknee. The bandageshouldbeappliedwiththefore- Elbow the thigh,andlowertails aroundthelowerleg. The centreispositionedinthehollowofhalf-bentjoint. The uppertails aretiedaround Back oftheknee thetwoupper tails are passed overthetemples andtiedontop ofthehead • holdingthebandage withthetips ofthefingers,place centreunderthe • casualty’s chin EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 71 72 The othertails are tiedtwoaroundthearm,butnottootightly, andtwoaroundthethorax. of theshoulderoninjured side,thentiedundertheoppositearmpit. then thewholethingisplaced inthearmpit,andmiddletails are crossedoverontop The steriledressingorpad ofmaterialispositioneddirectlyonthe centreofthebandage, keeping amoistdressinginplace. Boils inthearmpitarefrequent,andthistype of bandageisvirtuallytheonlymeans ticularly mobile,withafairamountofhairand,often, atendency toperspire. in placewithadhesiveplasterortape isverydifficult onthispart ofthebody, whichispar- This isoneofthemostfrequentlyusedforms tailed bandage,sincekeepingadressing Armpit the bandagefromslippingdown,andthentiedaround thethorax. especially witha“blowing”wound. The uppertails arepassed overashoulder, toprevent With threetails, itisthecentraltail thatkeeps thedressing inplace.Itisthereforetiedfirst, on theoppositesideofthoraxtowound. With twotails, thecentrekeeps inplacethedressingorpieceofcloth,andtails aretied “blowing” wound.Itmayhavetwoorthreetails. tailed bandagecanbeappliedtothethoraxkeepinplaceadressingusedseal A Thorax are thentiedaroundtheneck,nottootightly. placed againsttheearanduppertails aretiedabovetheoppositeear. The lowertails direction, oneithersideofthecentre. The pocketoffabric,containing thedressing,is the centre.Forpockettobeproperlyformed,knotmustinfacttiedsame Then, pass theendoftail underandthroughthe“buttonhole”createdoneithersideof it towardsyou,perpendiculartothenearertail. is toplacethebandageflatinfrontofyou,pickupfurthesttail oneithersideandturn dressing. This isthemostdifficult part ofthisbandaging technique. The simplestmethod It isfirstnecessarytoformasmallpocketofmaterial,bepositionedovertheearand Ear then, after beingpressedagainstthehead,tiedwithothertail behindthehead. on thesideofinjuredeye,twisteditself (diagonally)tokeeptheuninjuredeyefree, is placedabovetheearandtiedbehindhead. The lowertail ispassed undertheear other eye. The eyetobeprotectediscoveredwithadressing. The centreofthebandage The difficulty hereliesintheneedtocoveronlyoneeye,withouthamperingvisionfrom Eye ous totiethelowertails tootightlyatthebackofneck. Care shouldbetaken, asintheeventofabilateralfracturelowerjaw, itisdanger- The extraturnaroundtheheadisthereforeintendedtosecurethemattemples. top ofthehead,inasverticalapositionpossible,buttendtoslipbecausehair. long enoughforthebandagetobesecured. The tails putinplacefirstaresupportedbythe forehead. Inthatcaseastripofmaterialshouldbeattached tooneofthetails, sothatitis The bandageissometimesnotlongenoughforthelowertails tobetieddirectlyonthe to holdthedressinginplaceonchin. By foldingbackthelowertails, asmallpocketoffabricisformedwiththecentre,intended thetwolowertails arefoldedback,crossedoveratthebackofneckand • then tiedonthecasualty’s forehead,after passing overtheear EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Generalobservations 4.3.1 Rollerbandages 4.3 is amoresophisticatedtechnique,andtheequipmentusedlessimprovised. ple) betweenthecentreoftailed bandageandthegauzeorcottonofdressing. This To keepadressingmoist,itisadvisabletopositionwaterproofbarrier(plastic,forexam- shoulder, foranarm,orthekneehip,a leg. When bandagingalimb, start fromthe lowestpointandmoveuptowardstheelbow or vents thebandage fromrollingonitself andslipping. ner, whichisthentuckedinandheldplacewiththesecondturn. The tucked-inendpre- bandageisalwaysbegunwithtwoturns,thefirstslightlyslanting soastoleaveacor- A cuer. The bandageisheld betweenthethumbandforefinger. The rollshouldpreferablybeorienteduppermost, thatistosaypointingtowardstheres- rollerbandagehastwoparts: theendsandrollitself, knownasthehead. A bandaging techniques. between 5and8metres,whichisoften notenoughtoallowpropertyingwithtraditional tain bandages,usuallyavailableinwidths of5,7and10cm,withanaveragelength Apart fromthethreeusualtypesofrollerbandage(cloth,gauze,elasticised),therearecer- Rules ofuse with thethumbstowardspersonrollingbandage. the forefingeroneitherside. The forefingerssupportthebandage,androllismoved roll betweenyourhandsfromunderneath,withtheendsecuredthumband five timestostart off therollofbandage,whichisreferredtoashead. Then holdthe After washing,thebandageshouldberolledupagain.Foldoneendoveronitself fouror The techniquevariesaccordingtothematerialused: Washing There areseveraltypesofrollerbandage: Equipment used immobilise joints, especiallyasprainedankle. dressing orcleanpieceofclothonawoundburn,butthesebandagesarealsousedto Like triangularortailed bandages,rollerbandagescanbeusedtoholdinplaceasterile elasticisedbandagesshouldbetreatedlikewool; boilingandahotironare • clothrollerbandagescanbeboiled,toensure thattheyareproperlysterilised; • elasticisedcrepebandages,whicharemulti-use ifproperlylookedafter • clothrollerbandages,whichcanbewashedandironedlikeordinarylinen. • single-usegauzerollerbandages,whicharethrownawayeachtimethedress- • fully rinsed,theyshouldbedriedflatbetweentwotowels. therefore tobeavoided. After beingwashedinasuitable detergentandcare- they arethenironedlikeordinarylinenbutwithaveryhotiron. or otherlargepiecesofcloth,butthisremainsexceptional sional reliefworkers.Suchbandagescanbeimprovisedbycuttingupsheets Despite theireaseofuse,theyarenotverycommon,exceptamongprofes- ing ischanged EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY 73 74 .. Placingrollerbandages 4.3.2 rollerbandage 5to8cmwideisbestsuitedforuseonthe elboworknee. A when taking part incertain sports, forexample. This figure-of-eightbandage stays inplacewellandallowsfreedom ofmovement,even around thethighorupper arm. are alwaysmadearoundthelowerlegorforearm, andtheeven-numberedturnsalways If thefirsttwoturnsarenumbered1and2,itcan besaidthattheuneven-numberedturns of theknee,andfinishedoff withtwoturnsaroundthethigh. figure-of-eightbandageisapplied,crossingoverattheback The techniqueisthesame. A Knee the shoulder. Lastly, thebandageisfinishedoff withtwoturnsaroundtheupperarm,movingtowards age iscrossedoverinthehollowofelbowand formsafigureeight. upper arm,eachtimeoverlappingtheedgeofpreviousturnby1or2cm. The band- end) start attheelbowitself, thenalternateturnsaremadearoundtheforearmand As withatriangularortailed bandage,thearmisbent. The firsttwoturns(securingthe An elbowbandagemustallowmovementandleavethejointasflexiblepossible. There arethreebandagingtechniques: Techniques and willnotserveits purpose. bandagewhichistoolosewilltendto slip the casualty’s pulseatthewristorankle. A tight, hamperingorblockingcirculation.Withabandagedlimb,itisrecommendedtocheck After applyingabandage,therescuershouldalwayscheckthatbandageisnottoo bandage canbesecuredinthreeways: All bandagesarefinishedbymakingtwoturns.Dependingontheequipmentavailable,a Elbow acrossedorfigure-of-eightbandageisused forjoints (elbow orknee);the • theherringbonebandageismoreeffective, particularly forthelowerlegor • spiralbandages,whicharetheeasiesttoapply. These areusedforparts of • bytearingthelaststripofbandageinhalflengthways;twocutendscanbe • bytuckingtheendinunderpreviousturn • withasafety-pin,insertedfromtoptobottom,securingtheendpreviousturn • turns formtheshapeofafigure8orletterX the roll,orbyguidingmovementofbandagewithafinger on thepointwherebandageisfoldedover, whilechangingthedirectionof itself ateachturn,toformaV-shape. This isdoneeitherbypressingthethumb thigh, butmoredifficult toapply. After twoturnsthebandageisfoldedoveron previous turn limb inaspiral.Eachnewturnofthebandagecoverspart (1/2to2/3)ofthe extended position.Beginbandagingbelowthewoundorjointandmoveup limbs orwhenajoint(elbowknee)hastobeimmobilisedcompletelyinthe tailed bandage. two resultingendsarethentiedtogethertosecurethebandage,aswitha tied inasimpleknottopreventthefabricfromfrayingortearingfurther. The EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A narrow(3 to5cm)bandageshouldpreferablybeused.It should beappliedasfollows: A Finger pass the bandagediagonallyacrossthebackofhandand right uptothe • beginwithtwoturns around thewrist,toprovideastable base forthebandage • positioned on thewoundtoprotectit) end ofthefingertobecovered (asteriledressingshouldalreadyhave been EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY Fig. 15 Placing rollerbandages 75 76 Thorax the headandunderchinfinishwithtwo turnsaroundtheforehead. with thehand,asecondbandageisoften required.Continuewithtwofurtherturnsaround of injury, thefoldispositionedonwounditself orontheoppositetemple. As isthecase ples, thenpass itunderthechinandovertopofheadtwice.Dependingontype bandage inplacewithafinger, positionedonaslant,andfolditover ononeofthetem- the bandagefromleft toright,beginningonthetempleoppositedressing.Hold The bandageisbegunwithtwoturnsaroundthe forehead,abovetheears.Start applying bandage shouldbeused. This techniquecanalsobeappliedtofracturesofthelowerjaw. To hold acompressionpad inplaceandstopahaemorrhage atthetemple,a5cmwide Temple eye). The bandageisfinishedbywindingtwicearound theforehead. diagonally, eachturnpartly overlappingtheprevious one(onthesideoppositeinjured injured eyethenpasses downtothecorneroflowerjaw. It iswoundaroundthehead the neckandpassed verticallyacrossthemiddleofhead. The bandagecoversthe around theforehead,aboveears,thenbandageisfoldedovertowardsbackof An eyebandageisappliedusinga5cmwiderollerbandage. Two turnsarewrapped lodged init,piercingthepupil. ing andlimitmovementortoavoidanythingpressingontheeyewhenaforeignobjectis tailed bandageis,ontheotherhand,preferablewhereaimismerelytopreventblink- A The eyesometimeshastobeheldfirmlyclosed,inwhichcaseatailed bandagewillnotdo. Eye 5 to8cm). It isthereforenecessarytouseasecondbandageofthesamekindandwidth (preferably It israrelypossibletocompleteaproperhandbandagewithoftheusuallength. be protectedwiththebandage. around thefingers,sotheyarefullycovered. The thumb isusuallyleft free,butcanalso The bandageisbeguninthesameway, starting atthewrist,andwrappingitseveraltimes essary thefingersareseparated, forexamplewithanaccordion-foldeddressing. The woundiscoveredandprotectedwithasteriledressingorcleanpieceofcloth.Ifnec- Hand safety-pins and supportedwithstraps overtheshoulders, toavoidslippage. More often thannot, abandageisimprovisedoutoflargepieces cloth, heldinplacewith Use ofsuchabandageis dangerousifthecasualtyhasabrokenriborinternal contusions. The thoraxisrarelybandaged withatraditionalrollerbandageinanemergency. bent andnotpulledtoofarback,whichwouldrapidlycausediscomfortorevenpain. Before starting toapplythebandage,rescuershouldensurethatfingerisslightly finishoff thebandagewithtwoturnsaroundwrist • returntothewristandcontinueapplyingbandageinafigure-of-eight • take thebandagetobaseoffinger, pass itbackontopandholdin • pass thebandageunderfingerandholditinplacewithmiddleof • the edgesofpreviousturnsbyabout1/3bandage’s width shape, movingfromthetipoffingertowrist,successivelyoverlapping turns atthetipoffinger place withyourforefinger;thebandageisthenheldinoneortwo the otherhand EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY

BL - 3/A BL - 3/A .. Removingabandage 4.3.3 "Encyclopédia Universalis" 443, 1983(Pan American HealthOrganization(PAHO), Ankle to useatriangularortailed bandage(2or3tails) ratherthanarollerbandage. To keepinplaceadressingusedtoseal“blowing”woundofthethorax,itispreferable SOS PremiersSecours, Publication N0443,1983). Organisation Mondialedela Santé, Disasters” 407, 1981;(Pan American HealthOrganization(PAHO), Organisation MondialedelaSanté, Bibliography andreferencedocuments it wasapplied. The bandageisthenwashed,driedand rolledup. passed fromonehandtotheother, unwindingitintheopposite directionfromthatinwhich attempt torollupthebandagedirectlywhileunwindingit. The ballofbandageshouldbe Once theadhesivetape orsafety-pinsecuringthebandagehasbeenremoved,donot of adhesivetape orasafety-pin,insertedfromtoptobottom. off bywindingtheendaroundankletwiceandisheld inplace,preferablywithtwostrips thus formingaregularherringbonepattern onthetopoffoot. The bandageisfinished and theankle.Eachfigure-of-eightoverlaps theedgeofpreviousoneby1or2cm, back tothelowerleg,andthenwrappedinafigure-8pattern severaltimesaroundthefoot The bandageisthenwrappedaroundtheendoffootatbasetoes,brought for aslightsprain. ing inplaceadressingmoistenedwithsurgicalspirit,often recommendedasatreatment with twodiagonalturnsaroundtheheelandinstep. This isaneasiermethodofkeep- on eachsideoftheankle,or, asforabandageofthekneeorelbow, itispossibletobegin Various techniquesarepossible. The bandagecaneitherbesupportedbythemalleolus, position. an emergencyasimplefigure-of-eight,ordoubleloop,canbeusedtoholdthefootinthis The mainpurposeofimmobilisingthejointistokeepfootatarightangleleg.In able, butanelasticisedorsemi-stretchoneisoften usedinpractice. clothbandageisprefer- As fortheelboworknee,aimhereistoimmobilisejoint. A without experiencingdiscomfort. a minorinjury, theyallowacasualtytocontinuewithhisorherusualoccupations, tion fromdeteriorating,protectalargewoundorimmobilisejoint.Intheeventof Depending onthecircumstances, theycanbeusedtopreventacasualty’s condi- wide varietyoffields. thinking andcommonsense.Bandagingtechniquescanproveveryusefulina Application ofatriangular, tailed orrollerbandageis,aboveall, amatterofcareful , PublicationN0407,1981). EIA ASPECTSOFDISASTERS MEDICAL “Le GrandMédical” , 1992. FIRST-AID PROVISION FIRST-AID AND EMERGENCY “L’Organisation desservicesdesoinssantéencas désastre” “Opérations desecourssanitaires aprèsunecatastrophe naturelle” , EditoServiceS.A.,Genève. Conclusion “Health ServicesOrganization intheEventofDisaster” “Emergency HealthManagementafter Natural , N° , N° 77 , 78 ne :Managementofhealthreliefsupplies Annex 2: Classificationcard Annex 1: Use ofLocalStocks uting thoseonhand. In general,themainproblemisnotacquiringlarge amounts of newsuppliesbutredistrib- of relativelysmallbulk. Emergency suppliesthatmustcomefromabroad areoften limitedtofewessentialitems include sanitary engineeringequipment,vehicles,food,constructionmaterials,andthelike. ment fortreatingcasualtiesandpreventingcommunicable disease.Latersupplieswill During thefirstweek,healthreliefsupplieswillconsist mainlyofdrugsandmedicalequip- immediate needs. purchase orrequisitionthem fromprivatesuppliers,andreallocatebudgeted fundstomeet plies availableandtheir locationandconditionfollowingtheimpact, havetheauthorityto that theHealthReliefCoordinator updateorestablish aroughinventoryofthetypessup- The effective mobilizationof all localsourcesofmedicineandmedicalsupplies willrequire EIA ASPECTSOFDISASTERS MEDICAL Classification card FIRST-AID PROVISION FIRST-AID AND EMERGENCY /sorce: PAHO, ScientificpublicationN°443, 1983/

BL - 3/A BL - 3/A pharmaceutical storesorgovernmenthospitals, ordonationfollowingamajorcatastrophe. plies tobemadeavailableimmediatelythroughlocalstockpiling,increasesininventory Every disaster-pronecountryshouldprepare inadvanceits ownlistofbasicmedicalsup- National ListofEssentialDrugs D D D D D developed incoordinationwithUnitedNationsagencies. ernments anddonorsshouldadopttheproceduresLeagueofRedCrossSocietieshas need touseauniformsystemformarkingorlabellingreliefconsignments. Recipientgov- Long experienceindifferent internationalreliefoperations hasshownthatallagencies andMarkingConsignments Procedures forLabelling D D D D D D guidelines shouldbefollowed: To maximizethebenefitofscarceinternationalassistance tothecountry, thefollowing Submitting RequestsforInternationalAssistance greenformedicalsuppliesandequipment. • blueforclothingandhouseholdequipment • redforfoodstuffs • asters are: Colour code Supplies willbeduplicatedifthesamelistissenttoseveraldonors. port. facilities areavailableandspecialhandlingarrangements canbemadeattheair- Perishable products andvaccinesshouldnotberequestedunlessrefrigeration cost. Requests shouldbelimitedtodrugsofproventherapeuticvalueandreasonable disease. the sizeofaffected populationandtheanticipated occurrenceoftraumaand “vaccines” mustbeavoided. The amounts requestedshouldbecompatible with (e.g. tablets orsyrup).Vague requests for“antidiarrhealdrugs,”“antibiotics,”or The requestshouldclearlyindicatetheorderofpriority, amounts, andformulation this simplifiesandexpeditesprocurementshipping. Potential donorsshouldbeaskedtoprovidelargeamounts ofafewitemssince ings willresult. gency internationalrequests, forotherwiseduplication,confusion,andshortcom- singlegovernmentofficial shouldbemaderesponsibleforchannellingemer- A document allthedetails necessaryfor safe transportandeaseofhandlingatthe Advance noticetotheconsignee andHealthReliefCoordinator Contents unloading devicesarerarely availableatthereceivingend. dle (ideally, 25kg;uptoamaximumof50kg)since mechanicalloadingand Size andweight Englishshouldbeusedonalllabels(stencilledmarkings) • temperaturecontrols • expirationdateoftheproduct • Labelling EIA ASPECTSOFDISASTERS MEDICAL . Reliefsuppliesshould always bepacked bytype inseparate containers. . The labelshouldprovideessentialinformationon: . The coloursusedforthereliefsuppliesmostoften requiredafter dis- . Containers shouldbeofasizeandweightthatonemancanhan- FIRST-AID PROVISION FIRST-AID AND EMERGENCY . To cover inone 79 80 Assistance mayberequestedfromtheUnitedNationsorbilateralsources. is ofparticular value,referencelaboratorytestingandrecertificationshouldbearranged. drugs remainsafeandpotentformuchlonger. Whenconsignments arelargeandthedrug Expiration datesareveryconservativelysetfor some drugs,andwithsuitable storagethe Some drugsclosetoorpast theirstated expirationdatesareoften donatedoroffered. Expired Drugs,Perishable Products cedures devisedtohandlethem. Despite anysuchpolicy, thearrival ofunsolicitedsuppliesshouldbeanticipated andpro- tor abroadshouldbearrangedbeforeshipment. When possible,professionalinspectionofmedicalsuppliescollectedfromtheprivatesec- should beinformedofthepolicy. ernment. Nationalrepresentatives abroadandlocaldiplomaticmissionsaidagencies sent exceptinresponsetoaspecificrequestfromorafter negotiationwiththenationalgov- plies. This policystatement shouldingeneralsuggestthatinternational assistance notbe ing governmentshouldadoptafirmpolicyaboutacceptingunsolicited,unannouncedsup- Unsolicited drugsuppliesareoften amajorprobleminlargereliefoperations. The receiv- andDistribution ofIncomingSupplies Inventory D ment besenttodonorsasquicklypossibleafter consignments arereceived. Acknowledgement bythereceivingcountry. Itisimportant thatanacknowledge- instructionsorspecialrequirements forhandlingandstoringthesupplies;in • estimatedtimeofarrival(ETA) • agent,includingthenameofpersontobecontacted inthe thecarrier’s • typeofinsurance,namecompany, etc. • valueinthecurrencyofsendingcountry • adetailed listofcontents, includingweight,dimensions,andnumbertype • methodoftransport,including(whereapplicable)thenamevesselor • nameofconsignee • nameofsender • receiving end,thefollowinginformationisessential: ing orreceivingcountryboth most instances a receiving country of packages flight numberandits dateandportorairportofdeparture EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID pro forma AND EMERGENCY invoice isrequiredbytheauthoritiesinsend-

BL - 3/A BL - 3/A Annex 3: Medical care survey form Medicalcaresurvey Annex 3: EIA ASPECTSOFDISASTERS MEDICAL Medical caresurveyform FIRST-AID PROVISION FIRST-AID AND EMERGENCY /sorce: PAHO, ScientificpublicationN°443, 1983/ 81 82 EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY /sorce: PAHO, ScientificpublicationN°443,1983/

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BL - 3/A BL - 3/A EIA ASPECTSOFDISASTERS MEDICAL FIRST-AID PROVISION FIRST-AID AND EMERGENCY /sorce: PAHO, ScientificpublicationN°443,1983/ 91 It is strictly forbidden to reproduce any part of this publication for collective use without prior formal permission from the authors. Reproduction forbidden in any form or by any means (printing, photography, photocopy, scanner, etc.). Photographic credit: all rights reserved.

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