Instructor In-Depth Resource

Instructor In-Depth Resource
Instructor In-Depth
© 2011 EMS Safety Services, Inc.
Instructor In-Depth Resource
Table of Contents
AED Use ....................................................................................................................... 2 Allergic Reactions......................................................................................................... 9 Assessing a Victim ..................................................................................................... 11 Bites and Stings ......................................................................................................... 19 Bleeding...................................................................................................................... 29 Burns .......................................................................................................................... 38 Chest and Abdominal Emergencies ........................................................................... 42 Choking Management- Adult, Child and Infant .......................................................... 48 Cold Emergencies ...................................................................................................... 53 CPR ............................................................................................................................ 56 CPR/AED Overview ................................................................................................... 71 Dental Emergencies ................................................................................................... 77 Diabetic Emergencies ................................................................................................ 79 Eye Emergencies ....................................................................................................... 85 Head Injuries .............................................................................................................. 88 Heart Attack and Heart Disease................................................................................. 93 Heat Emergencies .................................................................................................... 100 Legal Issues ............................................................................................................. 104 Muscle, Bone and Joint Injuries ............................................................................... 108 Neck and Spine Injuries ........................................................................................... 115 Poisoning .................................................................................................................. 117 Positioning and Moving a Victim .............................................................................. 123 Respiratory Emergencies ......................................................................................... 129 Responding To Emergencies ................................................................................... 135 Seizures.................................................................................................................... 141 Shock Management ................................................................................................. 146 Stroke ....................................................................................................................... 148 Traumatic Injuries ..................................................................................................... 154 1
In most cases of adult cardiac arrest, a shock from a defibrillator is required to reset
the heart into a normal, beating rhythm. The sooner a shock is delivered, the more
likely it will work and the odds of survival are increased. Delays to defibrillation
decrease the odds for survival of SCA. 1,2
The Automated External Defibrillator (AED) can be used by citizen responders
before the arrival of EMS. This section teaches responders how to use an AED and
when to integrate an AED into a CPR rescue.
There are three basic steps to AED use that are performed no matter what AED type
is available to the responder:3
1. Turn on AED
2. Follow AED Prompts
3. Resume chest compressions immediately after the shock
The likelihood of an AED being in the same room as an SCA victim is low. Most of
the time, the AED will have to be retrieved quickly and brought back to the
emergency scene. If two responders are available, one starts CPR and the other
calls 9-1-1 and retrieves the AED. Providing effective CPR in the time between
collapse and AED use provides oxygen to the brain and heart, extending the time for
successful defibrillation.1 As a general rule:
 Adults: Use an AED as soon as it is available
 Children/Infants: Use an AED after about 2 minutes of CPR (5 cycles of 30:2)
Minimize interruptions to compressions as much as possible. One rescuer continues
compressions while the other rescuer readies the AED for use. Only stop CPR when
the AED prompts the responder to stop.
How to Use an AED
First power on the AED, then expose the chest. If needed, use the scissors that
come with the AED to cut the victim’s clothes. Cut around the hands of the
responder doing CPR so he or she does not have to stop compressions.
Power on the AED
Place the AED near the victim’s head and power on the AED. AEDs turn on in
different ways, depending on the model. A responder may need to push the power
button, lift up the hard cover, or pull the handle on the AED pads cartridge.
Once the AED is powered on, it will begin prompting. It is important to turn on the
AED before connecting the pads.
Follow the Verbal and Visual Prompts
All AEDs have verbal prompts to guide the rescuer. AEDs also use indicator lights
and lit symbols to show the rescuer visually what to do. Some AED models have text
screen prompts as well as verbal and visual indicators.
Attach Pads
When the AED is powered on it will do a brief self-check and then prompt the
rescuer to connect the pads to the victim’s bare skin. One pad is placed on the upper
right chest between the collarbone and nipple. The other pad is placed on the left
side of the chest, over the rib cage a few finger widths under the victim’s armpit
Follow the pictures on the pads for placement. Peel the first pad from the backing
and press it firmly to the victim’s skin. Repeat the process with the second pad.
Stop CPR When Prompted
Only stop CPR when prompted by the AED. It will need to analyze the heart rhythm
and determine if a shock is needed. The AED can’t analyze the rhythm while chest
compressions are being performed. If the first responder doesn’t hear the prompt to
stop CPR, the second responder may have to direct him to stop.
Switch Places
When the AED is assessing the heart rhythm, there is a brief pause in CPR. If there
are two rescuers, switch positions during the pause (every two minutes) so that the
rescuer operating the AED can take over compressions after the shock and the first
rescuer can rest. Switch every two minutes (or every AED pause) to reduce
responder fatigue.3
Clear the Victim
The AED will advise responders if a shock is required. Because electricity from an
AED shock can travel from the victim to a bystander, responders will need to visually
and verbally confirm that no one is touching the victim or the victim’s clothing.
To clear the victim before a shock, scan up and down to confirm no one is in danger
of being shocked. If the victim is wearing oxygen, move the mask or canula at least
three feet from the victim’s face. As you scan state loudly, “Clear!” or “Everybody
Press the Shock Button
Press the shock button when you are sure everyone is clear from the victim. The
victim will have a brief muscular contraction, and then relax. If an AED shock is not
advised, the AED will prompt responders to resume CPR.
Not all AEDs have a shock button. Some AEDs will shock automatically. Be sure that
the victim is clear before the AED shocks.
Immediately Resume CPR
Responders should be ready to resume CPR immediately after the AED has
delivered the shock. The AED will indicate when it is safe to touch the victim and
start CPR. Always resume CPR starting with chest compressions.
Some models will help rescuers stay on pace with an automatic metronome for
compression pacing. Continue to follow the prompts. Do not stop CPR unless the
victim begins to move or the AED prompts you to stop CPR.
If the victim begins to move and is breathing normally, keep the AED pads
connected. Monitor breathing until help arrives, and resume CPR/AED use if
AED Sequence
Power on the AED
Attach Pads
Stop CPR (when prompted by the AED)
Clear the Victim
Press shock button (unless shocks automatically)
Resume CPR
AED Use on a Child or Infant 4
Age for AED Use:
A child is between the ages of 1 and 8, or weighs less than 55 lbs.
An infant is less than 1 year old.
AED Use on a Child: Use pediatric pads or equipment if available. If pediatric AED
pads or equipment are not available, use adult pads or equipment.
AED Use on an Infant: It is best to use a manual defibrillator on an infant. If a
manual defibrillator is not available, use pediatric pads or equipment. If pediatric
AED pads or equipment are not available, use adult pads or equipment. Adult AEDs
have been successfully used on infants with few side effects and good outcomes.
Follow local protocols for AED use on an infant.
Pad Placement for a Child or Infant: Do not let AED pads touch or overlap. If the
victim is so small that the standard AED pad placement will not work, place one pad
on the front center of the chest and the other pad on the back, ‘sandwiching’ the
chest between the two pads.
Special Considerations
Very Hairy Chest
A lot of chest hair can limit the contact between the electrode pads and the skin,
making it difficult for the AED to read the cardiac rhythm and deliver a shock. Use a
razor to quickly shave a very hairy chest in the area of electrode placement before
applying pads. If the electrodes have already been placed and the AED cannot
analyze the heart rhythm, remove the pads with a quick movement to remove chest
hair, and apply a new set of electrodes.
Implanted Devices
Some people have electrical devices, such as a pacemaker or an Automated
Implantable Cardioverter Defibrillator (AICD or ICD), surgically implanted into their
bodies. These devices may initiate the electrical impulses for the heart, or internally
They appear as a small, hard, raised lump about 1 ½ inches in diameter. They are
found under the skin of the chest or abdominal area. Most people will have a small
scar where the device was inserted.
The presence of an implanted device does not prevent the use of an AED. However,
special care should be used when applying the electrode pads to the chest. Do not
place a pad directly over an implanted device. Adjust the pad location to place it at
least 1 inch away from the device to avoid interfering with the delivery of a shock
from the AED.
If a person’s ICD does activate, the rescuer will see the person react similarly to the
reaction to a shock from an AED. The ICD will not harm the rescuer. After 30-60
seconds, continue use of the AED according to CPR protocols and AED prompts.
Medication Patches
Transdermal medications are designed to enter the bloodstream by absorption
through the skin. The medication is embedded in an adhesive patch that is applied to
the skin. The medication is absorbed by the skin and delivered into the bloodstream.
Using the AED over a patch can burn the skin or block the electrical impulse
delivered by the AED. Use a gloved hand to remove any medication patches that
interfere with pad placement and wipe the skin clean with a towel before applying the
Preparing for a Cardiac Emergency
Safety-conscious companies and organizations have an internal emergency
response system that includes regular training to maximize its effectiveness. The use
of an AED should be part of the practice and training. The components of the
emergency response system should include:
1. Recognition of the emergency.
2. Internal notification of the emergency to a central dispatch location.
3. Activation of the corporate emergency response plan.
4. External notification (9-1-1) and dispatch of the internal response team to the
victim with an AED.
5. Direction of EMS to the victim.
Storage, Maintenance and Inspection
AED owners and operators should ensure the AED is ready for use at all times.
Proper storage and inspection should be part of every AED program.
An AED should be kept in an accessible area, close to a phone. If you are locking up
the AED, be sure that every trained rescuer has a key. Store an AED at room
temperature, protected from the elements. Follow manufacturer’s guidelines for
An AED can be stored in a specially-designed storage cabinet with a transparent
door for easy visibility. The cabinets are available with alarm and light strobe, if
It’s important to understand all of the operational components of the AED. Review
the User’s Manual to become familiar with the parts, their storage location, and their
normal operation. Follow manufacturer’s guidelines for recommended individual AED
Most AEDs perform a self-test every day or week and each time the unit is activated.
If service is required, the AED should activate an alarm. Refer to the manufacturer’s
guidelines for recommended AED inspection and testing. Use an inspection log to
record regular inspection of batteries, pads, status indicator and service indicator.
Ensure that expiration dates are current, and there is no visible damage.
Medical Direction
An AED is a medical device and requires a doctor’s prescription. Most AED
programs are overseen by a physician who will write the prescription, approve the
training, help develop an emergency response plan, and review AED events to
provide quality assurance and improvement.
If you perform regular maintenance and inspection of the AED, it is unlikely that the
unit will fail during an emergency. If the unit identifies a problem during AED use, it
will prompt you to quickly troubleshoot the problem. Have a second trained rescuer
continue CPR while you are attempting to troubleshoot the problem.
AED troubleshooting prompts can include:
 Check pads
o Press down firmly on the pads, or replace the pads with a spare set.
o Check the pad connection to the AED.
 Low battery
o Replace the battery and ensure connections are intact.
o Even in a low battery condition, an AED may be able to provide several
o Refer to the AED manufacturer for more information.
 Movement
o Movement can disrupt the analysis of the heart rhythm.
o When the AED is analyzing, make sure that no one is touching the
victim or cables.
o If the victim is in a moving vehicle, stop the vehicle.
 Connect electrodes
o Check the electrode pad connector to the AED.
o Check the pads.
AED Safety
Clearing the Victim
Always ‘clear’ the victim before delivering a shock. Look up and down the person
and loudly state, “Clear!” or “Everybody clear!”
Water is a great conductor of electricity. Defibrillating a person who is lying in water
could cause burning or shocking of rescuers or bystanders. Move a person who is
lying in a puddle or pool of water to a drier area prior to AED use. Ensure that the
rescuer or bystanders are not standing in water during AED use. Rain, snow, or
small amounts of water will not interfere with safe AED use.
Water or sweat on a victim’s chest can interfere with defibrillation. Quickly dry the
victim’s chest before attaching the pads to ensure that the pads attach securely, and
that the electrical shock travels through the heart and not over the wet surface of the
Always consider the environment during any rescue situation. The use of an AED in
a combustible environment where fumes or gases are present can be hazardous.
Some people may use oxygen at home or out in the community. Concentrated,
medical oxygen can be dangerous because it is combustible.
If a person is wearing oxygen, turn it off and remove the mask or cannula from the
person’s face before using the AED. If oxygen is being used with rescue breaths,
move the delivery device several feet from the victim before delivering a shock, then
resume rescue breaths with supplemental oxygen.
Allergic Reactions
The immune system is our body’s defense mechanism against foreign materials
(antigens). It uses white blood cells (cell-mediated immunity) and proteins in the
blood called antibodies (humoral immunity) to attack the invaders. White blood
cells, also known as T lymphocytes, or T-cells, organize the immune system’s fight
against infection and directly attack the antigens. Antibodies, which include
Immunoglobulin A, D, G, M and E, protect the respiratory and gastrointestinal
systems. An allergen is an antigen that produces an allergic reaction.
An allergy is an overreaction of your body’s immune system to a substance
(allergen). Approximately 50 million Americans suffer from allergies. When a
person comes in contact with an allergen, the body releases a massive amount of
histamine, a chemical that causes allergy symptoms. More severe allergic
reactions may occur depending on the amount of exposure and the sensitivity to the
allergen. Allergic reactions tend to get worse with each subsequent occurrence. The
quicker the onset of symptoms, the more severe the reaction.
Allergic reactions can cause the following conditions:
 Allergic rhinitis: Sneezing, nasal congestion, coughing
 Asthma: A more serious condition that causes wheezing and shortness of
breath due to narrowing of the airways and increased mucus production.
 Skin allergies: Rashes, oozing blisters, hives (red raised lesions with itching
and swelling) and contact dermatitis (poison ivy)
 Food allergies: Gastrointestinal disturbances
 Anaphylactic shock: The most severe result of an allergic reaction, causing
swelling in the airways and a sudden drop in blood pressure. Anaphylactic
shock is life threatening, and requires immediate emergency medical care.
Death can occur within minutes.
A person should never self-administer antibiotics prescribed for a friend or family
member due to possible allergic reactions.
Allergens can be inhaled, swallowed, or simply come in contact with the skin.
Common allergens include pollen, mold spores, household dust, pet dander, dust
mites, insect sting venom, shellfish, dairy products, drugs, eggs, chocolate, nuts and
poisons. Although allergies to any antigen can result in anaphylaxis, peanuts, bee
sting venom and penicillin can often cause a life-threatening reaction in highly
allergic people.
Food is the leading cause of anaphylaxis in the community. There are about 30,000
food-induced anaphylactic reactions treated in the emergency department each year
in the U.S. As many as 200 people die each year from anaphylaxis. When signs
and symptoms involve more than one body system
cardiovascular, skin, gastrointestinal), suspect anaphylaxis.
Signs and Symptoms:
 Hives, rashes, itchy skin
 Swollen face, eyes, throat, tongue
 Sneezing, difficulty breathing, coughing, congestion
 Stomach cramps, vomiting and diarrhea
 Dizzy, confused, agitated or anxious
 Flushed or pale skin
 Tightness in the chest and throat
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Assist the victim with use of his or her epinephrine auto-injector if the victim
requests help, you are trained and your state and workplace allow it.
4. Reassure the victim.
5. If allergic reaction is from a bee sting, quickly scrape off stinger with a
straight-edged object.
Epinephrine Auto-Injector8
People with known allergies may carry an epinephrine kit. Epinephrine is the most
commonly used drug for emergency treatment of anaphylaxis (severe allergic
reaction), because it quickly relaxes smooth muscles in the lungs to ease breathing,
constricts blood vessels and stimulates the heartbeat to maintain blood pressure,
and reverses swelling around the face and lips. The sooner it is given, the more
effective it is in stopping the reaction. Look for medical alert tags.
The EpiPen Auto-Injector is an example of a disposable drug delivery system
prescribed by a physician and carried by people who have the potential for fatal
allergic reactions. The EpiPen contains a concealed needle that a victim can use to
self-administer epinephrine for emergency treatment of a severe allergic reaction. It
can be used through clothing or on bare skin. Parents and caregivers of at-risk
children should be trained in its use.
Using an epinephrine auto-injector:
1. Carefully remove cap and press firmly against the thigh; hold for 10 seconds.
Handle carefully.
2. Rub the injection site for about 10 seconds.
3. Go to the nearest hospital emergency department for further care and autoinjector disposal.
Assessing a Victim
Skills in scene and victim assessment could protect the life of both victim and
rescuer. Teach students a systematic method with a logical sequence to determine
the seriousness of the emergency and what actions to take. There are three parts to
a basic first aid assessment.
Scene Size-Up
The scene size-up is a quick assessment of the scene for hazards, number of
victims, determination of what happened (mechanism of injury) and what resources
are needed to help. Before taking action, rescuers should size-up the scene.
Size-up the scene for safety
The very first step in any emergency is to take a look around and check for hazards.
Rescuers who are killed or injured only increase the number of victims and amount
of confusion at an emergency scene. Rescuers need to make a determination on
whether or not it is safe to act. Consider the need for specialized training or
equipment. Before approaching the victim assess for: 9,10
 Fire or danger from explosion and smoke
 Toxic substances, hazardous materials, low oxygen areas
 Vehicles that are unstable or positioned to be hit by other traffic
 Fuel or chemical spill
 Downed power lines, electricity
 Unstable surfaces – slope, water, ice
 Violence, hostile crowds, weapons
 Environmental hazards – rain, swiftly moving or rapidly rising water, extreme
heat or cold
 Contagious disease
Even simple clues can be a sign of trouble or an emergency; rescuers should use as
many senses as possible when assessing a scene for safety. 11
Look: Stalled vehicles, overturned furniture or potted plant, spilled medicine
container, broken glass, smoke/fire, multiple victims
Listen: Screams/yelling, moans or calls for help, breaking glass, clashing
metal, screeching tires, sudden loud voices, gunshots
Smell: Odors that are unrecognized or stronger than usual, burning smell
Exercise caution. Consider the need for specialized rescue training, protection or
equipment. If unsure if the scene is safe, do not approach the victim. Instead call 91-1 and bring the professionals to the scene.
Size-up the victims
After confirming the scene is safe, try to determine how many victims, and what has
happened to them. Look for more clues at the emergency scene to identify the
potential for serious injury or illness. The clues from an emergency scene may be the
only way to piece together what happened.
Identify the Number of Victims
Rescuers should identify the number of victims and potential resources. Look
carefully for more than one victim. If one victim is bleeding or screaming, you could
easily overlook an unresponsive victim, infant or small child.
Consider resources on the scene such as bystanders, first aid kits, personal
protective equipment, cell phone, etc. Deploy bystanders to call for help, control
bleeding, monitor scene safety, locate friends or family of the victim, get an AED, or
just hold someone’s hand.
Mechanism of Injury
The mechanism of injury is an evaluation of the forces that caused an injury to help
you determine the potential for serious injury. 9,12 For example, which mechanism of
injury has the greater potential for underlying, life-threatening injuries: a broken arm
from a bike fall or a broken arm from a bike vs. car accident? Inspect the scene and
gain information from the victim, family or bystanders to determine the mechanism of
A bit of common sense and a sharp eye are needed to help determine the
mechanism of injury. Take the following example:
There is a car crash involving two vehicles, one large, and one small.
The large vehicle has one driver, no passenger and minimal damage to
the front fender. The driver is in the vehicle on his cell phone with his
seat belt on. The smaller vehicle has severe front-end damage, the
windshield is cracked and there appears to be only the driver who is
slumped over the wheel bleeding from the forehead.
Which vehicle appears to have suffered the greatest amount of force from the
collision? Is it possible that the cracked windshield has something to do with the
head injury? Is there damage to the steering wheel that could indicate serious chest
injury or no seat belt? It is easy to determine from the above example which victim
has suffered the worst injury and needs your immediate attention.
Suspect serious injury in the following situations:10
 Vehicle accidents
 Rollover of vehicle
 Vehicle vs. pedestrian collision
 Ejection from vehicle
 Death in the same vehicle
 Motorcycle or bicycle crash
 Falls greater than standing height
Explosion or gunshot
Assessing the mechanism of injury provides clues to the rescuer about the cause
and potential seriousness of a victim’s injuries; it may also be beneficial in
determining the presence of internal injuries.9
Nature of Illness
When the emergency is not injury-related, quickly determine the nature of the illness
to identify the potential seriousness and what actions to take. Use the victim, family
or bystanders on the scene to help identify the nature of the illness.9 This may be
performed during the Initial Assessment.
Check the scene for clues such as prescription bottles, a medical alert tag, fallen
ladder, broken glass, drugs or alcohol. Ask the family about the victim’s medical
history. A person having shortness of breath may have a history of asthma and may
need the rescuer to help locate his or her inhaler.
Unusual appearances or behaviors that may provide insight include: 11
 Trouble breathing
 Clutching the chest or throat
 Slurred, confused or hesitant speech
 Unexplained confusion or drowsiness
 Sweating for no apparent reason
 Unusual skin color
If the rescuer is unable to determine whether the cause of the emergency is injuryrelated or medical in nature, he or she should assume the cause is traumatic injury.
Support the person in place, assess responsiveness, breathing and circulation, and
get help to the scene.
Activating EMS
When sending a bystander to call 9-1-1, be sure to identify one or two people by
name or description (i.e., “You in the blue shirt.”). Don’t just shout at a crowd to call
9-1-1, because no one may go, or more people than needed may call and tie up
dispatchers unnecessarily.
Give the instruction to go call 9-1-1 and come back and let you know it has been
done. If the victim is unresponsive, also instruct bystanders to get the AED. If you
are alone with an unresponsive adult victim, activate EMS first before beginning
care. Situations when EMS should be activated include but are not limited to:11,13
 Altered mental status or unresponsiveness
 Difficulty breathing or abnormal breathing
 Chest discomfort
 Severe or uncontrolled bleeding
 Pressure or pain in the abdomen that does not go away
Severe, persistent vomiting, vomiting blood or passing blood in the stool
Severe allergic reaction
Pregnancy emergency
First time seizure, seizure for more than 5 minutes, or more than one seizure
Diabetic emergency such as a seizure or strange behavior
Sudden severe headache, slurred speech, arm or leg weakness, especially
on one side of the body
Head, neck or back injury
Possible broken bones
Fall greater than standing height
Fire or explosion
Downed electrical wires
Swiftly moving or rising water
Presence of poisonous gas
Vehicle collision
Victims who cannot be moved easily
Any time you are not comfortable with a medical or dangerous situation
Critical burn
Suspected poisoning
In large buildings or public gathering places it may be helpful to send a bystander to
the entrance to guide the EMS personnel more quickly to the scene. Many offices
and public venues have prearranged meeting places for the EMS; advise security (or
other administration) of the emergency to reduce delay.
Remember to treat the victim in the position found. Only move a victim to provide
essential care, or if there is danger to the victim and rescuers. Instruct bystanders
not to move the victim.
Initial Assessment
The initial patient assessment is used once the rescuer is at the victim’s side. It is
used to assess the level of response, identify and treat any life-threatening
conditions, and determine the victim’s chief complaint.
1. Assess Response
Approach the victim from the side and gather a general impression.
Unresponsive: If the victim appears unresponsive, tap the shoulder and shout, “Are
you okay?” If there is little or no response, have someone call 9-1-1 (activate EMS),
get the first aid kit and AED. Go call yourself if you are alone with an adult victim.
Responsive: Introduce yourself, tell the person you are trained in first aid, and ask if
you can help. Ask questions to determine what happened. What is the chief
2. Assess Breathing
Unresponsive: Look up and down the victim for breathing.
If no breathing or only gasping, begin CPR if you are trained, or chest
compressions alone if you are not trained.
If breathing, continue assessment and closely monitor breathing.
Responsive: Check for the quality, rate and effort of breathing.
 Listen for noisy breathing. Is the airway clear?
 Can the person speak?
 Is the victim speaking in broken sentences, or working hard to breathe?
3. Assess Head-to-Toe
 Assess circulation and appearance using a systematic head-to-toe approach.
o Bleeding, skin temperature and color are indicators of circulatory
 Look for obvious signs of injury (bleeding, bruising, burns, twisted limbs).
o Control bleeding with direct pressure.
 Assess appearance
o Color, sweating, temperature, movement, position
 Treat life-threatening conditions first.
o Prioritize problems with responsiveness, airway, breathing, and
o When you find a life-threatening condition, stop the assessment and
give care.
4. Look for Medical Alert Jewelry
 If no signs of injury, look for a medical alert tag, bracelet, or shoe tag.
 Might indicate heart condition, diabetes, seizure disorder, asthma, allergy, etc.
If it is unclear whether the victim is injured or ill, treat as an injury. Support the head
and neck in the position found by placing your gloved hands at his or her ears while
waiting for EMS.9
S: Considerations during an assessment:15
Speak slowly and clearly, but do not exaggerate your speech.
Make movements slow and deliberate.
May answer questions slowly; be patient.
o Medications or fatigue may slow response.
May be difficult to differentiate between new problem and symptoms from a
chronic medical condition.
o e.g. Is mental confusion from hypoglycemia or from a previous stroke.
o Interview family members to find out.
May deny symptoms because does not want to risk losing independence.
o May not want to be a bother.
o May not want to go to the hospital.
If impaired vision and hard of hearing, do not assume the person cannot
o Talk directly to the person, not the family members.
 Stand where the person can see you.
 Stay within view as you ask questions.
 If the person wears glasses, get them for the person.
 If the person wears hearing aids, get them for the person.
 Turn down background noise (TV, radio, loud talking).
 Speak in lower frequencies.
o Difficulty hearing high-pitched voices.
o May understand male voices more easily.
 If cannot hear you, consider writing questions down.
C: Considerations during an assessment:
If more than 1 child, Go to the quiet one first. May be unresponsive.
Get down to child’s level.
Take your time with the assessment.
o Speak slowly and clearly.
o Make movements slow and deliberate.
o Ask a young child to point to where it hurts.
Involve parents or caregivers
 Do not separate the child from family or caregiver.
 Give the parent a task to perform.
o Apply pressure on a bleeding wound.
o Hold the child.
o Call 9-1-1.
 Ask for help reassuring a frightened child
 Ask about a child’s medical history.
After the emergency:
 Notify child’s parents or legal guardian of the emergency.
 Complete any required paperwork at school or childcare facility.
 Talk with other children who witnessed the emergency.
Infants: The most difficult to assess, because they cannot communicate
 Be alert for signs of listlessness or exhaustion, which indicate severe distress.
 Support the head of infants younger than 4 months.
Age 1-5: Easily scared by strangers.
 Do not remove clothing, and avoid any unnecessary touching.
 Use observation to help your assessment.
Age 6-12: When injured or stressed, may behave younger than their actual age.
 Be honest if something is going to hurt.
 Work slowly, avoiding any surprises.
 Give a simple explanation of what you are going to do.
Determine the Chief Complaint10
During the initial assessment the first aid responder will ask an alert victim questions
to find out what is bothering the person the most. It is the first piece of information
you need to obtain, and should be summed up in a few words (e.g. “squeezing in my
chest” or “twisted ankle”). In a situation in which injuries are obvious to the rescuer
(e.g. falling off a ladder), it is still useful to determine the chief complaint. Finding out
what is bothering the victim the most may lead the rescuer to unexpected or
unnoticed injuries.
The chief complaint is best obtained by asking open-ended questions like, “What
seems to be troubling you?” (illness) or “What is bothering you the most?” (injury).
Remember, if you don’t ask, you won’t find out.
Assess Appearance
During the head-to-toe assessment, the rescuer will use skin signs to help determine
the seriousness of the victim’s condition. Assessment begins the moment that you first
see and touch the person. Assess the skin for color, temperature and moisture.
Skin Color10
The color of the skin, especially in fair patients, reflects the underlying circulation as
well as the oxygen saturation of the blood. When the blood vessels are doing a good
job of supplying the tissues with oxygen, skin signs are warm and pink. For those
with darker pigmentation, assess the mucous membranes (e.g. inside the lip) or at
nail beds.
Abnormal skin colors and possible causes:
 Red: Fever, allergic reaction, carbon monoxide poisoning
 White (pallor/pale): Excessive blood loss, fright, cold, shock
 Blue: Low blood oxygen level, shock, cold
 Mottled (a mix of white, gray and red): Shock
Skin Temperature & Moisture119
Normal skin temperature is warm and dry. Skin temperature rises from fever, high
environmental temperatures, and certain medical conditions (e.g. anaphylactic
shock, heat stroke). Shock or severe stress can cause the body to sweat, or become
moist; dehydration and injury to the thoracic or lumbar spine can cause the skin to be
Abnormal skin temperature and possible causes:
 Hot, dry: Excessive body heat (i.e. heat stroke)
 Hot, wet: Reaction to increased internal or external temperature
 Cool, dry: Exposure to cold
 Cool, clammy: Shock
To Assess Skin Signs
Place your forearm or the back of your gloved hand against the patient’s forehead.
Hold your hand there for several seconds. Assess for temperature, color and
moisture of the skin. It can be helpful to assess the skins signs of the core (chest)
against the skin signs of the extremities (arms and legs) for differences. Cooler, paler
extremities, when compared with the skin signs of the core, are a sign of shock.
On-Going Assessment
After EMS has been activated and the initial assessment is completed, treat any
signs and symptoms or injuries according to need. Perform an on-going assessment
to update the status of the scene and your victim while you wait for professional
responders to arrive:
1. Ensure the scene is still safe.
2. Reassess and continually monitor responsiveness and breathing.
3. Observe for changes in the mental status of the patient (i.e. becomes
confused or unresponsive).
4. Repeat initial assessment as needed.
5. Ensure treatments are effective.
6. Protect the victim from the elements.
7. Calm and reassure the victim.
Activities: Demonstrate and Practice Assessing a Victim
Demonstrate the skill of assessing a victim to your students. Students are required to
practice before being tested on the skill.
Demonstration: Assessing a Victim
1. Select a volunteer.
2. Perform an Initial Assessment on the student volunteer.
a. Assess response, assess breathing, Assess head-to-toe for injury and
appearance, look for medical alert jewelry.
b. Ask the victim what is wrong.
Student Practice of Assessing a Victim:
1. Pair up the students.
2. Instruct one student to perform an Initial Assessment on the other student.
a. Assess response, assess breathing, Assess head-to-toe for injury and
appearance, look for medical alert jewelry.
b. Ask the victim what is wrong.
Bites and Stings
Animal Bites16,17,18,19
Millions of Americans each year are bitten by animals, including cats, mice, rats,
birds, and occasionally horses, cows and pigs. Wild animal bites are rare. Dogs,
however, are responsible for about 80% of all animal bites.
There are about 77.5 million domesticated dogs in the U.S. Almost 40% of U.S.
households has a dog as a pet. The family dog is responsible for half of all dog bites.
Dogs bite more than 4.7 million people each year; 2.8 million (60%) of the dog bite
victims are children. Children between the ages of five and nine have the highest
injury rates.
Approximately 800,000 dog bite victims seek medical attention each year, with an
estimated 368,000 of them treated in emergency departments. About a dozen
victims die each year from dog bites. Unneutered male dogs are involved in over
90% of reported dog bite cases. Most victims know the dog that bites them.2
Bites may produce slight bruising or large complex lacerations. The biggest concerns
with animal bites are bleeding and the possibility of infection. Deep animal bites,
such as those of a cat, are at highest risk for infection. Rabies and tetanus are the
biggest concern because there is no cure; immediate treatment is critical.
Rabies is a viral disease found in mammals that is usually transmitted through the
bite of a rabid animal. Bites from wild animals or non-immunized domestic pets carry
the risk of rabies. If a victim is bitten by a wild animal or unknown pet, notify animal
control personnel to request help in capturing it. A bite from a skunk, raccoon, bat,
fox, or another mammal that is unprovoked or behaving strangely is treated as a
rabies exposure.
Rabies vaccinations are important for the protection of humans and domestic
animals. The primary risk to humans is that a rabid wild animal may pass the
infection on to a domestic animal or a human. Vaccinations have significantly
reduced confirmed incidents of rabies in domestic dogs. There are only 1 or 2 cases
of rabies in humans each year. Rabies, when left untreated, is almost always
Tetanus, also known as lockjaw, is contracted when a cut or wound is contaminated
with the tetanus bacteria. It is found in the environment throughout the world,
commonly in soil, dust and manure. Tetanus causes such severe muscle spasms
that the person can no longer open his or her mouth. Approximately 10% of reported
cases are fatal. It is contracted through cuts or wounds, especially deep puncture
wounds such as those made by knives or nails. It is important to follow current
medical guidelines for tetanus vaccination and boosters. Always contact your
physician to determine if a tetanus vaccination is required after an animal bite.22
Dog Bite Prevention17,18,19
Dogs may bite while protecting their owners and territory. They are also likely to bite
when in pain, while eating, or when they feel threatened. Regardless of size, breed
or personality, all dogs can bite if provoked.
The great majority of dog bites are preventable. In order to reduce the number of dog
bites, it is necessary to educate people, especially children, about bite prevention,
and teach dog owners about responsible pet ownership.
Dog Bite Prevention Tips:
 If approached by a dog, stand still while it sniffs you and determines you are
not a threat.
 If threatened by a dog, remain calm and avoid eye contact. Do not run. Stay
still until the dog leaves, or slowly back away until the dog is out of sight.
 Teach children not to annoy or tease animals.
 Be wary of moms with pups.
 Do not approach an unknown animal.
 Do not disturb an eating or sleeping dog.
 Do not leave young children or strangers with a dog.
 Do not attempt to break up a dogfight.
 Ask permission from a dog’s owner before petting it.
 If knocked down by a dog, curl into a ball, protect your face and lie still.
 Keep pets on a leash when out in public.
 Neuter male dogs, since un-neutered male dogs bite most often.
 Train your dog to obey basic commands.
Signs and Symptoms:
 Skin break with or without bleeding (abrasions, lacerations, punctures, tissue
loss or avulsion)
 Bruising
 Pain
 Bite marks
 Crush injuries, fractures
 If infected, increased pain, redness, swelling, drainage, fever
1. Ensure scene safety. Do not touch or try to capture a potentially rabid animal
2. Ask a bystander to call 9-1-1 and get a first aid kit.
3. Assess response, breathing, circulation and appearance.
4. Wash wound immediately under pressure for several minutes with soap and
water. Irrigation has been shown to reduce the risk of rabies or bacterial
5. Control bleeding with direct pressure.
6. Apply antibiotic ointment and cover with a sterile dressing.
7. Seek medical care for further wound cleaning, sutures or vaccine, especially
for bites to the face, neck or hands, deep puncture wounds or large
8. Report bites to a police or animal control officer.
Seek medical care for bites to the face, neck or hands, deep puncture wounds or
large lacerations. Contact your doctor for evaluation if you have cancer, AIDS,
diabetes, liver or lung disease, or another condition that might weaken your ability to
fight infection. If your last tetanus shot was more than five years ago, you may need
a booster shot. Report any flu-like symptoms following an animal bite. All human
bites that break the skin should be treated with antibiotics.
If you are bitten by a domestic animal that appears healthy, the owner should confine
it for 10 days and observe it for illness. If you are bitten by an animal that appears ill
or becomes ill during the 10-day confinement, have it evaluated by a veterinarian for
rabies and seek medical care immediately for possible vaccination.
Human bites can be as dangerous as or more so than animal bites because of the
risk of infection from the bacteria and viruses contained in the human mouth. Most
human bites cause only a bruise or shallow laceration, because human teeth are not
very sharp. Human bites may occur when very young children are playing or
fighting, when trying to restrain a child, in mental institutions, in prisons, or selfinflicted during thumb sucking or nail biting.
When someone accidentally cuts his or her knuckles on someone else’s teeth, such
as might happen during a fight or a sports activity, it is also considered a human bite.
The “fight bite” frequently becomes infected, and may lacerate the finger tendon that
crosses over the knuckle. A physician should always evaluate human bites.
There are about 7,000-8,000 venomous snakebites each year in the US; about 5 of
those people die. Snakebites can be painful, but are rarely fatal. Most snakes are not
poisonous. There are four types of poisonous snake found in the US: the rattlesnake,
the coral snake, the water moccasin, and the copperhead. Rattlesnakes create a
rattling sound by shaking the rings at the end of their tail. Coral snakes have yellow,
red and black rings along their bodies. Water moccasins, also known as
cottonmouths, have a white, cottony lining in their mouth. Copperheads have a
copper-colored head and a reddish-brown hourglass pattern on the body.
Rattlesnakes are responsible for most poisonous snakebites in the U.S. The amount
of venom delivered by a poisonous snake will vary according to its size, age, the
timing of the bite, and how well it was able to sink its fangs into a victim. If venom is
injected during a poisonous snakebite, signs and symptoms of envenomation will
usually appear within the first hour. The symptoms vary greatly, depending on the
size, species and age of the snake, along with the location of the bite, the victim’s
age and health.
Signs and Symptoms:
 Fang marks (2 small puncture wounds)
 Burning pain
 Rapid swelling within minutes
 Bruising, necrosis (tissue turns black and dies)
 Tachycardia (rapid heart rate), low blood pressure
 Bloody wound discharge
 Diarrhea
 Convulsions, fainting, dizziness
 Weakness, loss of coordination
 Blurred vision
 Excessive sweating, fever
 Numbness and tingling
 Nausea and vomiting
 Increased thirst
1. Scene safety.
2. Call 9-1-1 to get medical help immediately. Antivenom must be given soon
after the bite.
3. Keep the victim calm and still, with the bite area lower than the heart.
4. Wash the wound gently with soap and running water.
5. Remove jewelry and constrictive clothing; swelling can progress rapidly.
6. Wrap an elastic bandage around the entire bitten arm or leg, starting furthest
from the heart. Use overlapping turns to wrap snugly, but still allow a finger to
slip under the bandage. Check temperature and sensation below the wrap to
make sure it is not too tight.
7. Mark the border of the swelling/redness every 15 minutes with a pen.
Do not apply a tourniquet.
Do not cut the wound or apply suction or local electric shock.
Do not apply ice.
Do not try to capture the snake.
All snakes should be shown respect and treated as poisonous until proven
otherwise. Do not play with or pick up a snake unless you are properly trained.
When hiking, remain on marked paths. Keep your hands and feet out of areas you
cannot visualize. Be cautious when picking up rocks or firewood.
Even nonpoisonous snakebites can cause infection or allergic reaction in certain
people. If bitten, consult a physician about the need for a tetanus shot.
Spider Bites and Scorpion Stings26,27,28,29,30
There are more than 50,000 species of spiders. Although they are beneficial to the
environment, they are often killed by humans out of fear, not because they pose an
actual danger. Spiders usually prefer to live in undisturbed areas, such as the
corners of a house or in a garden. When they bite, it is usually out of fear as they are
trying to defend themselves. Spiders generally bite only once, so if a victim has
multiple bites, it is usually from an insect such as a flea or bedbug.
In the U.S., spider bites and scorpion stings are rare. Most spider bites are harmless
to humans because their fangs are too short or fragile to penetrate human skin. All
spiders carry some type of venom. Only two spiders (the brown recluse and the
black widow) and one scorpion (the bark scorpion) pose a danger to humans. Those
most at risk include the very young and very old, those with cardiovascular disease,
and people who tend to have allergic reactions.
The black widow measures ½ to 1 inch in length, and is shiny black. It is identified
by the red or orange hourglass-shaped mark on its abdomen. Only the female is
dangerous to humans. The black widow spider is found in dark and damp places
throughout most of the Western hemisphere. Their venom is a neurotoxin, so it
affects the nervous system. Symptoms vary greatly, but may include immediate
pain, cramping and muscle rigidity. Death is rare; exceptions may be young
children, the elderly, and those with cardiovascular disease.
The brown recluse, also known as the fiddleback, or violin spider, is about ½ to 1
inch long and is identified by its light brown color and dark brown fiddle-shaped mark
on its upper back. These spiders live in the mid-South and lower Midwest. They
hide in dark, quiet, cool places that are out-of-the-way, like boxes, closets,
basements, and garages. Their bite is initially mild and often goes unnoticed.
Symptoms will develop hours or days later. Pain will usually start one to eight hours
later at the site of the bite. After one to two days, a generalized rash may develop.
Within two to three days, the venom causes local tissue destruction, often resulting
in a blister surrounded by bruising or a red ring, then a white ring (bull’s-eye effect).
The blister may fill with blood, then rupture and form an open wound.
Scorpions in the U.S. are found mostly in the southwest United States. Most are
relatively harmless. Only the bark scorpion, which is found primarily in Arizona, New
Mexico and on the California side of the Colorado River, is dangerous to humans.
Scorpions are characterized by an elongated body and a segmented tail. It is the tail
that contains the telson in which venom is produced and stored, and the stinger that
injects the venom.
Scorpions usually only sting when provoked or in self-defense. They are not
aggressive creatures. There seems to be an increase in stings in the cool evening
and night hours, when the nocturnal scorpion is out hunting for prey. Common
symptoms include pain, numbness and tingling at the site. Serious symptoms may
include difficulty breathing, muscle twitching, abnormal head, eye and neck
movements, increased salivation, sweating and restlessness. Children under 10 and
the elderly are more at risk to develop serious symptoms.
Signs and Symptoms:
 Immediate severe pain, burning
 Redness, swelling, rash, itching
 Two small puncture wounds
 A blister or ulcer that may turn black
 Headache, dizziness, weakness
 Elevated heart rate & blood pressure
 Sweating, fever, cramps
 Nausea, vomiting, salivation
 Respiratory distress
 Anxiety
 Unresponsiveness
1. Call 9-1-1 (activate EMS) for suspected bite from a black widow, brown
recluse, scorpion, or if any life-threatening signs are present.
2. Wash the wound with soap and running water. Apply antibiotic ointment if no
3. Apply an ice pack wrapped in a moist cloth.
 Destroy webs with a stick or broom.
 Check for spiders or insects before reaching into boxes or donning gloves,
shoes or articles of clothing that are lying on the floor or in a closet.
 Watch out for dark hiding places indoors.
 Clear shrubbery, logs and trash from around the home.
 Keep window screens in good repair; seal cracks and crevices leading into
the home.
Tick Bites:31,32
Ticks are related to spiders and scorpions, and attach themselves to the skin of
animals or reptiles to suck their blood. Although most tick bites are harmless, some
species can transmit life-threatening diseases. Two common types of ticks are the
deer tick and the dog tick. The deer tick is found in many parts of the U.S. Those
found in New England and parts of the Midwest are more likely to carry Lyme
disease than those found in other areas. The dog tick, which is very common, may
carry a disease called Rocky Mountain Spotted Fever.
The risk of disease transmission increases after 24 hours, so it is important to
remove a tick as soon as possible after discovery. Their bite is painless, so it is
necessary to check your skin and clothing for ticks when coming indoors. Check for
ticks on parts of the body that bend (underarms, knees, between fingers and toes),
on top of the head, behind the ears, on the neck and hairline, where clothing presses
on the skin (collar, wrists, ankles, waist, top of legs).
Ticks can be found in the woods, shrubbery, high grasses, gardens, marshes and
beach areas. When in areas known to have ticks, wear light-colored clothing (for
easier tick identification), a long-sleeved shirt with tight cuffs, long pants tucked into
socks, and a hat. Use repellant to prevent tick bites. Consult your physician about
the Lyme disease vaccine.
Tick Removal & Treatment:
1. Remove as soon as possible.
2. Use curved tweezers to grasp close to the skin.
3. Lift the tick straight out firmly and steadily without twisting or pinching until it
lets go.
4. Save the tick for testing if needed in a sealable container.
5. Wash the site with soap and water. Swab the skin with alcohol, and apply an
antibiotic ointment if no allergy.
6. Seek medical care if you cannot remove the tick completely, or if a rash or flulike symptoms develop.
7. High-risk patients (pregnant, or living in areas endemic to tick-borne disease)
should consult with their physician as to the need for antibiotics.
Do not crush or squeeze the tick’s body while removing it. The tick’s potentially
infectious body fluids may escape.
Do not use petroleum jelly, alcohol, or a hot match to kill the tick before removal.
These techniques may induce the tick to expel infected saliva into the bite site.
Do not handle the tick with your bare hands.
Insect Stings33,34
Insect stings can cause pain, swelling and allergic reactions, but are rarely serious.
Common biting insects include sand flies, horseflies, deerflies, mosquitoes, fleas,
lice, bedbugs, kissing bugs, fire ants and some water bugs. The reaction is usually
mild, resulting in a small, red, swollen, itchy area. Sometimes the sting area can get
infected, or more rarely, the victim has an allergic reaction. If a stinging victim
develops serious symptoms (breathing difficulties; severe swelling, especially around
the face; hives; nausea; dizziness), get emergency medical help immediately. A
single sting of a person who is severely allergic can be fatal.
Most severe sting reactions are caused by honeybees, yellow jackets, hornets,
paper wasps and fire ants. Thousands of people are stung each year.
These insects have venom in a sac attached to their stinging mechanism. The
venom is released into the body through a hollow conduit (stinger). A person who is
allergic to insect stings has an immune system that overreacts to the venom. After
the first sting, the victim’s body produces antibodies that, along with many other
substances, circulate throughout the body. When the venom from a subsequent sting
enters the body, antibodies work to fight off the venom (antigen). This conflict results
in the release of histamine and other chemicals that cause allergic symptoms.
People who are highly allergic to stings should carry an emergency epinephrine
auto-injector at all times and consider wearing a medical ID bracelet or necklace
stating their allergy.
Most honeybees will leave their barbed stinger, with the venom sac or pouch
attached, in the victim’s skin. The bee dies as a result of this. Hornets, yellow
jackets and wasps do not usually leave their stingers. If stung by a bee, quickly
place your fingernail or a straight-edged object (e.g. credit card) at the base of the
stinger and scrape it off. The speed of your response is most important, because
90% of the venom is delivered within the first 20 seconds. Do not pull the stinger out
with your fingers or tweezers, if possible, because you might squeeze the venom
sac, causing even more venom to be released.
Signs and Symptoms – Mild:
 Redness and swelling at site
 Localized burning and itching
 Blister formation about 24 hours after the sting (fire ant)
Treatment – Mild Reaction:
1. Move to a safe location to avoid more stings.
2. Remove the stinger quickly by scraping it off with your fingernail or a straightedged object.
3. Wash the area with soap and water.
4. Apply an ice pack wrapped in a moist cloth to reduce pain and swelling.
5. Consider an over-the-counter antihistamine, analgesic and corticosteroid to
relieve itching, pain and inflammation. Contact your physician for further
6. See your physician if the swollen area is large, if the sting site is in the mouth
or nose, or if you develop delayed reactions such as mild nausea, intestinal
cramps or diarrhea.
Signs and Symptoms – Severe (Anaphylaxis):
 Difficulty breathing or wheezing
 Hives and rash
 Dizziness, faintness
 Shock (very low blood pressure, rapid heart rate)
 Difficulty swallowing
 Facial, throat or tongue swelling
 Stomach cramps, nausea or diarrhea
Treatment – Severe Reaction:
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. If victim is carrying an epinephrine auto-injector, help to administer it if you are
asked, and if state and local regulations allow.
a. Remove the stinger quickly by scraping it off with your fingernail or a straightedged object.
4. Observe for signs of shock; treat as indicated.
Tips to Avoid Insect Stings:
 Avoid stinging insects’ nests. Most insects will not attack if left alone.
 Hire a trained exterminator to clear hives and nests from around your
 When you encounter a flying insect, remain calm and quiet, and move slowly
away. Do not swat at an insect, as this may cause it to sting.
 Avoid brightly colored clothing and perfume, perfumed soaps, shampoos and
deodorants when outdoors, so that you don’t resemble or smell like a flower.
 Avoid flowering plants.
 Be careful when eating, cooking or drinking outdoors. The smell of food
attracts insects.
 Wear closed-toed shoes outdoors.
 Keep outdoor eating areas and grills clean. Keep lids on trashcans.
Marine Animal Stings23,35
Coelenterates, which include jellyfish, corals, sea anemones and the Portuguese
man-of-war, have tentacles, which are the firing mechanism of the sting. The
nematocysts (stinging units) on the tentacles are the animal’s defense tool for
protection. They continue to function even long after the animal is dead.
Most coelenterate stings only require cleaning. The stinging sensation will go away
usually in one hour. Stings from the Portuguese man-of-war have been known to
cause death. Stings may also result in anaphylactic shock, which is life-threatening.
Signs and Symptoms:
 Pain, redness, hives/bumps/rash. The rash may develop into blisters, fill with
pus and then rupture.
 Nausea, weakness, headache
 Muscle pain and spasms
 Runny eyes and nose
 Fever, chills, sweating
 Severe reactions may include chest pain, difficulty breathing, coma and death.
1. Assess response, breathing, circulation and appearance for more serious
2. For Box Jellyfish stings, wash liberally with vinegar as soon as possible for at
least 30 seconds. This will inactivate the nematocysts so they can’t release
venom. If vinegar is not available, use a baking soda slurry.
3. Remove tentacles with tweezers or a gloved hand.
4. After the nematocysts are deactivated, immerse in hot water for at least 20
minutes to decrease the pain.
5. Seek medical treatment immediately for severe reactions.
Stingrays are very hard to see and are found in the ocean under sand as they try to
hide due to their cautious nature. Normally non-aggressive, the rays are found in the
U.S. on both the East and West Coast, in the Sea of Cortez and the Gulf of Mexico.
When a person steps on a stingray, it thrusts its tail spine into the victim’s foot or leg
and releases venom.
It should be noted that not all rays have a cartilage-like barb under the tail section.
This is strictly for protection and varies with species. Swimmers are encouraged to
wear water socks or other protective footwear when in ray habitat, and to shuffle
their feet to warn the creatures of approach.
Signs and Symptoms:
 Jagged, freely bleeding wound
 Immediate painful or throbbing sensation, redness, swelling
 Weakness, nausea, anxiety, fainting
 Less common symptoms include vomiting, diarrhea, sweating, cramps,
difficulty breathing
1. Remove person from water/environment.
2. Remove barb if it is superficial and not penetrating the chest, neck, or
3. Apply firm direct pressure with sterile gauze to control bleeding.
4. See a physician to clean the wound and remove any remaining fragments of
the spine. Stitches may be required.
The sculpin is a fish that is found in many areas throughout the world. It has
poisonous/venomous fin tips. Thick leather gloves or cutting the fishing line as close
to the fish as possible and releasing it are two methods for dealing with this creature.
Generally, most of these injuries are non-emergent and seldom require a physician’s
Signs and Symptoms:
 Redness
 Burning sensation
 Localized swelling
1. Immerse in hot water at least 110-115° F for 60-90 minutes.
2. Appropriate wound care.
Blood is a fluid that is made up of the following:
 Red blood cells (carry oxygen and give color to blood)
 White blood cells (attack foreign bodies and protect against infection)
 Platelets (assist in blood clotting)
 Plasma (a pale yellow liquid that carries nutrients)
Blood travels through the body in three types of vessels:
 Arteries (carry blood away from the heart)
 Veins (carry blood to the heart)
 Capillaries (very small blood vessels that carry blood throughout the body).
The human body contains an average of 10 pints of blood. Most people can lose
one pint of blood (the amount given for a blood donation) without any harmful effects.
If a victim loses two pints of blood, he or she may go into shock. The loss of five to
six pints will usually result in death. Children and the elderly have less tolerance for
blood loss, and may go into hypovolemic shock sooner than a non-elderly adult.
Control of severe bleeding by a bystander is a critical treatment that can truly save a
Types of Bleeding:
Bleeding is the body’s way of cleansing a wound and minimizing the chance of
infection. A damaged blood vessel will constrict and stop bleeding when the body
produces a blood clot that plugs the damaged area. Many minor wounds will actually
stop bleeding without intervention; the first responder is simply helping with the
process. Severe, uncontrolled bleeding, however, is life threatening.
Direct pressure on the wound will control most bleeding. This is the primary first aid
treatment for bleeding control, and has been validated through extensive research.
Apply firm, direct pressure until the bleeding has stopped completely or trained
rescuers arrive.
There are three types of bleeding:
 Arterial: Bright red blood spurting from the wound. The spurting coincides
with the beat of the heart.
 Venous: Dark red blood flowing steadily from the wound. There may be a lot
of bleeding due to the large size of some veins.
 Capillary: Blood slowly draining or oozing from the wound.
Arterial bleeding is the most serious type of bleeding due to the amount and speed of
blood loss. It is also the hardest type to control because of the higher pressure in the
Note: A scalp or facial wound may be small but bleed freely due to the location and
number of blood vessels under the skin.
Types of Wounds:
Incision: A clean break of the skin usually made with a sharp object (e.g.
sharp knife).
Laceration: A wound that is torn rather than cut. The wound is usually made
by a dull or blunt object (e.g. dull knife, machinery accident, piece of glass), so
the wound edges may be irregular.
Puncture Wound: Usually a deep wound with minimal bleeding (e.g. nail,
animal bite). Has the greatest chance of infection. Deep puncture wounds
may cause internal bleeding.
Abrasion: A scraping away of skin that is usually painful because many nerve
endings are involved. Common examples include skinned knees and rope
burns. Remove all embedded foreign particles that could cause infection or
“tattooing” of the wound.
Avulsion: A tearing injury in which a piece of skin or other tissue is
completely or partially torn from the body. There is usually severe bleeding.
o Fold or replace torn skin if possible.
o Wrap the wound as a laceration.
o If the skin or tissue is completely torn from the body, salvage it as an
amputated part.
o A skin tear is a tearing away of the skin from the tissue below. Treat it
as an avulsion.
Amputation: Loss of body part. (See Traumatic Injuries for more information)
Note: An abdominal wound may expose internal organs, such as bowels, and even
result in their protrusion through the wound. Do not attempt to push extruded organs
back into the wound. Cover them with moistened gauze or cloth, and avoid
excessive pressure.37
Severe Bleeding Treatment36,37
Do not attempt to clean the wound at this time. The priority is to stop the bleeding.
1. Call 9-1-1 if bleeding is severe, does not stop, there are signs of internal
bleeding or shock, or there is an impaled object.
2. Universal Precautions (gloves, mask, goggles, hand washing)
3. Assess response, breathing, circulation and appearance.
4. Lay the victim down. This will reduce the chance of fainting. Calm and
reassure the victim.
5. Remove any clothing over the wound so you can see where the bleeding is
coming from.
6. Apply steady, direct pressure. Use a gloved hand and the cleanest available
layered gauze or folded cloth. Add dressings as they become soaked with
blood; do not remove them, as this will disrupt the clot formation.
7. Release the pressure slowly and observe for bleeding. Severe bleeding may
take more than 10 minutes of continuous direct pressure to control. If the
bleeding does not slow or stop, make sure you are applying pressure
precisely over the wound.
8. Treat for shock – elevate legs and maintain body temperature.
9. After bleeding has stopped, consider the use of a pressure dressing to
maintain pressure, especially if you are the only rescuer and you must leave
to get help. Apply a roller or elastic bandage firmly around the wound to help
control bleeding.
10. If help is delayed, splint an extremity with a severe wound to prevent
movement that could restart bleeding.
11. Check regularly to make sure that swelling has not made the dressings too
Do not peek after a few minutes to see if the bleeding has stopped. This could
interfere with clot formation and prolong the bleeding.
Do not remove any deeply embedded objects, or attempt to clean the wound at this
time. The priority is to stop the bleeding.
Do not apply pressure to the carotid artery (neck).
TIP: Pack a large, open wound with sterile gauze before applying direct pressure.
Follow up with a physician for further care if:
a. The wound may require stitching (is more than ½” long or has gaping wound
b. The wound is large or deep.
c. Dirt or debris remains in the wound.
d. Tetanus shot is needed. Get a tetanus shot within 48 hours of the injury if you
haven’t had one in the past 5 years.
e. The wound is from a human or animal bite, puncture, burn, electrical or
chemical injury.
f. High risk or signs of infection (redness, warmth, increased pain, pus or cloudy
discharge, swelling, fever).
g. The wound is on the head, face or neck.
Tetanus, also known as lockjaw, is an infection of the nervous system caused by
common bacteria that live in the soil. Although it is serious and sometimes fatal, it is
completely preventable through vaccination. Tetanus signs and symptoms include
painful muscle spasms of the jaw and upper body, drooling, sweating, fever, hand or
foot spasms, difficulty swallowing, irritability, and incontinence. Treatment may
involve medication, bedrest, and surgery.
If someone has an open wound and has not had a tetanus booster in the past 5
years, he or she should get one, especially if the injury was exposed to soil or
sustained outdoors.22
Note: Previously, rescuers were taught to use elevation and pressure points to
control severe bleeding. These techniques are no longer recommended because
there are other methods that have been proven more effective. The primary method
to control bleeding is direct pressure; the use of elevation and pressure points may
actually be harmful by interfering with the application of direct pressure.23
Minor Wound Treatment and Bandaging23,40,41,42
After bleeding is controlled, the goals of wound care are to reduce the risk of
infection, control pain, and promote healing. Use the cleanest dressing materials
available, sterile if possible. Open packages and handle dressings carefully to keep
them as clean as possible.
1. Wear personal protective equipment. Wash your hands before and after
wound care.
2. Stop the bleeding with direct pressure. Minor bleeding may take only 2-5
minutes to control.
3. Clean the wound. Rinse thoroughly with clean water with or without soap. Do
not use alcohol, hydrogen peroxide or iodine-containing cleansers directly in
the wound, because they damage living cells and can delay healing.
4. Apply an antibiotic ointment (preferably a triple antibiotic ointment) to a
superficial injury or abrasion to keep the wound bed moist and reduce the risk
of infection. Ensure there is no history of allergy to the antibiotic ointment.
5. Cover the wound with a bandage to help keep it clean.
a. Control bleeding completely before you apply a bandage.
b. If an absorbent dressing is needed, apply sterile gauze directly over the
wound to keep it clean and absorb blood and wound drainage. Apply
adequate layers of gauze so that there is no strike-through of blood or
wound fluids through the outer layer of gauze. Secure with roll gauze or
adhesive tape, depending on the wound location.
c. If there is a concern that the dressing may stick to a wound, apply a nonadherent pad covered with gauze layers to the wound. This will allow
dressing changes without damaging the healing tissue and causing fresh
bleeding. Secure with roll gauze or adhesive tape, depending on the
wound location.
d. If there is minimal or no bleeding or drainage from the wound, apply an
adhesive bandage (e.g. band-aid).
e. Change the dressing daily, or if it gets wet or dirty.
6. Watch for signs of infection (redness, warmth, increased pain, pus, swelling,
7. Watch for possible allergy to adhesive tape or antibiotic ointment. (e.g.
redness, rash, hives, pain, etc.)
NOTE: A victim who has a bleeding disorder or is taking anti-clotting medication may
take much longer to stop bleeding.
Skin Tears38,39
A skin tear is a common type of wound in older persons due to the thinning of the
skin and the decrease in moisture, strength and elasticity with age. Some
medications may also cause the skin to become thinner, increasing susceptibility to
tears. They occur most commonly on the hands, arms and lower legs as a result of a
bump, fall, or even vigorous washing and drying of skin.
Risk factors include impaired vision, use of corticosteroids, malnutrition, dementia,
limited mobility, loss of pain perception.
Prevent skin tears when possible.
Create a safe environment: keep your home well lit; arrange furniture and
clear pathways to allow adequate space to walk without bumping furniture;
have a nightlight.
Protect yourself: wear long sleeves or pants; drink fluids between meals; eat a
healthy diet; use lotion on dry skin.
Consult a specialist: ask your doctor if your medications could contribute to
skin tears; talk to a nutritionist.
Train caregivers: use appropriate equipment to avoid friction or shearing when
positioning or transferring a patient (e.g. use transfer belt and draw sheet);
provide adequate fluids and nutrition; apply lotion to dry skin; use nonadherent dressings on fragile skin, and secure with paper tape, gauze wraps
or stockinettes.
Pressure Dressings
If the wound continues to seep after applying direct pressure, consider the use of a
pressure dressing. Pressure dressings should only be used on an extremity wound.
They need to be monitored closely to ensure adequate blood flow beyond the wound
so that a tourniquet effect is not created.
When applying a pressure dressing remember that the innermost wound dressing
should never be removed. Apply additional dressings and bandages over the original
To create a pressure dressing, place a large wad of folded material over the original
wound covering, then secure it in place with an elastic bandage, roller gauze, a
triangular bandage, or strips of torn cloth.
To Apply a Pressure Dressing:
1. Ensure adequate circulation below the level of the wound (i.e. to the foot or
2. Apply a wad of the cleanest available folded material such as gauze, a
triangular bandage or any pieces of folded cloth directly over the wound.
3. Prepare an outer bandage such as roller gauze, a triangular bandage,
handkerchief, sock, strip of torn shirt or any other similar material and fold it
into a long strip. Do not use narrow material such as shoestrings, as they
could damage the blood vessels and create a tourniquet effect.
4. Place the bandage directly over the wad of folded cloth. Secure the bandage
in place by rolling it over the wound and tying a non-slip knot in place directly
over the wound. An elastic bandage may also be firmly wrapped over the
wound, but not too tightly.
5. Check the person’s sensation, skin color, temperature and motion below the
wound periodically (every 5 to 15 minutes). Ensure there is no numbness or
tingling beyond the dressing. Loosen the pressure dressing as needed to
ensure adequate circulation below the wound.
Apply a tourniquet only if the victim has severe bleeding that cannot be controlled by
direct pressure and is in danger of bleeding to death. The use of a tourniquet can
damage nerves and blood vessels and can lead to the loss of an arm or leg, as well
as systemic complications and even death. These complications are associated with
duration of application and amount of pressure. A tourniquet may be used by first aid
providers if properly trained and only in certain circumstances, such as when EMS
responders are delayed. Further research is needed to identify the best design,
application and conditions for their use.
Tourniquet Application
Use only if the victim has severe, uncontrolled, life-threatening bleeding from an arm
or leg. The rescuer is making a decision to risk losing the limb to save a life.
1. Apply a tourniquet to the limb between the site of bleeding and the heart,
about 2 inches above the wound.
a. By placing the tourniquet close to the wound, more viable tissue can be
preserved above the tourniquet.
b. Do not apply the tourniquet over a joint or on the wound.
c. Use a commercial tourniquet, if available.
d. If a commercial tourniquet is not available, make a tourniquet using a
bandage at least 1” wide and 4 – 6 layers thick and wrapping it several
times around the limb. (Do not use a cord or string, because it will cut
through the skin.) Tie a square knot, place a stick over the knot, and tie
the stick in place with the loose ends of the bandage.
2. Tighten just to the point that bleeding is stopped.
a. Twist the stick, or tighten the device.
3. Secure the device or tightening stick in place with tape or another bandage.
4. Record the time of application. Write it on the tourniquet.
5. DO NOT cover the tourniquet with a bandage or clothing. Keep it in sight so
that rescuers remember that it is there.
6. Ensure that EMS is activated.
7. Inform professional rescuers of the time the tourniquet was applied.
8. DO NOT remove a tourniquet unless you are directed to by medical
professionals or local protocol. Allow advanced medical professionals to
remove it.
Follow local protocols for tourniquet application. Follow manufacturer’s directions for
use of a commercial tourniquet.
Topical Hemostatic Agents23
Hemostatic Agents are designed to control severe external bleeding by assisting with
clot formation. They are not recommended for routine use by first aid providers at
this time “…because of significant variation in effectiveness by different agents and
their potential for adverse effects, including tissue destruction with induction of a
proembolic state and potential thermal injury.” Some of these products may also be
difficult to remove in the emergency department.
Your workplace Medical Director can approve or require the use of certain bloodclotting products. Follow your Medical Director’s protocol and the manufacturer’s
guidelines for use of hemostatic agents in the workplace.
Internal Bleeding
Damage or injury to the chest, abdomen, or pelvis can lead to bleeding that is
concealed within the body. Swollen, deformed and painful extremities can also
indicate internal bleeding. A victim can lose blood rapidly from an injury to the liver or
spleen, or from fracture of the pelvis or a long bone such as the femur (thigh). The
main concern with internal bleeding is shock.43
Common causes of internal bleeding include both blunt and penetrating trauma
incidents such as automobile accidents, broken bones, knife and gunshot wounds.
Medical problems relating to the lungs, stomach or intestines can also result in
internal bleeding.
Initial Signs & Symptoms:
 Discolored, tender, swollen or hardened skin or tissues, especially in the
abdominal area and suspected fracture sites
 Rapid respiratory and pulse rates
 Pale, cool, moist skin
 Abdominal pain, tenderness, rigidity; guarding of the abdomen
 External bleeding from a natural opening (e.g. mouth, nose, ear, rectum,
vagina, urethra)
 Nausea; vomiting or coughing up blood (bright red or coffee ground
 Dark tarry or bright red stool
 Mental status changes: confusion, irritability
 Dizziness, unresponsiveness
1. Scene safety, PPE, get first aid kit and AED.
2. Assess response, breathing, circulation and appearance.
3. Call 9-1-1. Do not wait for the victim to visit the doctor on his or her own.
4. Calm and reassure the victim.
5. Treat for shock.
a. Place in a position of comfort.
b. Keep warm.
6. Monitor status.
Nosebleeds occur when the small blood vessels inside your nose break and bleed,
usually due to dryness or minor irritations. Most bleeding is from the nasal septum
which separates the two sides of the nose. Nosebleeds are very common and rarely
life threatening.
Occasionally a nosebleed may be a sign of a more serious problem, such as
hypertension. As blood pressure increases, the small arteries in the nose begin to
bleed. This may be a warning sign of an impending stroke.
1. Sit down and tilt your head slightly forward.
2. Pinch the soft part of your nose (just below the bony part) for 10 minutes.
Breathe through your mouth.
3. Apply an ice pack wrapped in a moist cloth to the bridge of the nose, if it does
not interfere with direct pressure.
Do not:
 Do not lie down or tilt your head back. This position will cause blood to flow
down the back of the throat, possibly upsetting your stomach and causing
 Do not pack your nose with gauze to stop the bleeding.
 Do not put your head between your knees; this will increase the blood
pressure to the veins of the nose, resulting in more bleeding.
 Do not blow your nose soon after bleeding has stopped.
Get medical help if:
 Your nose bleeds for more than 15-20 minutes.
 You have difficulty breathing.
 The bleeding is very fast or heavy.
 You feel dizzy or weak.
 It occurs after an injury to the head. It may indicate a skull fracture or broken
 The nosebleed is associated with hypertension.
Senior: Blood thinners or aspirin may cause or even worsen nosebleeds.
Child: Nosebleeds in children are commonly due to an object stuck in the nose or to
nose picking. Caregivers should try to peer inside the child’s nostrils and trim
fingernails as needed.
A person who experiences frequent nosebleeds should see a doctor for evaluation.
Repeated nosebleeds may indicate hypertension, allergies, a tumor of the nose, or a
bleeding disorder.
Help prevent nosebleeds by using a humidifier, nasal saline spray or water soluble
A blister is an area of raised skin filled with a watery liquid. It is usually the result of
friction, such as when you develop a blister on your heel from wearing a new pair of
shoes, or a blister on your hand from using a shovel. A blister may also occur as the
result of a 2nd degree burn or a skin rash.
Prevent a blister before it develops. Wear the right shoes for the right task, and
ensure that they fit well. Use gloves when indicated for physical labor. Wear
sunscreen to avoid sunburn.
If you do develop a blister, do not pop it. The layer of skin over the blister is
keeping microorganisms and foreign particles out of the wound, and maintaining a
clean and moist healing environment. Keep the blister clean and dry, cover it with a
bandage, and try to avoid putting pressure on it.
If the blister does pop, follow the Minor Wound Treatment protocol. Consult with a
physician if you develop signs of infection or for treatment of a large blistered area.
A splinter is defined as a thin piece of material (e.g. wood, metal, glass) that gets
embedded just below the top layer of skin (epidermis). Depending on the location of
the splinter, it can be very irritating and painful. Most splinters can be removed
without medical assistance.
Splinter Removal
1. Wash your hands and clean the area thoroughly with soap and water.
2. If the splinter sticks out from the skin:
a. Use clean tweezers to grab the splinter and carefully pull it out at the
same angle that it went in.
b. If the splinter is small and you can’t grab the splinter with tweezers,
apply a piece of sticky tape over the splinter and pull off the tape to
remove the splinter.
3. If the splinter is hard to grab or is under the skin:
a. Sterilize a sharp needle with rubbing alcohol or by placing the tip in a
b. Use the needle to carefully remove skin over the splinter and lift the tip
of the splinter out.
4. Follow Minor Wound Treatment guidelines.
5. Apply a bandage if the wound may get dirty.
You may also purchase a splinter removal kit to place in your first aid kit. Seek
medical attention if the splinter is close to your eye, if there are signs of infection, or
if it is large or deeply embedded.
There are about 450,000 burn injuries requiring medical attention each year in the
U.S. About 45,000 burn victims are admitted to hospitals: half go to specialized burn
treatment centers, and half to regular acute hospitals. There are an estimated 3,500
fire and burn deaths per year. The death rate from fire and burns has declined
steadily over the years. Children age 4 and younger and adults age 65 and older are
most at risk of fire-related injuries and death.
Smoke alarms decrease your risk of dying in a fire by 50%. Only 60% of the people
in the U.S. have a fire escape plan, and only 25% have practiced it.
While some burns are minor, others can cause permanent injury or even death.
Fast, effective burn treatment can minimize the degree of injury, and even save a
Burn treatment is directed toward stopping further burning, and making the victim as
comfortable as possible while awaiting emergency medical care. The young and the
elderly have the most difficulty recovering from severe burns. Critical burn areas
 Head
 Neck
 Hands
 Feet
 Genitals
 Over a large joint
Burns on these areas are more serious due to the potential for complications.
Scarring can significantly impair appearance, movement and function, resulting in
the need for cosmetic surgery or skin grafts.
Types of Burns50,51,52
Thermal burns are caused by direct or radiant heat exposures to extreme
temperatures. They result from fire, steam, hot liquids, or other exposure to
increased temperature. The first action is to stop the heat source. Deaths from fire
often result from smoke inhalation rather than heat or flames. Victims may suddenly
develop signs of respiratory distress. Rescuers should be cautioned to observe for
evidence of respiratory tract burns such as soot or singing of hairs around the mouth
and nose.
Chemical burns require large amounts of water to flush chemicals from the skin.
Powdered chemicals should be brushed from the skin, followed by flushing for 20
minutes. Do not use bare hands to brush off the chemicals. Ensure run-off water
does not flow over unaffected skin or onto the rescuer. Follow the first aid directions
on the label of the chemical container; locate the Material Safety Data Sheet
(MSDS). Contact the Poison Control Center. Obtain medical care as soon as
When treating a victim with an electrical burn, the most important consideration is
to make sure the power supply has been turned off. Rescuers should not attempt to
remove anyone from an electrical source unless they are specially trained to do so.
After the power source has been eliminated, treat the burn. Electricity follows the
path of least resistance through the body. Commonly there is an entrance and exit
Electrical burns can cause deep tissue injury and are always more severe than the
external signs indicate. Cardiac or respiratory arrest can also be caused by electrical
shock. Ordinary household current is powerful enough to cause severe burns. All
victims of electrical burns need to be evaluated by a physician. 7
Assessment of Burns50,51,52
Degree of Burn
1st Degree Burn: Burns the outer layer of skin (epidermis). There is redness, pain,
and swelling.
2nd Degree Burn: (or partial thickness burn) Burns the second layer of skin (dermis).
There are blisters, severe pain, and swelling, with a red and splotchy appearance.
3rd Degree Burn: (or full thickness burn) Burns all layers of the skin. It may involve
fat, muscle and even bone. There is no pain because nerve endings have been
damaged. Burned areas may appear charred black or gray and white. If there was
smoke inhalation, there may also be respiratory system damage. The victim may
complain of pain if areas of 1st or 2nd degree burns surround the 3rd degree burns.
Activate EMS, because 3rd degree burns are life threatening.
Rule of 9s
The Rule of 9s may be used to quickly assess the total body surface area (BSA)
burned. It divides the body up into units of surface area divisible by nine in the
following way:
Adult: (age 10 and older)
Head = 9%
Torso (chest and abdomen) = 18%
Entire back = 18%
Entire arm (front and back) = 9%
Entire leg = 18%
Infant: (up to age one; has a relatively larger head)
Head = 18%
Torso = 18%
Entire back = 18%
Entire arm = 9%
Entire leg (front and back) = 14%
Child: (age 1 to 9)
 The Rule of 9s is not as accurate for children due to the relative disproportion of
body part surface area.
o The head, neck and shoulders are larger.
o The hips and legs are smaller.
 Decrease head size and increase lower extremity size 1% annually (0.5% each
Rule of Palm: For scattered or small burn surfaces, the victim’s palm = 1% BSA.
Burn Care50,51,52,56
Cool Burns with Water
The preferred treatment for small or minor thermal burns is cooling the area with
water. In addition to providing pain relief, cool water will help stop the spread of the
burn. Continue the cooling process until the pain is relieved. If the victim begins to
shiver, discontinue the cooling process. Hypothermia may occur because extensive
burns reduce the body’s ability to retain heat.
Cover the Victim
Prevent further heat loss by covering the victim. Quickly estimate the burn area, and
then cover with a clean white sheet, blanket or other clean large cover. Remove any
clothing or jewelry that does not stick to the burned skin. Jewelry retains heat and
will continue to burn even after the heat source has been removed.
Burn Treatment:
1. Ensure scene safety. If electrical burn is suspected, ensure power source is
2. Extinguish flames (stop, drop and roll); remove victim from environment if
there is smoke and heat.
3. Activate EMS (call 9-1-1) for a critical burn.
4. Assess response, breathing, circulation and appearance. Assess airway for
evidence of respiratory tract burns such as singed hairs or soot around the
mouth or nose. Airway burns cause swelling, which may close the airway.
5. Cool small or minor thermal burns with water to relieve pain and stop the
burning process.
6. Cover the burn area with a dry, sterile dressing, or a clean sheet for a large
burn area. Keep as clean as possible to reduce risk of infection.
7. Assess for other life-threatening traumatic injuries.
8. Treat for shock.
9. Remove clothing or jewelry that does not stick, because burned areas swell
10. Stop the cooling process if the patient begins to shiver.
11. Maintain an open airway and continue to monitor breathing.
Do not break blisters. They protect the burn area from infection.
Do not apply ice directly onto the skin.
Do not apply butter, ointment or creams to a severe burn.
Activate EMS for a critical burn:
 Burn to head, neck, hands, feet, genitals, or over a major joint
 Large burn area or multiple burn sites
 Burn to the airway or difficulty breathing
 3rd degree burn, especially to the elderly or very young
 Chemical or electrical burn
 Burn with other traumatic injuries
Do not use butter, oil, salve or petroleum-based creams for the initial treatment of
burns. These retain heat and allow the burning process to continue. They are also
painful to remove for wound assessment. After medical evaluation of the burns,
appropriate wound and burn care products may be used.
Fire Safety Tips:56
1. If your clothes catch on fire, don’t panic: stop, drop and roll.
2. Escape first, and then call for help. If you cannot escape immediately, use the
phone and call the fire department, yell for help, or wave a sheet or large
object out the window to attract attention. Close all the doors that you can
between yourself and the fire. Use rags to seal the door.
3. Know two ways to escape from every room. Windows can be considered
emergency exits.
4. Practice escape routes, and keep them free of clutter.
5. Establish a meeting place at a safe distance outside the building.
6. Do not open doors that are hot to the touch. Open cool doors slowly, and
slam them closed if smoke pours in.
7. When escaping, never stand up; crawl low, and keep your mouth covered with
a moist cloth. Smoke rises, so the air is cleanest low to the ground.
8. Place smoke alarms in each room; change the batteries annually.
9. Respond to every alarm as if it were a real emergency.
10. Equip security bars or windows with a quick-release.
11. Never use an elevator during a fire.
12. Never re-enter a burning building to search for missing people or pets, or to
retrieve property. Always wait for firefighters.
Chest and Abdominal Emergencies
Rib Fractures or Flail Chest60
A rib fracture is painful but rarely life-threatening. The treatment for a single rib
fracture is usually pain medication and encouragement to continue taking full, deep
breaths in order to prevent a lung infection.
Complications may occur when sharp bone ends cause serious injuries, such as a
punctured lung or lacerated liver. Observe for signs of internal bleeding or respiratory
distress; limit activity and treat accordingly.
A flail chest occurs when two or more ribs are broken in at least two places, or
when the ribs are separated from the sternum (breastbone), producing a free-floating
(flail) segment. Due to the instability of the chest wall, these broken ribs no longer
aid in the breathing process. The flail area can damage the lung beneath it by
bruising or puncturing it, causing severe bleeding and possibly shock.
Signs and Symptoms:
 Consider the mechanism of injury (how the injury occurred).
 Bruising
 Pain with a deep breath
 Tenderness when palpating the injured area
 Swelling
 Deformity
 Paradoxical movement (The flail segment moves in the opposite direction of
the rest of the chest. As the patient breathes in, the flail section appears to
sink into the core of the body. As the person exhales, the flail section appears
to be pushed from the core.)
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Consider cervical spine (neck) damage based on how the injury occurred.
4. Treat for shock.
Sucking Chest Wound61,62
Trauma that has punctured the chest wall may create a sucking chest wound (open
pneumothorax). Each time the person breathes, a sucking sound is caused by the
passage of air through the wound. Air rushes into the chest cavity, collapsing the
lungs and preventing normal breathing. This severely reduces the lungs’ ability to
provide fresh oxygen to the blood, and is a life-threatening situation.
Signs and Symptoms:
 Difficulty breathing
 Sharp chest pain
 Bluish skin color
Sucking sound with breathing
Trauma to chest/ribs
1. Assess response, breathing, circulation and appearance.
2. Activate the EMS system (call 9-1-1).
3. Keep the person still.
4. Apply an airtight dressing (e.g. aluminum foil, plastic wrap, folded universal
dressing) to keep air from entering during inhalation. Tape only three sides so
that air can escape during exhalation to prevent pressure buildup.
Abdominal Wounds
An open abdominal wound is usually caused by a penetrating injury and may
expose internal organs. In extreme cases, organs may protrude through the wound
(evisceration). Do not remove objects impaled in the abdomen. Do not attempt to
push abdominal organs back in.
A closed abdominal wound (skin remains intact) is usually caused by blunt trauma
injury (e.g. steering wheel, seat belt, baseball bat, fall). Consider how the injury
occurred and the need for spine immobilization. Watch for signs of internal bleeding.
Common causes of internal bleeding include automobile accidents, knife and
gunshot wounds, as well as medical problems related to the stomach and intestines.
Signs and Symptoms:
 Weak, rapid pulse
 Pale, cool, moist skin
 Abdominal pain, tenderness or rigidity
 Nausea or vomiting
 Vomit that is bright red or looks like coffee grounds
 Dark tarry or bright red stools
 Back pain (kidney damage)
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Position on back with knees bent if does not increase pain.
4. Treat for shock.
5. Stabilize foreign object in place with a bulky dressing and adhesive tape. Do
not remove.
6. Cover eviscerated organs loosely with a moist, sterile dressing.
7. Cover dressing loosely with plastic wrap.
8. Do not give food or drink.
The appendix is a small, finger-like pouch attached to the intestines in the lower right
side of the abdomen. When it is blocked, it becomes inflamed and infected, a
condition known as appendicitis. It is most common in people between the ages of
10 – 30.
If appendicitis is not detected early enough, the appendix may rupture, leading to
peritonitis (infection of the lining of the abdomen). The contents of your intestines
and the infected appendix will spread throughout the peritoneal cavity. This is an
extremely serious complication, and may even result in death. Children are more
likely than adults to have a ruptured appendix because their symptoms may vary, or
the parents may think the child just has a stomachache.
Signs and Symptoms:
 Abdominal pain in the lower right abdomen. The exact location of the pain
may vary.
 Increased pain with palpation of the lower right abdomen
 Nausea and vomiting
 Loss of appetite
 Low-grade fever
 Distended (swollen) abdomen
 Constipation
The treatment for appendicitis is surgical removal of the appendix. If you suspect
appendicitis, visit your doctor promptly. If you have symptoms of peritonitis, it is a
medical emergency. Activate EMS or go directly to the nearest hospital emergency
room for evaluation.
Pregnancy-Related Emergencies14
Treatment of pregnancy-related emergencies is extremely complex. First aid
responders should activate EMS at any sign of sudden illness, complications, or
injury. All pregnancy-related abdominal injuries should be evaluated by a physician.
Position a pregnant woman on her left side to improve maternal blood flow and
A full term pregnancy lasts approximately 280 days from the first day of the last
normal menstrual period, and is divided into 3 "trimesters." The baby, or "fetus,"
develops in the mother's uterus. After this 9-month developmental process, the baby
emerges through a process termed "labor."
1st Trimester
Miscarriage: Loss of the pregnancy before the 20th week. One out of five
pregnancies results in a miscarriage. Causes of a miscarriage can include:
 Acute/chronic illness in the mother
 Abnormalities of the fetus
 Abnormal attachment of the placenta
Signs and Symptoms:
 Vaginal bleeding, often heavy
 Cramping abdominal pain
 Passage of tissue
Ectopic pregnancy: Occurs when the egg becomes implanted outside of the uterus.
As the egg begins to grow, it can rupture surrounding tissues and blood vessels.
Signs and Symptoms:
 Lower abdominal pain (Abdominal pain in a female patient of childbearing age
should be considered an ectopic pregnancy until proven otherwise.)
 Signs of shock
 Missed menstrual period
2nd Trimester
Complications during the 2nd trimester are relatively rare, although miscarriages
may occur during this time.
3rd Trimester
Abruptio Placenta: Occurs when the placenta (the organ which nourishes the
fetus) prematurely separates from the wall of the uterus. A large placental
separation can result in massive maternal bleeding and fetal death. This condition is
more likely if the mother has a history of hypertension, many pregnancies, or a
previous history of abruptio placenta. This occurs in one out of 400 pregnancies.
Signs and Symptoms:
 Sudden severe, constant abdominal pain
 Bleeding, dark red (not always present)
 Signs of shock
 Frequently occurs after trauma (e.g. a fall or motor vehicle accident)
Placenta Previa occurs when the placenta (normally situated near the top of the
uterus) forms over the opening to the birth canal. It can result in severe bleeding as
the uterus opens during the start of labor and tears the placenta. This occurs most
often in women over the age of 35, or women who have had many previous
Signs and Symptoms:
 Painless vaginal bleeding, bright red
 Signs of shock
Pregnancy Induced Hypertension (PIH), formerly called eclampsia, develops
gradually during the pregnancy. It is characterized by sudden weight gain, blurred
vision, swelling of the face/hands/feet, and an increasing blood pressure. The most
serious complication of PIH occurs during the 3rd trimester, when the patient may
develop seizures. Seizures are very harmful to the fetus because they deprive it of
Treatment for all pregnancy-related emergencies:
1. Assess response, breathing, circulation and appearance.
2. Treat for shock; place mother on her left side.
3. Maintain temperature.
4. Save any passed tissue.
5. Rapid transport to the hospital emergency room (activate EMS).
Childbirth is seldom an emergency situation, but all first aid providers should be
prepared to assist with the delivery and initial care of the newborn.
Labor is characterized by 3 phases:
First Phase: The onset of labor to the opening of the birth canal.
Labor contractions are generally a cramping pain that radiates from the front to the
back, at approximately 5 – 15 minute intervals. They become increasingly longer,
more intense, and closer together as delivery of the baby nears. Labor can last
many hours.
Typically, labor becomes shorter and less severe with each
subsequent pregnancy.
Second Phase: The opening of the birth canal to the delivery of the baby.
This phase is the actual delivery of the newborn. You can determine that birth is
imminent if:
 Contractions are less than five minutes apart.
 The mother feels an urge to push or bear down. Do not let her go to the
If delivery is imminent you should assist the mother by supporting the infant as
he/she emerges. DO NOT PULL! Protect the infant from falling; he/she will be very
slippery. You can anticipate about two cups of blood-tinged fluid to be expelled with
the baby.
Your first priority after delivery of the newborn is to assess response, breathing,
circulation and appearance. Provide ventilation as needed. The baby’s temperature
must be maintained: quickly but gently dry off the baby and wrap him or her in
blankets; ensure that the head is insulated and the face is visible.
Third Phase: Delivery of the baby to the delivery of the placenta.
This phase is the delivering of the placenta. The mother will begin to feel
contractions again, and in 15-30 minutes will deliver the placenta. Transportation to
the hospital should never be delayed waiting for the delivery of the afterbirth.
Abnormal presentations: Usually the baby presents headfirst. On a rare occasion,
an arm, leg or buttocks (breech) appear first, or the umbilical cord protrudes from the
birth canal. These are all true emergencies and usually require a C-section to
deliver the baby. The best treatment is safe, rapid transport to the emergency room.
Activate EMS (call 9-1-1).
Choking Management- Adult, Child and Infant
Choking is a common cause of unintentional injury in a child or infant, even though it
is preventable. Severe airway obstruction, if not treated in the first few minutes, will
result in death. Treatment is usually successful, with survival rates above 95%. Most
deaths from choking occur in children younger than 5; 65% of them are infants.
When teaching FBAO management, instructors should focus on preventing the
causes of choking, recognizing a choking emergency, understanding and
recognizing the difference between mild and severe obstructions, and treatment of
the responsive and unresponsive choking victim.
Although studies have shown that chest thrusts, abdominal thrusts, and back blows
(slaps) are all effective in relieving an obstruction, students are trained to give only
abdominal thrusts to a responsive victim age 1 or older for simplicity of training.
Infants are given a combination of chest thrusts and back slaps. Chest thrusts are
given to a large or pregnant victim, and CPR is given to an unresponsive victim of
choking. 3
Causes of Choking in the Unresponsive Victim
When a person is unresponsive, the tongue is the most common cause of
obstruction. The tongue may fall backwards into the upper airway and block the
entrance of air. Other causes of choking in the unresponsive victim can also include
blood from head and facial injuries, and regurgitated (vomited) stomach contents.
Causes and Prevention of Adult Airway Obstruction3,4,64
Any time a responsive person suddenly stops breathing, becomes cyanotic (blue)
and eventually becomes unresponsive, choking should be considered a potential
cause of the person’s condition, especially in a younger victim. Signs such as
coughing or stridor (high-pitched sound), without accompanying fever or other
respiratory symptoms, may also indicate a serious obstruction.
Common factors that contribute to choking in a responsive adult include poorly
chewed food, elevated blood alcohol level, dentures, and talking and laughing while
eating. Meat is the most common food associated with adult choking.
Tips to Prevent Adult Choking:
1. Cut food into small pieces; chew completely and eat slowly.
2. Denture wearers should exercise extra caution when eating.
3. Avoid talking and laughing when chewing and swallowing food.
4. Avoid excessive alcohol intake.
Causes and Prevention of Child and Infant Airway Obstruction
Most reported episodes of choking in infants and children occur when parents or
caregivers are close by, usually during eating or play. Food or small objects are the
most common obstructions in children, while liquid obstructions, such as juice or
formula, are the most common obstructions in infants and younger children.3,4
Tips to Prevent Child and Infant Choking
1. Cut food into small pieces; chew completely and eat slowly.
2. Encourage children to sit at the table until finished eating; do not allow them to
run or otherwise play with food or objects in their mouth.
3. Avoid talking and laughing when chewing and swallowing food.
4. Do not have objects around small children and infants that will fit through a
standard roll of toilet paper.
Recognition of Choking3,4,64
Knowing what to do won’t help if rescuers don’t recognize the emergency. Rescuers
need to be able to differentiate between a choking emergency and other
emergencies such as fainting, heart attack, seizure, asthma, stroke, or other causes
of acute respiratory distress or unresponsiveness.3
The sudden onset of respiratory distress associated with coughing, gagging, or a
high-pitched noisy or wheezing sound when breathing (stridor) should cause
rescuers to consider a choking emergency. Be alert to potential choking while a
person is eating or a small child is playing.
Airway obstructions can be classified into two groups: mild obstruction and severe
obstruction. During a mild airway obstruction the victim will be able to breathe with
good air exchange, as evidenced by a forceful cough or the ability to speak or cry
audibly. If the victim of a mild airway obstruction has good air exchange and can
cough forcefully, do not interfere, as coughing is the best way to relieve an
Severe Airway Obstruction
A victim with a severe airway obstruction is unable to breathe, speak, make sounds,
or cough effectively. These signals usually develop suddenly with no other signs of
illness or infection.
Signs of a severe choking emergency include:
 Inability to speak, cry or make sounds
 Weak, ineffective cough
 Cyanosis (blue color, especially around the lips and fingernail beds)
 High-pitched sounds with inhalation (stridor) or wheezing
 Difficulty or no breathing
 Bulging, tearing eyes
 Universal sign of choking (an adult or child may grasp the throat with one or
both hands)
Relief of Choking in a Responsive Child or Adult3
Immediate action is required for a severe obstruction. The foreign object blocking the
airway needs to be removed quickly, or the victim will soon become unresponsive
and die.
Abdominal thrusts, also known as the Heimlich maneuver, are the preferred
technique to relieve an obstruction in the responsive adult and child (age one or
older). Abdominal thrusts performed in the subdiaphragmatic area (below the
diaphragm) elevate the diaphragm, increasing airway pressure and forcing air from
the lungs. This creates an artificial cough and expels the foreign body from the
1. Identify if the victim is choking by asking, “Are you choking?”
2. If the victim nods “yes” or is unable to speak, he or she has a severe
obstruction. Do not leave the victim if you are alone with him or her.
3. With the victim sitting up or standing, stand behind the victim and wrap your
arms around his or her midsection, keeping your arms under the victim’s
arms. For a child or shorter victim, you may need to kneel down.
4. Make a fist with one hand and place it just above the navel, well below the
xiphoid process (tip of the sternum), with the thumb side against the
5. Grasp the fist with your other hand and perform a quick inward and upward
6. Repeat the abdominal thrusts one after another until the obstruction is
relieved or the victim becomes unresponsive. Deliver each thrust with the
intent to relieve the obstruction.
Relief of Choking in a Responsive Infant4
When the choking victim is an infant age one or younger, use a combination of back
blows (slaps) and chest thrusts. If the victim is older than one year, use abdominal
thrusts, as with an adult victim.
Perform Back Slaps and Chest Thrusts:
1. Identify if the victim is choking; observe for inability to cry or cough effectively,
cyanosis, bulging or tearing eyes. If the victim is unable to make sounds or
has other signs of severe airway obstruction, send a bystander to call 911. Do
not leave the infant if you are alone with him or her.
2. Hold the infant face down with the head slightly lower than the chest, resting
on your forearm. Support the head by grasping the jaw, not the throat. Rest
your forearm on your thigh to support the infant.
3. Deliver 5 back slaps forcefully in the middle of the back between the infant’s
shoulder blades.
4. Place your free hands on the infant’s back and turn the infant while carefully
supporting the head and neck.
5. Hold the infant face up, with the head lower than the body.
6. Provide 5 quick downward chest thrusts using the same landmark and hand
position as those of infant CPR (lower half of the sternum), approximately 1
per second. Give each thrust with the intention of creating an “artificial cough”
to dislodge the foreign body.
7. Repeat the sequence of 5 back slaps and 5 chest thrusts until the object is
expelled, the infant cries or becomes unresponsive.
Complications Associated with Abdominal Thrusts
Abdominal thrusts may lead to complications, such as damage to the internal
organs. Victims who receive abdominal thrusts should be evaluated by a physician to
rule out any serious complications. Minimize the risk of complications by ensuring
your hands are located below the xiphoid process and above the navel in the midline
of the stomach area during abdominal thrusts.
When dealing with an infant, there is a lack of protection of the upper abdominal
organs by the rib cage, creating additional risk of injury during the performance of
abdominal thrusts. Because of the increased risk of injury, abdominal thrusts are not
recommended for the relief of choking in an infant victim.
Chest Thrusts on a Pregnant or Large Victim
When a person is pregnant or large, the method of using abdominal thrusts to
remove an FBAO is not recommended. Rescuers may not be able to reach around
the midsection of a pregnant or large victim. Rescuers should use chest thrusts
instead of abdominal thrusts if the victim is pregnant to provide a more effective
method of removing the FBAO, and to avoid injury to the fetus. Use the following
1. Stand behind the victim and wrap your arms around the chest, under the
2. Place one fist in the middle of the victim’s sternum, above the xiphoid process
with your thumb against the chest. This is the same location as chest
compressions in CPR.
3. Grasp the fist with your other hand. Perform continuous backward thrusts until
the object is expelled or the victim becomes unresponsive.
Unresponsive Adult Choking Victim3
When a rescuer is performing abdominal thrusts on a responsive adult who becomes
unresponsive, use the following guidelines.
1. Pull the victim close to your body and assist to the ground.
2. Send a bystander to call 911; if alone with an adult victim, immediately
activate EMS, then return and begin CPR.
3. Perform CPR with the added step of looking in the mouth after each set of
compressions. If you see the obstruction, remove it and continue CPR.
a. If you see the obstruction, sweep it up and out of the mouth with your
gloved finger.
b. Do not blind sweep the airway.
4. Perform CPR until the victim begins to breathe normally.
Unresponsive Child or Infant Choking Victim3,4
When a rescuer is performing abdominal thrusts on a responsive child choking victim
who becomes unresponsive, use the following guidelines.
1. Place the victim on the ground or on a firm, flat surface such as a desk.
2. Send a bystander to call 911. If alone with a child or infant victim, perform
CPR for two minutes before going to call 911.
3. Perform CPR with the added step of looking in the mouth after each set of
compressions. If you see the obstruction, remove it and continue CPR.
a. If you see the obstruction, sweep it up and out of the mouth with your
b. Do not blind sweep the airway, especially in a child or infant.
4. Call 9-1-1 after about 2 minutes of CPR.
a. You may bring an uninjured infant with you to the phone.
5. Perform CPR until the victim begins to breathe normally.
Alone and Choking
A choking victim can attempt abdominal thrusts on him or herself to relieve an
FBAO. Caution: These methods can cause internal injury.
Self-Administered Abdominal Thrusts
Make a fist with one hand and place it with the thumb side against the abdomen,
above the navel and below the xiphoid process. Grasp the fist with your other hand
and perform quick upward thrusts.
Another option when alone and choking is to use a firm surface to perform the
abdominal thrusts. The victim should press the upper abdomen over the back of a
chair, side of a table, railing, or any firm surface. Several thrusts may be needed to
relieve the obstruction.
You can also call 911 from a land line and leave the phone off the hook. Go outside
to attract attention and wait for help.
Cold Emergencies
Hypothermia occurs when the core body temperature drops to 95° F or below. It may
result when the body loses more heat than it produces. The body’s internal control
mechanism fails to maintain the normal body temperature of 98.6° F. Nearly 700
people die of hypothermia annually in the U.S.
There are five ways that the body loses heat:
 Conduction: Losing heat from touching an object that is colder than the body.
 Convection: Heat transfer from the circulation of currents from one region to
another. (e.g. A person wearing lightweight clothing outside loses heat to the
air when cool air moves across the body.
 Evaporation: Body heat is lost when sweat or water evaporates from the
 Radiation: Heat loss from being in a cold environment (e.g. a cold room, or
 Respiration: The exhalation of warm air from the lungs releases body heat.
Immersion in cold water is the most common cause of hypothermia. Your body loses
heat in water up to 25 times faster than it does in air. The colder the water, or the
longer you are in the water, the less the chance of survival. Hypothermia does not
occur solely in extremely low temperatures. Cases have been recorded in
temperatures as high as 65° F. Hypothermia can be mild, moderate or severe.
Death due to cardiac and respiratory failure may result within hours of the first signs
and symptoms.
The greatest risk is to the elderly and very young, whose body temperature
regulation mechanisms do not work as well or are not fully developed. Children in
general are more prone to heat loss because they tend to lose more heat through
their head, which is disproportionately larger than an adult’s head. They also may
not take adequate precautions against the cold. Homeless people and those who
are exposed to the elements are also at risk. People with medical conditions that
impair sensation, blood flow or movement, and those who are mentally ill or
impaired, have an increased risk for hypothermia. Alcoholics are also at higher risk.
Signs and Symptoms:
 Shivering is the body’s attempt to generate heat. (It will stop after the body
core temperature drops below 90° F.)
 Cold, gray skin
 Drowsiness
 Slurred speech
 Exhaustion
 Unresponsiveness
 Abnormally slow breathing rate
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Remove from cold environment.
4. Remove damp clothing; replace with warm and dry clothing, blankets, etc.
5. Insulate head – victim can lose up to 70% of body heat through the scalp.
6. Place victim in warm environment (inhalation re-warming).
7. Use your own body heat to warm the person.
8. If far from medical care, warm with heat pads or containers of warm water.
Keep a barrier between heat source and skin.
Do not manipulate extremities. Doing so forces cold blood back to the heart, which
may result in cardiac arrest.
Do not give alcohol or coffee (caffeine).
Do not apply direct heat if near medical care.
When the person is transported to the hospital, the doctor may warm the person
from the inside out. The person may receive warm fluids directly into a vein (I.V.), or
in a severe case of hypothermia, may receive hemodialysis to remove the blood,
warm it rapidly outside the body, and then return it to the body.
Frostbite is caused by prolonged exposure to cold as body tissues actually become
frozen. As the tissue begins to freeze, ice crystals develop, damaging the cells in
the frozen area. It most commonly affects the hands, feet, cheeks, ears and nose.
Frostbitten skin appears white and waxy, and feels numb and hard. Frostnip (white,
numb skin) is an early indication of frostbite. Prevent frostbite by recognizing the
early signs of frostnip.
Children are more at risk of developing frostbite than adults, as they lose heat more
rapidly than adults, and they may be more reluctant to go indoors from their outdoor
Signs and Symptoms:
 Pale, cold, waxy skin
 Painful, burning sensation, or numbness
 Blisters
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Remove victim from environment.
4. Remove wet clothing; replace with dry clothing, blankets, etc.
5. Place frostbitten part next to your body.
6. Remove rings, bracelets and watches.
7. Avoid partial thawing and refreezing. It may cause severe tissue damage.
Do not pop blisters.
Do not re-warm with direct heat (over a stove, open flame or with heating pad).
Do not rub frostbitten skin.
It is critical that a victim of frostbite receive emergency medical help right away. If
help is delayed, you can warm severely frostbitten hands or feet in warm (not hot)
water (about 100-104° F). Do not let the frostbite victim determine the water
temperature, because he or she cannot feel the heat and may be severely burned. It
is important that the frozen areas slowly warm, over 25-40 minutes, to avoid causing
tissue damage.
As the frozen tissue gradually thaws, it will become red and painful. Keep warming
frostbitten parts until normal sensation, movement and color have returned. Cover
the frostbitten areas with dry sterile dressings, and do not disturb any blisters.
Tips to Prevent Hypothermia and Frostbite:68
 Wear extra clothing in loose layers to keep you warm in cold weather.
 Wear clothes that are windproof and water-resistant.
 Cover your head, hands and feet when outdoors in cold weather.
 Keep as dry as possible.
 Be aware of changing weather conditions and wind chill factor.
 Pay attention to early signs of hypothermia.
 Take frequent breaks indoors to warm up.
 Keep your vehicle in good repair to avoid risking a break down in cold
 Heat your home in cold weather, especially at night.
 Drink warm, sweet drinks for energy. It takes energy to keep your muscles
 Do not drink alcohol to keep warm. Although alcohol gives a temporary
“warming” sensation, it causes vasodilation, which lowers your body’s ability
to retain heat.
 Avoid overexertion in cold weather. Sweating in cold weather can cool the
body too much. If you do exercise, wear a base layer of clothing that will wick
(draw) sweat away from your body and keep your skin dry.
 If trapped in your car in the snow, avoid running your car for extended
periods, as fumes may enter the car. Snow may also block the exhaust
C-A-B (Compression-Airway-Breathing)3,70,71
Recognition of cardiac arrest, activation of EMS and immediate CPR is critical to
survival of Sudden Cardiac Arrest (SCA).
C-A-B stands for Compression, Airway and Breathing. The acronym identifies the
sequence of actions that give an SCA victim the best chance at survival. The C-A-B
sequence is used by community and professional responders for resuscitation of
adults, children and infants.
Check for Response
If a responder witnesses the sudden collapse of a person or finds a person down,
ensure the scene is safe and put on PPE, then check the victim for response.
Go to the side of the victim; tap the victim on the shoulder and shout, “Are you
alright?” Assess for any response that could be a sign of life, such as eyes opening,
moaning, breathing or talking. Checking for a response should only take a few
seconds. Do not delay calling 9-1-1 to check for breathing. If there is no response,
activate EMS.
Activate EMS
Any time a bystander is available, send him or her to call 9-1-1 and get an AED if
one is available. Identify a person and state, “You. Go call 9-1-1, get the AED and
come right back.” If there is more than one bystander, split the tasks. Other
bystanders can be sent to meet the EMS responders outside and guide them to the
When alone with an unresponsive adult victim, go call 9-1-1 yourself, and then check
for breathing.
Check for Breathing
Scan the victim for breathing for 5-10 seconds. If there is no breathing or only
gasping, immediately begin the C-A-B sequence starting with chest compressions.
C: Compression
When sudden cardiac arrest occurs, the victim usually has unused oxygen in the
blood and lungs.72 The problem is that the heart isn’t pumping it. By starting with
compressions, responders circulate the oxygenated blood already present in the
Quality chest compressions are directly linked to survival of SCA.73 Sadly, most
responders do not start compressions soon enough, or push fast or hard enough.74
Beginning quality compressions early and minimizing interruptions increases the
odds for survival. Delayed, interrupted or poor compressions have the opposite
Compressions are tiring and even the fittest responders fatigue quickly. If a second
responder is available, quickly switch responders every two minutes to maintain
good quality compressions. To begin the C-A-B sequence, the responder and the
victim must be positioned correctly.
Victim Positioning for Chest Compressions
Position the victim face up on a firm, flat surface. If the victim’s head is raised above
the heart, there is little to no blood flow to the brain. Soft surfaces, such as a bed or
couch, also prevent effective compressions. If the victim is found face down, roll him
or her as a unit, without twisting the neck or back. A victim who must be dragged
from a tight space can be pulled by the arms or legs along the long axis of the body.
Remove clothing if it interferes with compressions.
Responder Positioning and Hand Placement
Kneel at the victim’s side in a position that allows you to perform both chest
compressions and rescue breathing without repositioning. For chest compressions
position yourself over the victim with your shoulders directly over your hands so that
the thrust of each compression is straight down on the victim’s sternum
(breastbone). Your arms should be as straight as possible. Use your body weight,
not arm strength, to achieve proper depth.
Place your hands in the center of the chest on the lower half of the sternum. To
locate the proper area for hand placement:
1. Place the heel of one hand in the center of the chest between the nipples.
2. Place the heel of the other hand on top of the first.
3. Extend or interlace fingers to keep them off the chest.
Keep your hands above the tip of the sternum.
Chest Compression Technique
Perform chest compressions hard and fast; minimize interruptions and allow for full
chest recoil between each compression. Use the following techniques:
Rate: The rate of chest compressions is at least 100 per minute. Students can retain
the rate and tempo of chest compressions better when a metronome is used during
Clapping, using the EMS Safety DVD practice chapter, an AED compression
metronome or a familiar song (with 100 beats per minute) can all help responders
make the muscle brain connection to achieve the correct rate of chest compressions.
Ratio of Compressions to Breaths: Lay responders will provide 30 compressions
followed by 2 rescue breaths (30:2).
Depth: Compress the chest at least 2 inches for an adult victim.
Minimize Interruptions: The goal of chest compressions is to force oxygenated
blood to the heart and brain. It takes several compressions to build up enough blood
pressure and increase cardiac output to the point where the brain and heart are
being oxygenated.
When compressions are interrupted, the blood pressure drops much faster than it
builds. Interruption of chest compressions is a lot like trying to blow up a leaky
balloon. As soon you stop blowing, the air rushes out and you have to start all over
from the beginning. Interruptions to compressions drop blood pressure and reduce
cardiac output; the brain and heart are not receiving oxygen until the ‘balloon’ is full
Full Recoil Allowing the chest to fully expand between each compression is as
important as the depth of compression for maximizing blood flow with CPR. Often a
responder who is fatigued may lean on the chest. The responder needs to take his or
her full weight off the victim’s chest while maintaining hand-to-chest contact.
Restricting full recoil reduces cardiac output and makes compressions less effective.
Common Mistakes: Compressions
1. Crisscrossing hands: Keep hands parallel so the force of compressions goes
through the heel of the hands.
2. Improper hand placement: Use the center of the chest between the nipples
(adult, child). Keep hands off lowest portion or tip of sternum (xiphoid
process). Lift fingers off chest wall.
3. Compressions from the side: Rocking back and forth. Instruct students to
compress straight up and down (like a piston) with shoulders over hands.
4. Bent arms: Keeping arms straight and using body weight rather than arm
strength (bent arms) reduces fatigue.
5. Too shallow: Most responders don’t press hard enough. Instruct students to
compress harder, at least 2 inches for adults.
6. Too fast or too slow: Using a metronome, clapping or a familiar song (100
beats/min) during practice helps students learn and retain the correct
compression rate.
7. Not enough recoil: Remove all weight from the chest between compressions
but keep hands in contact with the chest.
8. Bouncing compressions: Students may try to achieve full recoil by bouncing.
Instruct students to lift all body weight off the chest between each
compression while maintaining hand contact with the chest.
A: Airway
After 30 compressions, open the airway quickly and efficiently by tilting the head
back and lifting the chin. It should not take more than a few seconds to position the
head for rescue breaths.
The tongue is the most common cause of airway obstruction when an unresponsive
victim is on his or her back. When it relaxes, the tongue falls into the back of the
throat, blocking the passage of air. Tilting the head and lifting the chin moves the
tongue out of the way of the trachea, allowing air to flow.
Head Tilt/Chin Lift
The head tilt/chin lift method is the preferred way for a lay responder to open the
airway of an injured or non-injured victim.
1. Place one hand on the victim’s forehead.
2. Place 2 or 3 fingers of your other hand near the chin.
3. With the hand on the forehead, apply firm, backward pressure with your palm,
tilting the head back.
4. While tilting the head, use the fingers of the other hand to lift the jaw upward
to bring the chin forward and the teeth almost to occlusion.
Keep your fingers on the bony part of the jaw. Do not press deep into the tissue
under the chin. Do not use your thumb to lift the chin.
If the victim wears dentures, the head tilt/chin lift will help keep loose dentures in
place, creating a better seal around the mouth. Remove the dentures if they cannot
be kept in place.
No Jaw Thrust for Lay Responders3
Lay responders are not taught the jaw thrust technique. It is difficult to teach and
learn. Often, attempting a jaw thrust creates more neck movement with poor airway
management. Lay responders are usually able to use the head tilt/chin lift more
effectively and safely than the jaw thrust, even for victims with suspected spinal
injury. The jaw thrust technique is only taught to professional responders.
B: Breathing
After 30 compressions, quickly open the airway and provide two rescue breaths,
then immediately resume compressions.
The oxygen that remained in the victim’s body in the moments following SCA will
need to be replaced through rescue breaths. The exhaled air from rescue breaths
contains enough oxygen to keep a victim alive for a short time.
Rescue breaths should be delivered carefully; provide just enough air to see a visible
chest rise. Do not over-inflate the lungs. Do not breathe too hard or too fast.
Excessive breaths (over-inflation of the lungs) causes gastric inflation which leads to
vomiting, reduces cardiac output by decreasing the venous return to the heart, and
can reduce the odds for survival of SCA.3
Avoid Over-Inflation of the Lungs
1. About 1 second each breath
2. Visualize the chest during each breath. When the chest begins to rise, stop.
3. Take a regular-sized breath, not deep, to fill your lungs. Regular breaths
reduce over-inflation of the victim’s lungs and decrease dizziness or
lightheadedness of the responder.
Steps for Rescue Breaths: Mouth-to-Mouth
1. Maintain an open airway with a head tilt/chin lift.
2. Pinch the victim’s nose.
3. Inhale a regular-sized breath.
4. Seal the victim’s mouth with yours.
5. Breath into the victim’s mouth, approximately one second.
6. Look for chest rise.
7. Break the seal by lifting your mouth off the victim’s mouth.
8. Repeat for a second breath.
9. Immediately resume compressions after two breaths.
It should take no more than 10 seconds to stop compressions, deliver 2 rescue
breaths, and resume compressions.3
If you are unable to deliver the first breath, reposition the head and reopen the
airway, then attempt a second breath. If the breath still does not enter (no chest rise)
after repositioning, immediately resume chest compressions.
Common Mistakes: Rescue Breaths
1. Head Tilt/Chin Lift: Not enough head tilt will block the adult’s airway.
2. Failure to pinch the nose: Air will come out of the nose and not enter the
lungs. Pinch the nose during rescue breathing.
3. Not creating a seal: Press your lips firmly on the victim’s lips.
4. Not visualizing chest: Look toward the chest to see it rise with rescue breaths.
5. Over-inflation of lungs: Watch for chest rise.
6. Multiple attempts at repositioning: If the chest doesn’t rise, attempt to
reposition only once, then proceed to chest compressions.
C-A-B Sequence: Adult Victim
1. Check response (tap and shout). If no response:
2. Call 9-1-1, get the AED (send a bystander if available)
3. Check for breathing. If no breathing or only gasping:
4. C-A-B: 30 Compressions
5. C-A-B: Open Airway (head tilt/chin lift)
6. C-A-B: 2 Breaths
7. Repeat cycles of Compressions and Breaths
CPR Barriers
CPR barriers are small, portable devices that are designed to help prevent the
transmission of disease during rescue breathing by providing a barrier between the
victim and the responder. Although barrier devices have not been proven to
decrease the risk of infection transmission, responders are encouraged to carry a
CPR barrier device with them. The risk of acquiring an infection while performing
CPR is very low, but the use of a barrier device may overcome a responder’s
hesitation to provide rescue breathing.3
CPR barrier devices are small enough to be carried on a key chain, in a first aid kit,
glove compartment, desk drawer, purse or briefcase, golf or gym bag, or even a
pocket. They come with various features, and can be broken down into two major
categories: face masks and face shields.
Face Mask
The CPR face mask is a transparent, molded, mask-like plastic piece designed to fit
over the mouth and nose of a victim. Some face masks have a two-way valve that
diverts the victim’s exhaled air away from the responder. Most have a one-way valve
that will require the mask to be lifted off the victim’s face between breaths and during
chest compressions. Some face masks come with an oxygen inlet allowing for the
use of supplemental oxygen.
Proper Fit of the Face Mask
To be effective the face mask needs to fit properly to create a seal. Masks that are
too big or too small will not work. The face mask fits properly when:
 The narrow top of the mask does not extend past the bridge of the nose.
 The wide bottom of the mask does not extend past the chin.
Using a Face Mask
The responder is positioned at the side of the victim in the same location as CPR
with mouth-to-mouth rescue breaths.
1. Apply the mask to the victim’s face and create a seal.
a. Place the thumb and index finger of your upper hand (closest to the top
of the victim’s head) along the upper border of the mask.
b. Place the thumb of your lower hand on the lower border of the mask,
and the remaining fingers along the chin and bony part of the jaw.
2. Perform a head tilt/chin lift while lifting the jaw.
3. Pull the face into the mask and press firmly to maintain the seal.
4. Breathe into the mask for 1 second; observe for chest rise.
5. Break the seal if needed to let air escape the lungs.
Face Shield
A CPR face shield is a waterproof plastic shield that usually contains a built-in oneway valve and/or filter. The advantage to using a face shield is that it is smaller and
more portable than the face mask, and is therefore more likely to be on or near a
responder at the time of an emergency that requires rescue breathing.
Using a Face Shield
1. Place the opening (filter or valve) over the mouth of the victim.
a. If a valve is present, position it in the victim’s mouth, between the teeth.
2. Open the airway with a head tilt/chin lift, pinch the victim’s nose closed, and
seal your mouth over the valve or filter of the face shield.
3. Breathe into the shield for 1 second, and observe for chest rise with each
4. Allow the victim’s exhaled air to escape between the shield and the victim’s
face by lifting your mouth off the shield between each breath.
Adult CPR5
In the adult population, the cause of cardiac arrest is usually heart-related. Early and
effective chest compressions and early AED use are critical actions that give adult
victims the best chance of survival.
In any emergency situation, such as the witnessed sudden collapse of an adult, it is
easy for the responder to feel overwhelmed. Breaking the CPR sequence into
smaller parts makes the techniques easier to learn and more likely to be performed
successfully in a real emergency. This section will teach how to perform adult CPR
using the C-A-B sequence.
Defining the Adult Victim
For the purpose of CPR, the adult victim is anyone who shows signs of puberty:
underarm or facial hair for males, and breast development for females.
Adult CPR Using the C-A-B Sequence
1. Check response
a. Tap and shout.
b. If no response:
2. Activate EMS and get an AED, if one is nearby.
a. Yell for help.
b. Send a bystander to call 9-1-1 if available.
3. Check for breathing.
a. Turn the victim face up if needed.
b. Scan the chest for breathing for 5-10 seconds.
c. If no breathing or only gasping, begin CPR.
4. C-A-B: 30 Compressions
a. Position: Face up on a firm, flat surface.
b. Location: 2 hands in the center of the chest between the nipples.
c. Rate: At least 100/minute
d. Depth: At least 2” down
e. Allow full chest expansion between compressions.
5. C-A-B: Open Airway
a. Use the head tilt/chin lift to open the airway.
6. C-A-B: 2 Breaths
a. Give 2 rescue breaths for about 1 second each.
b. Watch for chest rise.
c. Do not over-ventilate.
7. Repeat cycles of 30 Compressions and 2 Breaths.
a. After 2 breaths, immediately resume compressions.
b. Minimize interruptions.
c. Take no more than 10 seconds to stop compressions, give 2 rescue
breaths, and resume compressions.
Child CPR4
The techniques of Child CPR are slightly different than those for adults due to
physical differences and also a difference in the usual cause of cardiac arrest.
Cardiac arrest in a child usually results from respiratory arrest, not from a cardiac
problem. Common causes include injury, poisoning, choking, drowning, and asthma.
It’s important to recognize and react to the signs of a child in distress before it leads
to cardiac arrest.
Child and Infant cardiac arrest victims typically need CPR before defibrillation. This is
why responders who are alone will provide 2 minutes of CPR before leaving to
activate EMS.
Chest compression techniques are also different. The depth of compressions for a
child victim is 1/3 the depth of the chest, or about 2 inches. A responder may use 1
or 2 hands to perform compressions.
Defining the Child Victim
For the purpose of CPR, the child victim is anyone from age 1 to just before puberty.
If the child shows signs of puberty (underarm or facial hair for males, and breast
development for females), treat the victim as an adult.
Child CPR Using the C-A-B Sequence
1. Check response
a. Tap and shout.
b. If no response, yell for help.
c. Send a bystander to call 9-1-1 if available.
2. Check for breathing.
a. Turn the victim face up if needed.
b. Scan the chest for breathing for 5-10 seconds.
c. If no breathing or only gasping, begin CPR.
3. C-A-B: 30 Compressions
a. Position: Face up on a firm, flat surface.
b. Location: 1 or 2 hands in the center of the chest between the nipples.
c. Rate: At least 100/minute
d. Depth: About 2” down
e. Allow full chest expansion between compressions.
C-A-B: Open Airway
a. Use the head tilt/chin lift to open the airway.
C-A-B: 2 Breaths
a. Give 2 rescue breaths for about 1 second each.
b. Watch for chest rise.
c. Do not over-ventilate.
Repeat cycles of 30 Compressions and 2 Breaths.
a. After 2 breaths, immediately resume compressions.
b. Minimize interruptions.
c. Take no more than 10 seconds to stop compressions, give 2 rescue
breaths, and resume compressions.
Activate EMS and get the AED.
a. If you are still alone after 5 cycles of CPR (about 2 minutes), stop CPR
to go activate EMS and get an AED, if one is close by.
b. Return quickly and resume CPR until EMS arrives or the child begins
to move.
If EMS is already activated, provide continuous cycles of 30:2.
Use an AED as soon as it is available.
Note: When performing chest compressions with one hand, do not use the free hand
to hold the airway open. Rest it on the floor. Attempting to open the airway while
compressing the chest may cause injury to the head or neck.
Infant CPR4
The techniques for Infant CPR are slightly different than those for child and adult
Cardiac arrest in an infant also usually results from respiratory arrest. Common
causes include injury, choking, SIDS, and respiratory illness. Recognize and react to
the signs of an infant in distress before it leads to cardiac arrest.
The depth of compressions for an infant victim is 1/3 the depth of the chest, or about
1 ½ inches. A responder will use 2 fingers to compress the chest. Open the airway to
neutral. During mouth-to-mouth rescue breathing, the responder covers the infant’s
mouth and nose.
Defining the Infant Victim
For the purpose of CPR, the infant victim is up to 1 year old, based on body weight
and size.
Infant CPR Using the C-A-B Sequence
1. Check response
a. Tap the bottom of the foot and shout.
b. If no response, yell for help.
c. Send a bystander to call 9-1-1 if available.
2. Check for breathing.
a. Turn the infant face up if needed.
b. Scan the chest for breathing for 5-10 seconds.
c. If no breathing or only gasping, begin CPR.
3. C-A-B: 30 Compressions
a. Position: Face up on a firm, flat surface.
b. Location: 2 fingers in the center of the chest, just below the nipple line.
c. Rate: At least 100/minute
d. Depth: About 1 1/2 inch down
e. Allow full chest expansion between compressions.
4. C-A-B: Open Airway
a. Use the head tilt/chin lift to open the airway.
b. Only open the airway to neutral. Overextending the neck may actually
close block airway.
5. C-A-B: 2 Breaths
a. Give 2 rescue breaths for about 1 second each.
b. Cover the mouth and nose with your mouth.
c. Watch for chest rise.
d. Do not over-ventilate.
6. Repeat cycles of 30 Compressions and 2 Breaths.
a. After 2 breaths, immediately resume compressions.
b. Minimize interruptions.
c. Take no more than 10 seconds to stop compressions, give 2 rescue
breaths, and resume compressions.
7. Activate EMS.
a. If you are still alone after 5 cycles of CPR (about 2 minutes), stop CPR
to go activate EMS.
b. Bring the infant to the phone if not injured or too heavy.
c. Return quickly and resume CPR until EMS arrives or the infant begins
to move.
8. If EMS is already activated, provide continuous cycles of 30:2.
Special Consideration: CPR
Electrical Shock
Because our circulatory and respiratory systems work on electrical signals from the
brain and heart, exposure to an electrical shock or lightning strike can result in
respiratory or cardiac arrest.
When dealing with the victim of an electrical shock, your own safety is the primary
concern. Electricity can easily travel from the victim to the rescuer with direct contact.
Before rendering aid, make sure that the power source has been shut down and the
victim is not touching the power source. Turn off the fuse box or unplug the
appliance. In cases where the victim is outside, the power company may have to be
Cold Temperatures
During the instruction of CPR, we teach rescuers that brain damage will begin four to
six minutes after the victim’s breathing and circulation have stopped. In a cold
environment, however, this time frame may be extended. Situations that involve
hypothermia and/or cold water drowning may provide rescuers with more time to
oxygenate the brain.
Do not assume it’s too late to start CPR when in a cold environment. A common
saying among professional rescuers who work in the cold is, “A person isn’t dead
until they’re warm and dead.”
Hypothermia occurs when a person’s body temperature falls below the normal
functioning range and the body loses more heat than it produces. In hypothermic
situations the body’s metabolism (the breakdown and use of stored energy and
creation of waste product) slows down, reducing the need for oxygen.
The result of hypothermia is that brain cells take longer to die. In a cold environment
CPR can be started later than normal with less risk of brain damage or death. If the
victim is not breathing, begin CPR immediately. If the victim is responsive, gently
remove him or her from the cold environment, remove damp clothing, dry and
insulate. Activate EMS.
Similar to hypothermia, cold water drowning can extend the amount of time for CPR.
In 1974 a case was documented in which a victim was submerged for over 40
minutes, removed from the water, declared dead, and then started to breathe on the
way to the morgue. He fully recovered. There have been many cases since then in
which the cold water delayed or prevented the onset of brain damage or death.
Remove the victim quickly from the water, but pay attention to your own safety. Once
the victim is removed from the water, begin CPR immediately. If the rescuer has
special training, rescue breathing can be started while the patient is still in the water.
Mouth-to-nose rescue breathing may be easier while in the water than mouth-tomouth.
In some cases the drowning is termed a “dry drowning” because laryngospasm
occurred, preventing water from entering the lungs. If the person did aspirate water,
there is still no need to clear the airway of water because it will not act as an
obstruction in the airway.
Studies have shown that vomiting is frequently associated with drowning. If the
victim vomits during CPR, log roll him or her to the side, remove the vomitus with
your finger, then return the victim to supine to continue CPR.
Vomiting During CPR
A person in cardiac arrest will often vomit. Vomiting is not a sign of circulation; it only
means that trapped air escaped the stomach. Vomiting can lead to aspiration and
If the victim vomits during CPR, quickly but carefully turn the victim’s body to the
side, clear the mouth by wiping out any foreign contents with your finger, return the
victim to the supine position (on the back) and continue CPR.
Try to prevent vomiting by providing just enough air to make the chest rise during
rescue breaths (not over-ventilating). Be prepared for vomiting by knowing what to
do and using proper personal protective equipment.
Cardiac Arrest in a Pregnant Person
When treating a pregnant victim, you may need to accommodate the person’s
physiological differences.
 A pregnant victim may have an elevated diaphragm due to the increased
abdominal contents. Hand placement for chest compressions should be
slightly higher on the sternum, just above the center, to accommodate the
diaphragm and abdominal contents.
 The recovery position should be on the person’s left side to improve
 Use an AED if indicated. Saving the mother is the best chance of saving the
CPR Alternatives
There are alternatives to traditional CPR methods that may benefit a cardiac arrest
victim, depending on the circumstances of the emergency.
Compression-Only CPR72
The lay responder should feel confident that he or she can perform both
compressions and ventilations. Untrained responders and those who are unable or
unwilling to give rescue breaths should perform chest compressions without rescue
breaths. This is called Compression-Only CPR, or Hands-Only CPRTM by the
American Heart Association.
To do Compression-Only CPR, provide continuous chest compressions at a rate of
at least 100 per minute without pausing. The victim will receive oxygen as
compressions force air in and out of the lungs.
After the witnessed collapse of an adult victim:
1. Call 9-1-1.
2. Place hands in the center of the chest.
3. Push HARD and FAST, at least 100 times per minute.
Compression-only CPR is for the witnessed sudden collapse of an adult victim. It is
not to be used for children or infants, or for adults with cardiac arrest due to
suffocation (e.g. drowning). Children, infants, and adult victims of suffocation
require rescue breaths to improve the odds for survival.
Mouth-to-Nose Rescue Breathing
A rescuer may use mouth-to-nose rescue breathing for the following reasons:
inability to open the victim’s mouth; serious injury to the mouth; and when a tight seal
around the mouth is difficult to obtain.
Drowning Victims and Mouth-to-Nose Rescue Breathing:70 During drowning
situations, rescuers may benefit from the use of mouth-to-nose breathing while the
victim is still in the water. Responder’s hands are often occupied with supporting the
victim’s head and shoulders, making a chin lift difficult. If the rescuer has special
training, mouth-to-nose breathing can be started immediately after the victim’s head
comes out of the water. Otherwise, remove the victim from the water as quickly as
possible and begin CPR. Do not attempt compressions in the water.
To provide mouth-to-nose breathing:
1. Open the airway.
2. Close the victim’s mouth.
3. Breathe into the nose, sealing your lips around the victim’s nose.
4. Lift your mouth from the victim’s nose to allow passive exhalation.
5. Open the victim’s mouth periodically to allow free exhalation.
Mouth-to-Stoma Breathing
Rescuers should use mouth-to-stoma breathing when a person has a tracheostomy
(a surgical opening at the neck used for breathing) and needs rescue breathing. A
tracheostomy tube is used to maintain a clear stoma. If the tracheostomy tube is
obstructed and cannot be cleared, it will need to be removed.
To provide mouth-to-stoma breathing:
1. Seal your mouth over the stoma.
2. Breathe into the stoma; observe for chest rise.
3. Lift your mouth from the victim to allow passive exhalation.
4. If necessary, apply a face mask or seal the victim’s mouth and nose to
prevent significant air escape.
When to Stop CPR
Adult CPR is repeating the C-A-B sequence over and over. Repeat the sequence of
compressions, airway, breathing as long as possible.
Stop CPR if:
1. The victim begins to move, moan or respond.
2. Help arrives and is ready, by your side, to relieve you.
3. An AED is attached and prompts you to stop CPR.
4. You are exhausted and unable to continue.
5. The airway is blocked by a visible obstruction. Remove the obstruction or roll
the victim to the side and clear the airway, then resume CPR.
6. The scene becomes unsafe
Complications from CPR
Complications can occur during CPR, even when it is performed correctly.
Complications Associated with Chest Compressions
Complications from chest compressions may include a fractured sternum or
separation of the ribs from the sternum. When a rib breaks it may cause other
problems internally, such as a punctured lung or perforated liver.
Do not let the risk of injury to the victim impede prompt and vigorous CPR; the
alternative to CPR is death. If a rib fractures, do not stop or reduce CPR efforts.
Recheck hand position and continue CPR.
To minimize rib and internal injury resulting from chest compressions, rescuers
should ensure proper placement of the hands and positioning of the rescuer. Remain
directly over the victim; maintain contact with the chest (i.e. no bouncing
It should be noted that these types of injury rarely occur in children and infants, who
have softer and more flexible bones than adults.
Complications Associated with Rescue Breathing
Complications from rescue breathing usually result from gastric inflation – air
entering the stomach. When air enters the stomach during rescue breathing, it
becomes trapped and the stomach begins to fill as more air is introduced.
Gastric inflation causes regurgitation (vomiting), aspiration (foreign matter enters the
lungs, possibly leading to infection), pneumonia, decreased venous return, and
decreased lung capacity due to the distended abdomen elevating the diaphragm.
Reduce the risk of exposure by being prepared with PPE, including a CPR barrier
mask, in case the victim vomits.
The usual cause of complications from rescue breathing is improper chin and head
positioning. If air doesn’t enter the lungs, avoid forcing air; reposition the airway one
time and give a 2nd breath. If the second breath does not cause the chest to rise,
resume compressions.
If there is gastric inflation, do not attempt to manually relieve the distention of the
abdomen, as this will almost certainly cause vomiting.
Two Rescuers: Lay Responder70
When two rescuers are present, one should go activate EMS and get an AED, if
available, while the other begins CPR. After returning from activating EMS, the
second rescuer should be ready to relieve the first.
CPR is hard work. After only a couple minutes of continuous CPR, the rescuer will
be tired and out of breath. Studies have shown that compression rate and depth
decrease with rescuer fatigue. If there is a second trained rescuer, he or she may
rotate performing CPR and observing every 2 minutes. The rescuers should be
positioned on opposite sides of the victim.
Although two trained rescuers can effectively share the tasks of CPR, with one
providing rescue breaths and the other performing compressions, it requires practice
and coordination. It is easier and often more effective for lay providers to relieve one
another rather than perform 2-rescuer CPR. Professional rescuers and health care
providers are trained to provide 2-rescuer CPR.
CPR/AED Overview
Chain of Survival3
The purpose of this topic is to demonstrate the stark realities of cardiac arrest in the
United States and the importance of how a coordinated response can increase the
odds for surviving a cardiac arrest.
Clinical vs. Biological Death
The first few minutes of cardiac arrest is where the trained bystander can make the
difference between life and death. People who suffer cardiac arrest, especially SCA,
need rapid intervention to restore oxygen flow to the brain or brain cells will begin to
die. After 4–6 minutes of cardiac arrest, the brain will suffer permanent, irreversible
brain damage. After 10 minutes without oxygen the brain is dead. The goal of
bystander CPR is to restore oxygen flow to the brain and sustain life until
professional help arrives.
When cardiac arrest occurs, the victim is clinically dead. Clinical death is reversible.
Brain death (the death of all brain cells), also known as biological death, usually
occurs within 10 minutes of cardiac arrest if effective CPR is not started. Biological
death is irreversible.
Increasing the Odds
There are five critical interventions to increase the cardiac arrest victim’s chance of
survival. Delays in initiating care or between each step decrease a person’s chance
of surviving a cardiac arrest. The key concept you will teach your students is early
intervention. Early intervention saves lives.
1. Activate EMS: Recognize cardiac arrest and activate the Emergency Medical
Services (EMS) by dialing an emergency number. In most communities the
number to dial is 9-1-1. If a person is unresponsive to a shout and tap, teach
your students to instruct a bystander to quickly call 9-1-1, get the AED and
return to you. If your student is alone with an adult victim, teach him or her to
go call 9-1-1, get the AED and return.
 The dispatcher will gather the information and simultaneously be
routing the appropriate emergency personnel to the scene.
 The call will only take a few moments.
 Teach your students to be prepared to give their name, location and
the nature of the emergency, and always hang up last.
 9-1-1 operators can help provide instructions to the bystander.
2. Early CPR: Basic Life Support, or BLS, is a term referring to CPR. The earlier
BLS care is delivered, the better the odds of survival. Properly performed
CPR, when initiated immediately after cardiac arrest, can reduce loss of brain
cells, sustain life until trained professional help arrives, and increases the
chance of successful defibrillation.
3. Early Defibrillation: Early defibrillation is critical to surviving sudden cardiac
arrest, especially in the adult patient. In previous years bystanders relied on
the arrival of the paramedics to provide life saving electrical shocks known as
defibrillation. Today, lay rescuers can provide defibrillation with an AED before
the arrival of EMS personnel, giving the victim the best chance of survival.
4. Early Advanced Care: By calling 9-1-1 early, the bystander can initiate the
next link in the chain of survival. EMS responders trained in Advanced List
Support (ALS) can provide advanced airway management and drug therapy in
addition to CPR on the scene and en route to the hospital. The effectiveness
of ALS depends on high-quality BLS.
5. Post-Arrest Care: Once the heart is beating and stabilized, doctors, nurses,
therapists, and many others will continue to provide care to improve the
chance of continued survival with the least amount of disability.
Pediatric Chain of Survival
The chain of survival is slightly different for children, since the cause of cardiac arrest
is usually related to respiratory arrest. The pediatric chain of survival emphasizes
prevention and chest compressions.
1. Prevention of Arrest
2. Early CPR
3. Activate EMS
4. Early Advanced Care
5. Post-Arrest Care
Anatomy and Physiology
The cardiovascular system is comprised of the heart, blood vessels and blood. It is
responsible for the delivery of oxygen to the cells. The heart is the main pump in the
body. Arteries are vessels that transport blood away from the heart to the tissues,
while veins carry blood back to the heart. As the blood circulates, oxygen is
exchanged for carbon dioxide, which is transported out of the body through the
interaction of the cardiovascular and respiratory systems.
The heart is a hollow organ responsible for moving blood throughout the body. It is
about the size of your fist and is located in the center of your chest behind your
breastbone. The coronary arteries provide a fresh supply of oxygenated blood to the
heart muscle to keep it alive.
The heart is divided into four chambers. The chambers on top are the right and left
atria, and the chambers on the bottom are the right and left ventricles. The septum is
a thick muscle wall that separates the right and left sides of the heart.
When electrically stimulated, the atria contract and pump blood from the top of the
heart to the ventricles below. The ventricles contract and pump blood to the body
tissues. First the atria pump, followed by the ventricles. The pumping action of the
heart is controlled by the electrical conduction system (pacemakers) of the heart.
The right atrium receives deoxygenated blood from the body and pumps it into the
right ventricle. From the right ventricle the deoxygenated blood is pumped into the
lungs. As we exhale we blow off carbon dioxide, a waste product. Inhalation brings
fresh oxygen to the lungs. From the lungs the freshly oxygenated blood is pumped
into the left atrium, down into the left ventricle, through the aorta to the body.
The Electrical Conduction System of the Heart
All muscular movement in the body is stimulated by electrical impulses. The brain
sends impulses down the spinal cord and through the nerves, which causes
individual muscles to contract. The heart, however, is unique. Its electrical impulses
originate from within and it doesn’t rely on the brain for stimulus to beat. The
electrical impulses are generated by a series of specialized cells called pacemakers.
The chief pacemaker of the heart is the sinoatrial node (SA node), located in the
right atrium. The SA node is a group of specialized muscle cells that creates
electrical impulses at a specific rate. These impulses are conducted down the fibers
of the heart’s specialized conducting system, from the top to the bottom of the heart.
As the electrical impulse travels, it stimulates the heart muscle to contract, creating a
heartbeat and moving oxygenated blood throughout the body.
Other pacemaker cells in the heart can take over the work of pacing (stimulating) the
heart’s pumping action. If the chief pacemaker fails, the heart can continue to pump
because of these back-up pacemakers.
Ventricular Fibrillation
During a heart attack the heart muscle is deprived of oxygen. Cardiac cells in the
affected area become irritated from the decreased supply of oxygen. Pacemaker
cells also become irritable and premature contractions begin to occur, further
depleting the oxygen supply to the heart.
As the heart works harder to obtain more oxygen, it demands more oxygen to
compensate for the increased workload. More oxygen demand means more
electrical impulses. As the heart is overloaded with electrical impulses, it may go into
a lethal rhythm known as ventricular fibrillation.
During ventricular fibrillation the heart is overwhelmed by chaotic electrical impulses.
The heart quivers or twitches erratically instead of following its normal pumping
action. The heart stops beating and the person becomes unresponsive due to a lack
of oxygen to the brain.
CPR Overview
CPR is an abbreviation for Cardiopulmonary Resuscitation. When a person suffers
cardiac arrest, CPR is used to restore blood flow to the brain. The goal of CPR is to
provide oxygen to the brain to keep it alive until normal breathing and heartbeat
return. Bystander CPR, when performed early and correctly, is critical to survival of
cardiac arrest. Among cardiac arrest victims treated by EMS, only 31% received
bystander CPR!69
CPR combines external chest compressions with rescue breathing to provide oxygen
to the brain after a cardiac arrest has occurred. During CPR the rescuer becomes
the victim’s heart and lungs. The rescuer breathes into the victim’s mouth to pass air
into the lungs so that oxygen can enter the bloodstream. The fresh oxygen is
circulated to the brain when external chest compressions replace the pumping action
of the heart.
A common question during CPR is, “How can I exhale carbon dioxide (CO2) and still
be able to provide oxygen to a victim in need?” The answer boils down to simple
math. The air we breathe consists of many types of gases; 21% of it is oxygen. Our
body uses only about 5% of the oxygen we inhale. Our exhaled air contains
approximately 16% oxygen. This percentage is enough to sustain life.
The air is passed from the mouth through the trachea (windpipe) down into the
lungs. External chest compressions squeeze the heart between the sternum
(breastbone) and the spine. Chest compressions force the blood from the heart to
the lungs, where it picks up oxygen. The oxygenated blood is delivered to the brain
through continuous chest compressions.
As pressure on the chest is released, the heart fills with more blood (passive filling)
for the next compression. It is important to note that CPR is only about 30% as
effective at delivering oxygenated blood when compared to the normal, beating
heart. For rescuers this means that extended CPR times, without the return of
normal circulation, provides dismal outcomes.
To optimize the benefits of CPR, it must be performed on a firm, flat surface.
Compressions must be performed at the proper rate and depth, and with adequate
force. Prolonged pauses between cycles of compressions (e.g. taking too much time
for rescue breaths) allows the blood flow produced by the compressions to slow and
reduces oxygen delivery to the brain and heart. This decreases the survival rate.3,69
If compressions are not performed correctly, with minimal interruptions, and on a firm
enough surface, CPR will not be effective.
AED Overview
CPR can keep the brain alive for a short time after cardiac arrest, but it will not
restore a heartbeat in an adult victim of sudden cardiac arrest. A shock from a
defibrillator is needed to restore a normal heart rhythm. CPR keeps the brain alive
while EMS is activated and paramedics rush a defibrillator to the scene.
The defibrillator shocks the heart with electricity to momentarily stop the chaotic
electrical impulses and help it resume normal electrical conduction and, hopefully,
pumping. CPR provided immediately after collapse increases the likelihood that
defibrillation will be effective, and can significantly increase a victim’s chance of
survival. If bystander CPR is not provided, an SCA victim’s chance of survival
decreases 7-10% for every minute that passes without a shock from a defibrillator.69
An AED is a small, portable defibrillator brought to the scene and used by lay
providers prior to the arrival of EMS. Reducing the time between cardiac arrest and
defibrillation dramatically increases the effectiveness of defibrillation and provides
the victim with the best chance to live.
The AED is a sophisticated tool that is easy to use. It assesses the cardiac rhythm of
an unresponsive victim and determines if a shock is needed. If needed, the user is
prompted by a series of voice and on-screen commands to provide a shock.
The heart rhythm analysis and electrical shock are delivered through electrode pads
that are placed on the victim. By attaching the adhesive pads to the victim’s bare
chest, then connecting them to the AED, the rescuer provides the connection that
the AED needs to begin its analysis of the cardiac rhythm (the electrical activity of
the heart). The AED sends the signal of the electrical activity of the heart through the
electrodes to a microprocessor that records and analyzes the cardiac rhythm to
determine if it is consistent with VF or other shockable rhythms. If a shock is needed,
it is delivered from the AED, through the electrodes, and into the victim.
Most AEDs operate under the same principles. If a defibrillation is needed, the AED
prompts the rescuer to prepare for defibrillation while it charges up. The AED
delivers a rapid, powerful electrical current through the heart. The powerful current
creates a pause of the overloading electrical activity in the heart, giving a chance for
the normal cardiac rhythm to take over and restore the pumping action.
The AED requires the user to attach electrodes to the victim. Most AEDs require the
user to turn on the unit, connect the electrodes to the AED, and press the shock
button when instructed. Some AEDs power up automatically when the case is
opened, and the electrodes come pre-connected to the unit. Other AEDs are fully
automatic and will shock without the push of a button once a shockable rhythm is
Defibrillation within 3-5 minutes of collapse will produce the highest survival rates.
When placed in the hands of lay rescuers, trained workplace responders, security
officers and law enforcement, AEDs reduce the time to defibrillation, increasing
survival rates. The time from collapse to defibrillation, in conjunction with bystander
CPR, are the most important determinants of survival from cardiac arrest.
AEDs are often made available to the public through Public Access Defibrillation
(PAD) programs sponsored by many municipalities. AEDs are commonly seen in
police cars, at airports, stadiums, sporting events, shopping malls, golf courses,
schools, and other public venues. Although the widespread use of AEDs in the U.S.
could save numerous lives each year, only about 2% of cardiac arrest victims have
an AED applied by a lay responder before EMS arrives.69
Dental Emergencies
Dental trauma is extremely common. Five million teeth are knocked out each year.
Dental emergencies may include a fractured, loosened or displaced tooth, or
avulsed (knocked out of the socket) tooth. Most dental trauma occurs in children
and is preventable. Use mouth guards and face shields when appropriate during
sports to significantly reduce the incidence of injury. When driving, always wear a
seat belt and ensure that young children are in a car seat. Do not chew ice, hard
candy, or popcorn kernels, as they can crack a tooth.
Knocked-out Permanent Tooth76,77,78,23
While a baby tooth does not need to be put back in, fast action is critical to save an
avulsed permanent tooth. If a tooth is quickly placed back in its socket with minimal
handling, it is usually retained permanently. If reimplantation is delayed, the success
rate for long-term retention drops, and root resorption usually occurs. Ideally, a
patient should see his or her dentist within 30 minutes of an injury, one hour at
the longest.
A person with an avulsed tooth should not try to reinsert it back in the socket him or
herself. A consensus of medical experts has determined that the potential harm from
attempting to reinsert a tooth exceeds the potential benefit.
1. Handle the tooth by the crown (biting edge), not the root.
2. Rinse the tooth gently in water if dirty, but do not scrub it. Touching or
cleaning the root could remove periodontal ligament fibers and reduce the
chance of successful reimplantation.
3. Cleanse the bleeding wound with clear water or saline.
4. Place the tooth in a container of cool milk, or water if milk is unavailable. DO
NOT let the tooth dry out.
5. Bite down on a sterile gauze pad or clean cloth to control bleeding.
6. Apply an ice pack wrapped in a moist cloth to the face near the injury.
7. See a dentist within 30 minutes, or one hour at the longest, to replant the
tooth. The longer the tooth is out of the mouth, the less likely it can be saved.
8. Remain alert for signs of airway compromise due to blood or broken teeth.
If an avulsed tooth is lost, the patient should have a chest x-ray to determine if the
tooth was aspirated (inhaled) or swallowed. A patient may also require antibiotics
and a tetanus shot.
Broken or Loose Tooth
1. A broken or chipped tooth should be held in place with sterile gauze until
you can contact your dentist. Locate and save any broken tooth fragments.
2. A loose or displaced tooth should be gently repositioned without forcing the
tooth. Stabilize the tooth by biting down.
Rinse your mouth with warm water.
Apply an ice pack wrapped in a moist cloth to reduce swelling.
Contact your dentist immediately.
Avoid drinking or eating until you have consulted the dentist.
Although not a medical emergency, a toothache can be very painful. It is usually a
sign of tooth decay, and is a common problem with a long onset. A toothache can
also indicate an infection. Field treatment options are limited and include rinsing the
mouth with water, and removing any food trapped between the teeth with dental
floss. Avoid sweets, very hot or cold liquids, and gum chewing.
Do not medicate the tooth. Placing crushed aspirin or another painkiller on a tooth
may burn the gum and destroy tooth enamel. Seek care from a dentist as soon as
Jaw Injury80,81
A jaw fracture is suspected after trauma if there is pain on palpation, swelling, limited
opening of the mouth, a new malocclusion (poor bite), irregularity in the contours of
the face, diplopia (double vision), or facial anesthesia (numbness).
To reduce pain from a possible jaw fracture, close the mouth and immobilize the jaw
by splinting it with gauze. If a gauze roll is unavailable, use a towel, shirt or necktie
to secure the jaw. Avoid interfering with the airway and do not over-tighten. Remain
alert for airway complications. Apply an ice pack wrapped in a moist cloth to the
fracture site to reduce swelling. Seek professional medical attention promptly. If
there is airway obstruction or uncontrollable bleeding, activate EMS.
Bitten/Bleeding Tongue, Lip or Cheek75
Control bleeding by applying direct pressure to the affected area using a sterile
gauze pad. Use an ice pack wrapped in a moist cloth to reduce swelling. Apply
continual pressure for at least six to ten minutes. If you are unable to control or stop
the bleeding after 15 minutes, activate EMS (call 911) or go to a hospital emergency
Observe for signs of airway compromise. Position the person so that blood is
allowed to drain out of the mouth, either sitting up with the head tilted slightly down,
or in the recovery position. Blood that is swallowed can irritate the stomach and
cause vomiting. In the unresponsive patient, blood or teeth from a mouth injury can
obstruct the airway or be aspirated.
Diabetic Emergencies
Diabetes is one of the leading causes of death and disability in the United States. It
is a serious, lifelong condition that is associated with long-term complications that
affect almost every part of the body. The disease often leads to blindness, heart and
blood vessel disease, stroke, kidney failure, amputations, and nerve damage.
Uncontrolled diabetes can complicate pregnancy, and birth defects are more
common in babies born to women with diabetes.
What is diabetes?83,84
Diabetes mellitus is a group of diseases characterized by high levels of blood
glucose. It is a disorder of metabolism – the way our bodies use digested food for
growth and energy. Most of the food we eat is broken down into glucose, the form of
sugar in the blood. Glucose is the main source of fuel for the body.
After digestion, glucose passes into the bloodstream, where it is used by cells for
growth and energy. For glucose to get into cells, insulin must be present. Insulin is
a hormone produced by the pancreas, a large gland behind the stomach.
When we eat, the pancreas automatically produces the right amount of insulin to
move glucose from our blood into our cells. In people with diabetes, however, the
pancreas either produces little or no insulin, or the cells do not respond appropriately
to the insulin that is produced. Glucose builds up in the blood, overflows into the
urine, and passes out of the body. Thus, the body loses its main source of fuel even
though the blood contains large amounts of glucose.
Almost 26 million people in the United States (8.3% of the population) have diabetes.
Of those, 19 million have been diagnosed, and about 7 million people have not yet
been diagnosed. Each year, about 1.9 million people aged 20 or older are diagnosed
with diabetes.
 27% of adults over age 65 has diabetes.
 Adults with diabetes have heart disease-related death rates up to 4 times
higher than adults without diabetes.
 Risk of death is twice as high among people with diabetes when compared
to those without diabetes.
 Diabetes is the leading cause of new cases of blindness (12,000-24,000
each year)
 Diabetes is the leading cause of new cases of blindness among those
aged 20-74 years.
 Diabetes is the leading cause of non-traumatic amputations. Over 65,000
people have diabetes-related leg, foot or toe amputations each year.
Types of Diabetes82,83
There are three main types of diabetes: type 1 diabetes, type 2 diabetes, and
gestational diabetes.
Type 1 diabetes (previously called insulin-dependent diabetes mellitus, IDDM, or
juvenile-onset diabetes), is an autoimmune disease. The immune system attacks the
insulin-producing beta cells in the pancreas and destroys them. The pancreas then
produces little or no insulin. A person who has type 1 diabetes must take insulin daily
to live.
Type 1 diabetes develops most often in children and young adults, but can appear at
any age. Symptoms of type 1 diabetes usually develop over a short period, although
beta cell destruction can begin years earlier. Symptoms include increased thirst and
urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not
diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a
diabetic coma.
Type 2 diabetes (previously called non-insulin-dependent diabetes mellitus, NIDDM,
or adult-onset diabetes) is the most common form of diabetes. About 90 to 95
percent of people with diabetes have type 2. This form of diabetes is associated with
older age, obesity, family history of diabetes, previous history of gestational diabetes,
physical inactivity, and ethnicity. Type 2 diabetes is increasingly being diagnosed in
children and adolescents.
When type 2 diabetes is diagnosed, the pancreas is usually producing enough
insulin, but for unknown reasons, the body cannot use the insulin effectively, a
condition called insulin resistance. After several years, insulin production decreases.
The result is the same as for type 1 diabetes – glucose builds up in the blood and the
body cannot make efficient use of its main source of fuel.
The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as
in type 1 diabetes. Symptoms may include fatigue or nausea, frequent urination,
unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of
wounds or sores. Some people have no symptoms. Often, the only way we become
aware that a person has the disease is if a problem arises.
Gestational diabetes develops only during pregnancy. Like type 2 diabetes, it
occurs more often in African Americans, American Indians, Hispanic Americans, and
among women with a family history of diabetes. Women who have had gestational
diabetes have a 35 to 60 percent chance of developing type 2 diabetes within 10 to
20 years.
People with pre-diabetes, a state between “normal” and “diabetic,” are at risk for
developing diabetes, heart attacks, and strokes. Studies show that weight loss and
increased physical activity can prevent or delay the development of type 2 diabetes
among high-risk adults. Studies have also shown that medications have been
successful in preventing diabetes in some population groups. About 35%, or 79
million, Americans aged 20 or older have pre-diabetes.
Diabetes Management83
People with diabetes can take steps to control the disease and lower the risk of
complications. Glucose, blood pressure and blood lipid control, along with preventive
care for eyes, kidneys and feet, can prevent serious complications. While some
control their diabetes by proper diet, others need to take medication to keep it in
check. The primary goal of diabetes management is to keep blood glucose levels as
close to the normal range as safely possible.
Today, healthy eating, physical activity, and taking insulin via injection or an insulin
pump are the basic therapies for type 1 diabetes. The amount of insulin must be
balanced with food intake and daily activities. Blood glucose levels must be closely
monitored through frequent blood glucose testing.
Healthy eating, physical activity, blood glucose testing and losing excess weight are
the basic management tools for type 2 diabetes. In addition, many people with type 2
diabetes require oral medication, insulin, or both to control their blood glucose levels.
Diabetic Emergencies
People with diabetes must take responsibility for their day-to-day care. Much of the
daily care involves keeping blood glucose levels from going too low or too high.
There are two primary emergency medical problems associated with diabetes:
diabetic coma, which is related to hyperglycemia, and insulin shock, which is
related to hypoglycemia. Signs and symptoms can occur rapidly (insulin shock), or
may occur over a period of several days (diabetic coma).
Diabetic Coma85
A person can become ill if blood glucose levels rise too high (hyperglycemia).
There is not enough insulin in the body to break down the sugar for use as fuel.
When glucose is not available as a fuel source for the body, there is a buildup of
ketones (acids that are by-products of fat metabolism). The liver increases
production of glucose to combat the problem, but the cells cannot use the glucose
without insulin, so blood glucose levels become elevated. Without intervention, the
hyperglycemia will progress to diabetic coma (diabetic ketoacidosis, or DKA).
Sometimes an initial diagnosis of type 1 diabetes is made when the patient is in a
diabetic coma.
Early signs and symptoms of hyperglycemia include increased thirst, frequent
urination and dry mouth. A diabetic person may recognize the warning signs of
hyperglycemia and take appropriate action before the condition progresses. He or
she should contact a physician for further instructions or medication adjustment.
Severe hyperglycemia is a medical emergency. Ketoacidosis (dangerously high
levels of ketones) can result in cell damage, especially in those who have fallen into
a coma due to a delay in treatment. The condition can lead to severe illness or
Signs and Symptoms of Diabetic Coma:
 Dehydration
 Frequent thirst/urination
 Weak, rapid pulse
 Fatigue
 Muscular stiffness or aching
 Nausea, vomiting
 Abdominal pain
 Altered mental status (lethargy, confusion, coma)
 Rapid, deep sighing respirations
 A sweet or fruity odor on breath
 Gradual onset (may be over several days)
Insulin Shock86
Excessively low blood glucose (hypoglycemia) results from taking insulin but not
eating enough, or taking too much insulin. It commonly occurs when your body’s
glucose is used up too quickly, such as when you exercise without increasing food
intake, or exercise harder than usual. It may also occur when glucose is released
into the bloodstream too slowly (e.g. drinking alcohol).
Early symptoms of hypoglycemia include feeling shaky, nervous, irritable and
confused. Judgment can be impaired, so often family, friends and coworkers must
recognize the signs and symptoms of hypoglycemia, and know how to treat it. If a
person with diabetes has the early signs and symptoms of hypoglycemia, he or she
should check the blood glucose (if there is time and access to a meter), and eat or
drink something to quickly raise the blood glucose level. There should be an
immediate improvement in symptoms.
If blood glucose falls too low, it can result in a loss of consciousness, as the brain
needs glucose in order to function. Severe hypoglycemia is a medical emergency.
It can quickly lead to insulin shock, resulting in a loss of consciousness, seizures
and even death.
Signs and Symptoms of Insulin Shock:
 Altered mental status (confusion, irritability, aggression)
 General discomfort, nervousness or uneasiness
 Pale, cool moist skin
 Dizziness or headache
 Fatigue
Full, rapid pulse
Rapid onset
Tremors or seizures
Blurry or double vision
Treatment for Diabetic Coma and Insulin Shock:85,86
For the first aid provider, treatment is the same:
1. Assess response, breathing, circulation and appearance.
2. Activate EMS system (call 9-1-1).
3. Position of comfort.
4. If person is responsive, give sugar (orange juice, honey, syrup, or a sugar and
water solution).
5. If person is drooling, do not give anything by mouth. The person is unable to
protect his/her airway.
Sugar administration is recommended in all diabetic emergencies. Untreated
hypoglycemia will progress to insulin shock, which may cause serious brain damage
and respiratory arrest, ultimately leading to cardiac arrest. Administering sugar easily
reverses this. On the other hand, there is little risk of worsening the condition of a
person in a diabetic coma (severe hyperglycemia).
Examples of foods or drinks that can quickly raise your blood glucose level:
 4 oz. of orange juice
 A regular (not diet) soft drink
 Two teaspoons of sugar dissolved in water
 Hard candy (equal to about 5 Life Savers)
 Honey or syrup
 Glucose tablets (nonprescription sugar pills)
 Glucose gel (nonprescription form of sugar that is rapidly absorbed)
Avoid Diabetic Emergencies:
 Obtain medical clearance before beginning an exercise program.
 Discuss with your physician how to manage low or high blood glucose levels
during exercise.
 Learn your individual blood glucose response to exercise. Check your blood
glucose before and after exercise, and be consistent in the amount and
intensity of exercise.
 Drink water before, during and after physical activity.
 Always carry a ready source of fast-acting carbohydrates in case of low blood
 Wear a medical identification bracelet or necklace.
 Keep a record of each blood sugar measurement to help spot patterns and
potential problems. Plan ahead for factors that can affect your blood sugar.
 Be consistent each day in the time and amount of food you eat. Do not skip
Remember that light physical activities such as gardening, housework, or
standing for prolonged periods can affect your blood glucose.
Physical or emotional stress can cause your body to produce hormones that
prevent insulin from working properly, resulting in an increase in your blood
glucose level.
Physical stress includes illness (e.g. a cold, flu, infection, or heart attack) or
injury (trauma, surgery).
Emotional stress may cause you to neglect your regular daily routine.
Drink alcohol only moderately and always with food; choose drinks that are
lower in carbohydrates. Alcohol disrupts the liver’s normal production of
sugar. After drinking, your liver is occupied metabolizing the alcohol and does
not release its stored sugar when your blood glucose level begins to drop. If
you have diabetes-related complications, avoid alcohol completely.
Do not ignore early signs and symptoms of hyperglycemia or hypoglycemia.
Educate family, friends and coworkers about the signs and symptoms.
Eye Emergencies
Almost one million Americans have permanently lost some degree of sight due to an
eye injury. There are approximately one million new eye injuries each year. About
43% of them occur in the home. The leading causes include household chemicals,
yard and workshop debris, sports accidents, fireworks, battery acid, over-exposure to
UV radiation, and inappropriate games and toys with inadequate supervision. There
are about 40,000 sports-related eye injuries each year; 90% of them are
There are about 2,000 work-related eye injuries every day in the U.S. One third of
the injuries require treatment in the emergency department. Nearly 90% of all
workplace eye injuries are preventable with the use of proper safety eyewear.
The best way to avoid serious eye injury is to take precautions and wear appropriate
protective eyewear in the home, garden, workshop, workplace, and during sports
Eye injuries are the most common preventable cause of blindness. If you are unsure
about the need for medical attention, err on the side of caution. Do not delay
medical care; the injury could worsen and result in permanent vision loss or
Penetrating Trauma to the Eye90,91
Penetrating trauma to the eye can be upsetting for the rescuer and the victim.
Treatment is directed at stabilizing the object, not removing it.
1. Monitor response, breathing, and circulation.
2. Calm the person.
3. Send a bystander to activate EMS (call 9-1-1).
4. Control bleeding as necessary.
5. Cover the uninjured eye. The eyes move together, so covering the uninjured
eye will also reduce movement of the injured eye. Explain to the person what
you are doing.
6. Use a cup, bulky dressing and gauze roll to stabilize the object in place.
a. Remove the bottom of the cup, cutting a hole for the foreign object.
b. Secure the foreign body with a sterile dressing.
c. Place the hollow cup over the eye, being careful not to touch the
foreign object.
d. Secure the cup in place with gauze and tape.
7. Keep all pressure off the eye.
8. Do not remove an impaled object from the eye.
9. Do not attempt to wash the eye.
Debris in the Eye91
Small, loose foreign bodies in the eye will usually be removed by tears, which are
natural flushing agents.
1. Instruct the victim to blink several times.
2. Gently flush the area with lukewarm water. Use an eyewash station if one is
3. If flushing does not remove the object, use a swab or similar thin, stiff object
and lay it across the top of the eyelid.
4. Fold the lid over the swab and flush the eye with lukewarm water, or attempt
to remove with wet sterile gauze. Do not try to remove something that is
directly over the cornea; the particle might scratch the cornea and cause an
5. If you are unable to remove the source of irritation, seek medical care.
6. Do not rub the eye.
7. Do not apply ointments or creams.
Chemical Injury91
Chemicals splashed into the eye can lead to injuries causing loss of vision. It is
critical to immediately flush chemicals from the eye.
Tilt the head down toward the affected eye, and apply a gentle stream of water to the
bridge of the nose. The runoff water will then cross the eye and flush out the
chemical. Keep the affected eye lower than the unaffected eye to avoid flushing the
chemical into the unaffected eye. Flush the eye with copious amounts of water for at
least 20 minutes, keeping the eye open as widely as possible. Be sure to remove
contact lenses. Ensure that runoff water does not come into contact with other
rescuers, but goes directly down the drain or is contained.
Contact your local poison control center for specific instructions. Seek medical care
immediately. Take the label or chemical container with you.
Corneal Abrasions91
A corneal abrasion is a scratch on your cornea (the clear, protective single layer of
cells over the front surface of the eye). It can be caused by many things, including
dust, dirt, sand, a fingernail, tree branch or even a contact lens. When the cornea
becomes abraded, it is often described as a continual feeling that something is in the
eye. The cornea is very sensitive, so a corneal abrasion is usually very painful. The
eye may look red, or you may notice tears, blurred vision, or sensitivity to light. A
corneal abrasion must be evaluated by a physician. He or she will often provide
antibiotics and an eye patch.
Blow to the Eye91
Gently apply a cold pack to reduce pain and swelling. Do not apply pressure to the
eye. If the victim develops a black eye, pain, or changes in vision, see a physician
immediately. A black eye may be a minor injury, but it can also be a sign of a
significant eye or head injury.
Tips to Prevent Eye Injury…
In the Workplace:90,92,93
 Identify operations and areas that present eye hazards, such as working
around a chainsaw or sandblaster.
 Offer vision testing to your employees.
 Provide protective eyewear designed for a specific operation or hazard.
(OSHA’s eye and face protection standard, 29 CFR 1910.133, requires the
use of face and eye protection when workers are exposed to eye or face
hazards such as flying objects, molten metal, liquid chemicals, acids or
caustic liquids, chemical gases or vapors, or potentially injurious light
 Ensure that safety eyewear fits properly and is comfortable.
 Establish a written eye and face protection program, to be administered by a
qualified program administrator who is knowledgeable in eye and face
 Provide annual training on protective eyewear and eye safety. Make
participation in the safety program mandatory for management and general
 Train employees in first aid procedures for eye injuries, and ensure that they
have access to eyewash stations.
During Sports:
 Wear protective eyewear (helmet with face protection, sports goggles or face
shields) when there is a chance of eye injury.
At Home:
 Keep infant’s and young children’s fingernails cut short.
 Trim low-hanging tree branches.
 Apply contact lenses carefully.
 Pad or cushion sharp edges or corners of furniture and fixtures.
 Use seat belts and child safety seats when driving.
 Avoid toys that fly or fire projectiles, or that have sharp or rigid points or
 Keep chemicals and household products locked up securely.
 Use guards on power equipment.
 Be aware that regular eyeglasses do not always provide adequate protection.
 Wear safety goggles to protect against flying particles, and chemical goggles
to protect against exposure to pesticides and fertilizers.
Head Injuries
There are an estimated 1.7 million traumatic brain injuries (TBI) each year. More
than 230,000 victims require hospitalization and survive. About 52,000 people die
annually from TBIs. Common causes include traffic accidents, falls, accidents at
work, home, or during sports activities, or physical assault. Half of all TBIs are
caused by motor vehicle accidents.96
The skull protects the delicate brain inside. The brain is surrounded by
cerebrospinal fluid (CSF), which cushions it from the light bumps and bounces of
everyday activities. The fluid, however, may not be able to absorb the force of a hard
blow to the head or a sudden stop. The result can be brain injury from a severe
concussion or from tearing of nerve fibers or blood vessels around the brain (closed
head injury). An external object, such as a bullet or a nail, can also damage the
brain (penetrating head injury).
Head injuries can be classified as external, involving the scalp, or internal, involving
the skull, blood vessels or brain itself. Skull fractures may be obvious with open
wounds, or assumed because of how the injury occurred, or pain in the affected
area. A serious brain injury can be life threatening. Providing immediate first aid can
save a victim’s life.
Assume that any person with a head injury also has a neck injury. When caring for a
victim with a suspected head injury, stabilize the head and neck together to prevent
further injury. Do not continue the injury assessment. Monitor response, breathing,
circulation and appearance. Treat the victim in the position found. All head injuries
should be evaluated by a physician.
External Head Injuries95
Most falls or blows to the head result in external injuries. Scalp lacerations (small or
large wounds to the scalp or face) bleed profusely because the scalp is well supplied
with blood vessels. Treat a scalp laceration by controlling bleeding and providing
appropriate wound care. The person should be seen by a physician for a large or
deep laceration, or if there are any signs or symptoms of brain injury.
A hematoma, or “goose egg,” is a large swelling on the scalp after a blow. It is
caused by the scalp’s veins leaking blood into the tissue just beneath the skin. The
hematoma may last for several days or even weeks. Apply an ice pack wrapped in a
moist cloth to the area for 20 minutes, and observe for any signs of brain injury.
A “black eye,” or bruising around the eye, is the result of bleeding around the eye
and under the skin. Most black eyes are not serious and can be treated by gently
applying an ice pack wrapped in a moist cloth up to 20 minutes. Avoid any pressure
on the eye itself. Since bruising around the eyes can be a sign of brain injury or
even skull fracture, other symptoms of head injury must be evaluated carefully. If
there is bleeding within the eye, it can result in permanent damage to vision. Seek
emergency medical care if there is bleeding in the eye or from the nose, vision
problems, or other signs of head injury.
Trauma to the nose is usually caused by blunt injury. Consider the mechanism of
injury and a possible brain or cervical spine injury. Cervical spine immobilization may
be necessary. Control bleeding as necessary. Apply an ice pack wrapped in a moist
cloth to reduce swelling.
Consider a facial fracture if there is irregularity in the contours of the facial bones,
pain on palpation, or diplopia (double vision). Seek emergency medical care to
determine if the victim has sustained a fracture. Be observant for possible brain or
cervical spine injury. Cervical spine immobilization may be necessary. Control
bleeding as needed. Apply an ice pack wrapped in a moist cloth to reduce swelling.
With any external head injury, it is important to observe carefully for signs of internal
head injury. If the victim shows any changes in mental ability, behavior or physical
skills, or has a headache or vomiting, seek emergency medical care immediately.
Internal Head Injuries95,96,97,98,99
Any head injury that causes a period of unconsciousness indicates at least a
concussion, and maybe even a more severe injury.
A concussion is defined as a bruise to the brain, and may or may not include a
temporary loss of consciousness or amnesia of the period surrounding the injury.
The person with a concussion will sometimes repeat the same question to the
rescuer over and over again. A concussion is caused by a violent jolt (e.g. whiplash,
roller coaster) or blow to the head (e.g. a fall with the head striking an object, or a
moving object striking the head). A concussion is usually not life threatening, but
can have serious effects. The signs and symptoms may appear gradually and can
last for weeks. Early symptoms may be overlooked by the victim, family and friends.
There could be bleeding in or around the brain, or swelling of brain tissue. Although
a person who has had a concussion will usually make a full recovery, it is important
to watch closely for signs and symptoms of further brain injury (see below). A
physician should evaluate anyone who has suffered a loss of consciousness or
received a significant head injury. The physician may ask you to wake the person
during the night to make sure there are no further signs of a brain injury. If the
person displays signs or symptoms of brain injury, it is a medical emergency.
Activate EMS (call 9-1-1).
A subdural hematoma is a collection of blood on the surface of the brain, just below
the dura mater (outer covering of the brain). Those at most risk for a subdural
hematoma are victims of a head injury, the very young or very old, chronic alcohol
abusers, and persons taking anticoagulant medication (blood thinners). Symptoms
can take weeks or even months to develop, and may worsen as the hematoma
gradually increases pressure on the brain.
About 15% of head trauma victims develop a subdural hematoma. Many subdural
hematomas are so small they don’t cause any symptoms or need surgical removal.
More serious cases may result in permanent brain damage or even death. The
person may need a neurosurgeon to perform a craniotomy (opening a section of
skull to evacuate the hematoma) or drill a burr hole through the skull to drain the
trapped blood and relieve the pressure on the brain. If someone has symptoms of a
brain injury, activate EMS (call 9-1-1).
An epidural hematoma, or extradural hemorrhage, occurs when there is bleeding
between the dura mater and the inner skull. It happens more commonly in young
people, because the dura mater is not as firmly attached to the skull. Usually a
severe head injury causes a rupture of a blood vessel, which bleeds into the space
between the dura mater and the skull. A hematoma (collection of blood) develops,
pressing on the brain, increasing the pressure within the skull (intracranial pressure),
and causing further injury to the brain.
A skull fracture is a crack or break in the skull (the bony covering of the brain). It
can affect the brain directly by damaging brain tissue, or indirectly by resulting in the
formation of subdural or epidural hematomas, which increase pressure on the brain.
Common causes include motor vehicle accidents, falls, physical assault, and sports
injuries. Symptoms may be similar to those of other head injuries. Certain
symptoms may indicate a basilar skull fracture (fracture at the base of the skull):
bloody drainage from the nose or ear immediately after the injury, raccoon’s eyes
(bruises around the eyes), and Battle’s sign (bruising behind the ears) seen several
days after the skull fracture.
Signs and Symptoms of Head Injury:95
 Head trauma (bleeding, bruising, localized swelling, soft spots or indentations)
 Constant or recurrent headache
 Raccoon’s eyes (swelling and bruising under the eyes)
 Bruising behind the ears seen several days after a basilar skull fracture
(Battle’s sign)
 Confusion, amnesia, repetitive questions, slowed mental processing
 Slurred speech
 Nausea and repeated vomiting
 Difficulty with movement or sensation; loss of balance
 Blurred or double vision; unusual eye movements
 Unequal pupils
Bleeding from the nose, ears, eyes, mouth
Loss of consciousness
Ringing in the ears (tinnitus)
Abnormal breathing
Drowsiness, fatigue
Neck pain or stiffness
Loss of bowel or bladder control
Difficulty swallowing
Change in sleeping pattern (sleeping much longer or insomnia)
Change in behavior or mood (irritability, sadness, anxiety, listlessness)
1. Assess response, breathing, circulation and appearance.
2. Activate EMS system (call 9-1-1).
3. Immobilize cervical spine (neck) with your hands.
4. Control bleeding (do not apply direct pressure to a suspected skull fracture, as
this may increase pressure to the skull).
5. Monitor mental status.
6. Apply an ice pack wrapped in a moist cloth to the bruised area to control
swelling. Do not apply pressure.
7. If the person vomits, roll to the side to clear the airway, keeping the head and
neck stabilized.
8. Be prepared to report to EMS personnel the mechanism of injury, how long a
victim was unresponsive, initial and on-going assessments, person’s prior and
current mental status, and any past history of head injuries.
9. Do not move the victim unless it is absolutely necessary.
10. Do not remove a penetrating object.
11. Do not leave the person alone.
Shaken Baby Syndrome
Shaken baby syndrome is a form of child abuse with severe consequences. When
an infant or toddler is shaken, the brain bounces back and forth inside the skull,
causing brain bruising, swelling, and possible brain damage or death. The child is
usually younger than 2 years old, but it may be seen in children up to 5 years old.
Injury can occur with as little as 5 seconds of shaking. 7
Prevent Falls101
Falls are the leading cause of traumatic brain injury (TBI). People age 75 and older
have the highest incidence of injury and death from fall-related TBI. It’s important to:
 Reduce the risk for falls.
 Recognize a TBI after a fall.
 Get medical help immediately.
Tips to Prevent Head Injury: 102
1. Always wear a helmet when:
 Riding a bike, motorcycle, all-terrain vehicle or snowmobile
 Playing a contact sport such as football, boxing or ice hockey
 Using roller skates, in-line skates or skateboards
 Skiing or snow boarding
 Batting or running bases in softball or baseball
 Riding a horse
2. Select the right helmet.
 Make sure helmets fit properly (see manufacturers’ guidelines).
 Consider newer and more advanced helmet designs which may
provide better protection.
 Inspect equipment annually for signs of wear and tear. Follow
manufacturers’ and state athletic associations’ testing guidelines.
 Bike helmets should be worn directly on the top of the head, covering
the top of the forehead. They should not be tipped forward or back.
They should be snug, but comfortable. Make sure the chinstrap is
attached, and the helmet does not move side-to-side or front-to-back.
Most helmets can be customized for fit with the removable pads that
are included.
3. Parents and sports coaches should be well educated in the signs and
symptoms of a concussion. Coaches must know when to remove players
from a game or practice, and parents must be alert to signs of head injury,
since many epidural and subdural hematomas are slow to form.
4. Avoid participating in sports activities until cleared by a physician or
trained healthcare professional after a previous concussion with
unconsciousness. Studies have indicated that a person who has had a
prior concussion has an increased risk of serious brain injury and
even death in subsequent brain injuries.
5. Always wear a seat belt in a motor vehicle, and place infants and small
children in appropriate child car seats.
6. Keep firearms unloaded and locked away securely. Firearms are involved
in 10% of all TBIs, but 44% of TBI-related deaths.63
7. Prevent falls in the home.
a. Install child safety gates at the top and bottom of stairs.
b. Install handrails on stairways.
c. Use non-slip mats in tubs and showers.
d. Install grab bars next to the toilet and in the tub or shower.
e. When reaching for high objects, use a step stool, preferably with a grab
f. Install window guards to protect young children from falling out of
8. Make sure your child’s playground surface is made of a shock-absorbent
9. Do not dive into water if the depth is unknown.
10. Wear a hard hat when indicated at work.
For more information:
Brain Injury Association of America (BIAA)
(800) 444-6443
Heart Attack and Heart Disease
Heart disease is the leading cause of death in the United States. About every minute
someone dies of a coronary event in the United States. More than 1.25 million
Americans have a first or recurrent heart attack each year. About 70% of the deaths
from heart attack occur before the victim reaches the hospital. Heart disease is
The term heart attack can mean many different things to people. Instructors of CPR
and First Aid will have to explain to students what a heart attack is, the signs and
symptoms of a heart attack, and the appropriate actions to treat the symptoms of a
heart attack or other acute coronary syndrome (ACS). It is important to know the
difference between a heart attack and cardiac arrest, and understand that a heart
attack can lead to cardiac arrest.
Acute Coronary Syndrome (ACS)
ACS is a term that encompasses many different heart problems that may result in an
acute narrowing or blockage of the coronary arteries, leading to death or damage of
the heart muscle. It could cause sudden cardiac arrest (SCA). ACS can include
acute myocardial infarction (heart attack) and unstable angina.103
Angina pectoris is chest pain or discomfort due to inadequate blood flow and
oxygen delivery to the heart muscle. Angina can be stable, predictable episodes of
chest discomfort, often brought on by exertion or stress, and relieved by rest and/or
nitroglycerine. It can also be unstable, characterized by unexpected chest
discomfort, usually occurring at rest. Stable angina can become unstable, leading to
a heart attack.
To reduce confusion among lay providers and for simplification, ACS and unstable
angina will be described as a heart attack. ACS or heart attack often results from
coronary artery disease (CAD).
Coronary Artery Disease (CAD)
Coronary artery disease results from a disease process known as atherosclerosis.
Atherosclerosis is the thickening of the arterial walls from fatty deposits that
produce irregularities in the inner lining of the artery. Narrowing of the vessels results
in reduced blood flow and the inability of the artery to dilate when the heart requires
more oxygen. Atherosclerosis is a form of arteriosclerosis, also known as
“hardening of the arteries,” which causes a loss of elasticity in the vessel.
CAD creates increased risk for heart attack or other forms of acute coronary
syndrome. CAD is a process that begins slowly, through atherosclerosis, relatively
early in life. Almost 32% of children 2 – 19 years of age are overweight or obese.
Since being overweight or obese is a significant risk factor for heart disease, this
trend will make the fight against heart disease even more difficult in the future.
Cardiovascular disease is the underlying cause of death in 1 out of every 3 deaths in
the U.S.69
CAD can occur faster or slower in people depending on their weight, diet, fitness
level, age, sex, and family history, among other factors. The buildup of plaque inside
the arterial walls comes from fats and cholesterol contained in many of the foods we
eat. Cholesterol is carried by the blood and can attach to the artery walls. Over time
the arterial walls narrow, which leads to reduced blood flow.
Heart Attack104
The heart is a muscle that receives nutrients and oxygen through coronary arteries.
Because of CAD, a narrowed and hardened artery can easily become obstructed by
a fatty mass that has broken off from another vessel and traveled to the coronary
artery, or by a blood clot that has formed in the coronary artery (thrombosis).
A heart attack (myocardial infarction, or MI) occurs when a coronary artery is
blocked, causing prolonged inadequate blood flow and oxygen delivery to a portion
of the heart. The result is death of the heart muscle cells that are normally supplied
by the blocked coronary artery.
The severity of a heart attack is determined by the location and extent of the clot,
including how much heart tissue is affected. If the area of infarction (cell death from
lack of oxygen) is small, the heart may still function adequately. If the MI is large,
severe cardiac arrhythmias or SCA may occur.
Is a heart attack the same thing as cardiac arrest?
A heart attack and cardiac arrest are not the same thing. A heart attack is the death
of heart muscle. Cardiac arrest occurs when the heart stops pumping blood. When a
person’s heart stops unexpectedly with little or no warning, it is called sudden
cardiac arrest, or SCA. A heart attack may lead to cardiac arrest and sudden death,
but they are not the same thing.
Risk Factors Associated with Heart Disease69
There are risk factors that contribute to CAD and heart attack. Some risk factors are
controllable, while others are beyond our control. We should all be aware of the risk
factors and do what we can to prevent or reduce our risk of CAD and heart attack.
Combined risk factors significantly increase the incidence of CAD and the likelihood
of heart attack.
Controllable Risk Factors
Reducing the controllable risk factors associated with heart attack is important in
order to live a long and healthy life. Consult your doctor before beginning an exercise
program or significant lifestyle changes. Your doctor can identify your risk factors,
and then develop a plan to reduce your risk. Consider the following:
Smoking: Smoking is the number one preventable cause of serious illness such as
heart disease, stroke and lung cancer. It reduces the amount of oxygen in your
blood, and increases heart rate and blood pressure.
Physical Activity/Obesity: Regular physical activity improves blood pressure and
cholesterol levels, helps control weight, reduces the risk of diabetes and reduces
stress. Obesity (30 pounds or more overweight) is a significant risk factor for heart
attack and stroke. It is caused primarily by eating more calories than are burned
through daily activity. The excess calories are stored as fat. Maintain a healthy
weight with a varied, healthy diet, more appropriate portions, regular exercise and
increased daily activity. Consult your doctor prior to beginning an exercise program.
Diet: Foods that are high in saturated fat, trans fat and cholesterol contribute to heart
attack and stroke. Healthy foods (a variety of fruits, vegetables, whole grains, low in
saturated fat) reduce risk. High salt intake can lead to high blood pressure. Eat a
varied, healthy diet with plenty of fruit and vegetables.
Excessive Alcohol: Some studies have indicated that one or two drinks a day may
increase “good” cholesterol (HDL); however, heavy drinking can lead to high blood
pressure, heart disease and stroke.
High Blood Pressure and High Blood Cholesterol: Hypertension and high blood
cholesterol levels are direct contributors to heart attack and stroke. Keep levels low
through regular checkups with your doctor, exercise, a healthy diet and weight, and
medication as needed.
A good blood pressure is 120/80 mm Hg. If it’s over 120/80 mm Hg, have it checked
more often and report your findings to your doctor. High blood pressure is
considered to be 140/90 mm Hg or higher. Sustained high blood pressure
(hypertension) is known as the “silent killer,” since it occurs over years without any
signs or symptoms. Hypertension causes damage to the blood vessels and
increases risk of heart attack and stroke.
High levels of cholesterol are associated with heart disease. Low Density
Lipoproteins (LDL) carry cholesterol to the tissues and arteries. High Density
Lipoproteins (HDL) carry cholesterol to the liver to remove it from the body. When
there is too much LDL circulating in the bloodstream, plaques (cholesterol and other
materials) build up on the inside of the artery walls, leading to narrowing of the inside
of the artery and hardening of the artery wall. Good levels: <100 mg/dl LDL; >60
mg/dl HDL; <200 mg/dl total cholesterol.
Diabetes: Diabetes leads to vascular disease, which automatically increases the risk
of heart disease and stroke. Type 2 diabetes can often be prevented with a healthy
diet and weight.
Non-Controllable Risk Factors
Age: The older we get, the more risk of heart disease we have.
Sex: Men have higher death rates from CAD than pre-menopausal women. Women
have comparable death rates later in life.
Heredity: A family history of heart disease is a strong indicator of increased risk. For
persons with a family history of heart disease and stroke, it is even more important to
identify and control the other risk factors associated with CAD.
Race: African Americans are more likely than Caucasians to have high-blood
pressure, which can lead to heart disease and stroke.
Recognition of Heart Attack105
When a person suffers a heart attack (or other form of ACS), he or she usually has
some common signs and symptoms that should be considered a red flag. Call 9-1-1
right away when you recognize possible signs or symptoms of heart attack.
Signs and symptoms of a heart attack can occur in either sex, and even to young
adults at any time or place. Early recognition of the signs and symptoms associated
with heart attack or ACS combined with early action (activate EMS) is directly linked
to increased survival rates; delays in recognizing signs of heart attack are associated
with increased mortality.
Although CAD has a gradual onset, the signs and symptoms from a heart attack or
other ACS are usually sudden and intense. In many instances, a victim is not sure
what is going on, or is in denial of having a heart attack and waits too long for help. A
victim doesn’t have to “look bad” to be having a heart attack. If the following signs
and symptoms are present, call 9-1-1 (activate EMS):
Signs and Symptoms of Heart Attack (RED FLAGS)
 Chest Discomfort: Most heart attacks create some form of chest discomfort
in the center of the chest that will last for several minutes, or may go away
and come back. Chest discomfort is described as pain, pressure, crushing,
tightness, squeezing, or fullness (i.e. gas or bloated feeling).
 Radiating Discomfort: Discomfort from the chest can radiate or appear in
other areas of the upper body. Pain or discomfort can radiate down one or
both arms, to the back, neck, jaw, or stomach.
 Shortness of Breath: Sometimes shortness of breath occurs before the
chest discomfort, or is associated with the onset of chest discomfort. For
some victims the shortness of breath is more significant than the chest
 Associated Symptoms: Pale, cool, sweaty skin; nausea, vomiting; dizziness,
No one wants to believe that he or she is having a heart attack. Many times heart
attack victims deny their symptoms or attribute them to another cause. Common
statements include: “It’s indigestion or something I ate.” “It can’t happen to me – I’m
too healthy.” “I don’t want to bother my doctor.” “I don’t want to frighten anyone.” “I’ll
treat this at home.” “I’ll feel ridiculous if it is not a heart attack.” Don’t be fooled by
denial. Delay in calling 9-1-1 costs lives. Most deaths from heart attack occur in the
first 4 hours after onset of symptoms.3
The warning signs of a heart attack may come in any combination, or all at once.
Call 9-1-1 (activate EMS) immediately.
What if I’m not sure if this is a heart attack?
Rescuers should err on the side of caution when considering the signs and
symptoms of a heart attack. Call 911 if the victim shows any of the signs and
symptoms listed above.
Women, Diabetics and the Elderly3,105
Women, diabetics and the elderly can experience a heart attack without the classic
signs and symptoms listed above. Often called a “silent heart attack,” the symptoms
of heart attack experienced by seniors, women and diabetics are often more diffuse
and can include:
 Cold sweats
 Nausea
 Lightheadedness
 Discomfort between the shoulder blades
 Unexplained weakness and fatigue
 Sense of impending doom
 Neck, back or jaw pain
Emphasize to your students that women are as likely to have a heart attack as men.
Healthcare providers are often unaware of this, so symptoms often go untreated, and
many heart attacks in women are undiagnosed. Heart disease is undiagnosed in half
of the women who have a first heart attack.106
The PQRST Assessment
When managing a potential heart attack victim, EMS personnel commonly use the
PQRST Assessment. It helps rescuers identify and pinpoint the possibility of a heart
attack vs. other problems that mimic a heart attack. If there is time, use the PQRST
assessment and pass the information on to the professional responders:
Provoke: What provoked the onset of chest pain? Activity? What makes the chest
discomfort better or worse (e.g. taking a breath makes the pain worse, or nothing
makes it better).
Quality: Describe the quality of the discomfort. Let the victim use his or her own
words. Common descriptions include pressure, squeezing, and fullness (gas or
Region/Radiation: What is the region of discomfort? Does it radiate? If so, where
Severity: How severe is the pain: mild, moderate or severe? Has it gotten better or
Time: How long ago did the discomfort begin?
Treatment of Heart Attack
If any of the signs and symptoms of a heart attack are present, call 9-1-1. Early
recognition and treatment of heart attack can limit damage to the heart. Rescuer
actions should be aimed at reassuring and calming the victim to reduce the demand
for oxygen, and giving aspirin.
1. Call 9-1-1 (activate EMS).
2. Place the person in a position of comfort; rest and reassure.
a. The usual position of comfort for someone with signs or symptoms of
heart attack is sitting down.
b. Due to shortness of breath, do not lay the victim down unless he or she
becomes unresponsive, dizzy, lightheaded or faint.
3. If the victim is alert and able to swallow, offer aspirin (1 adult or 2 baby) if no
allergy, no signs of stroke, and no recent gastrointestinal bleeding.
Consider what you will do if the victim becomes unresponsive.
4. If the victim becomes unresponsive:
a. Lower the victim to the ground.
b. Send a bystander to call 9-1-1 and get an AED. If you are alone, go call
9-1-1 and retrieve the AED.
c. Assess breathing. If no breathing or only gasping, begin CPR starting
with chest compression. Use an AED as soon as it is available.
Family members of a person at risk for ACS must learn to recognize the signs and
symptoms of heart attack and call 9-1-1 instead of a family doctor, or driving the
person to the hospital themselves.
The Use of Aspirin
Victims of heart attack may benefit from taking aspirin in the early stages of a heart
attack. Chew the aspirin to help with fast absorption. Take either 1 adult nonentericcoated aspirin (325 mg) or 2 baby aspirin (81 mg each).
Persons who are at risk for heart attack should check with their physician to make
sure aspirin is safe for them (no allergy or contraindications such as recent
gastrointestinal bleeding). Never delay calling 9-1-1 while a person takes aspirin.
Make sure that the victim is alert and able to swallow and it is medically safe before
you offer aspirin to the victim of a heart attack.
Time is Muscle – The use of “Clot-Busters”
Clot-busting medication (fibrinolytic therapy) can be administered to a victim in the
early hours of a heart attack. It is most effective if it is provided in the first few hours
after onset of symptoms. It can reduce the effects of a heart attack by reducing or
eliminating the clot at the source. It is administered through an intra-venous line (IV)
and circulates through the blood stream. Its job is to locate the clot and attempt to
dissolve it. Receiving clot-busting medication could make the difference between
complete resolution of the heart attack and its symptoms, or lifelong disability or
death. Studies have shown a 47% decrease in mortality with the use of fibrinolytic
therapy within the first hour after symptoms began.105
When discussing the damage a heart attack causes, instructors should indicate,
“Time is muscle.” As more time passes between the onset of heart attack symptoms
and getting to the emergency department, more heart muscle is dying. Save time,
save muscle. There is a risk of hemorrhage associated with the use of fibrinolytic
The Use of Nitroglycerin
Some people with a history of heart disease have a prescription for nitroglycerin, a
potent vasodilator. It can relieve angina discomfort by dilating the coronary arteries
and providing increased blood flow to the heart muscle. Because nitroglycerin lowers
the blood pressure, which could cause dizziness and fainting, the person taking
nitroglycerin should be in a sitting position. A headache and dizziness are common
side effects.
Nitroglycerin comes in a spray or pill form. It is administered under the tongue (not
swallowed). It should only be used by the person whose name is on the prescription
In a person with a known history of heart disease who has been advised to take
nitroglycerin before calling 9-1-1, use the following guidelines:
1. Recognize the signs and symptoms of heart attack or ACS.
2. Have the person stop activity and sit down in a position of comfort.
3. Help the person locate and self-administer prescribed nitroglycerin according
to physician’s orders.
4. Call 9-1-1 if chest discomfort is not relieved within 5 minutes by 1 dose of
5. If you are not sure if the person has improved or is out of danger, call 9-1-1
Heat Emergencies
Heat-related emergencies are a true medical emergency. They occur most often in
the early summer before people have become acclimated to high temperatures.
Commonly the temperature is around 100 degrees, the humidity is high, and there is
little or no breeze. More than 1,500 people die in the U.S. each year from excessive
Heat-related illness often results from heavy exercise, work, or play in hot weather,
accompanied by inadequate fluid intake. These emergencies commonly occur when
the salt and water electrolyte balance in the body becomes skewed. Complications
also arise when individuals replace water but not salt, or vice versa. The prevention,
management and outcome can be determined by pre-hospital intervention.
Most heat-related emergencies happen to people over 65 years of age. Individuals
with a diminished response to thirst or impaired ability to sweat are particularly
susceptible. Competitive athletes, laborers, alcoholics, unfit or obese people
(inadequate cooling mechanism), and soldiers are also extremely susceptible to
heat-related emergencies. Other risk factors include aging, dehydration, chronic
illness or cardiovascular disease, use of certain medications, and wearing personal
protective equipment such as a respirator or protective suit.
Sweating is your body’s natural cooling mechanism. It is the evaporation of sweat
from the skin that produces the cooling effect. The evaporation rate decreases,
however, as the humidity level rises. Our bodies also radiate heat through the skin,
especially in areas where blood vessels are close to the surface. Since heat always
travels to cold, if the outside air temperature is high, our body heat will not effectively
travel from the skin to the air (temperature gradient). In environments with extreme
heat or high humidity, the cooling system may fail, allowing heat to build up.
When you exercise, wear clothes that are comfortable and allow evaporation of
moisture, such as natural fiber (cotton) clothing. Do not overdress in hot weather.
Dehydration can be a dangerous heat-related illness. It is normal for the body to
lose water daily through urine, sweat, tears, and breathing. When the rate of water
loss is excessive, and the fluids and electrolytes are not replenished (hydration), the
result is dehydration. Dehydration can also be caused by fluid loss from vomiting or
Children and older persons are especially susceptible to dehydration. Signs and
symptoms of dehydration include thirst, dry mouth, less-frequent urination, dizziness,
fatigue, confusion, dry skin, and increased heart and respiratory rates. Children may
have few or no tears when crying, fussy behavior, and no wet diapers for several
Hydration (consumption of fluids) is critical when working or exercising in hot
environments. Consider your body’s rate and individual reaction to the fluid loss
from sweating and breathing. Drink fluids before and during exercise or activity to
maintain hydration. To help you determine how much fluid you lose while working or
exercising, weigh yourself before and after the activity. Drink enough fluids to
replace at least 80% of that lost. Don’t wait until you are thirsty.
Heat emergencies are broken into three categories, which range in severity from
mild heat cramps to heat exhaustion to potentially life-threatening heat stroke.
Heat Cramps107,108,109
Painful muscle spasms that generally occur during intense exercise in a hot
environment. People are most susceptible when they have not been drinking enough
Signs and Symptoms:
 Hot, flushed skin
 Cramps usually in legs, arms, abdomen or back, but may involve any muscle
group involved in the exercise.
1. Remove from environment.
2. Rest and cool down.
3. Gently stretch cramping muscles.
4. Massage cramps.
5. Replenish with water or a sports drink.
Heat Exhaustion107,108,109
A condition that can produce signs and symptoms similar to those of shock. It may
progress to heat stroke. When people work, exercise or play in a hot, humid
environment and lose excessive body fluids through sweating, their body may
Signs and Symptoms:
 Pale, clammy skin (sweating), or hot, red, dry skin
 Elevated temperature, generally less than 104° F
 Elevated heart rate
 Low blood pressure
 Intense thirst
 Fatigue, weakness, faintness
 Anxiety
 Headache
 Cramps
Heat Stroke107,108,109
A potentially life-threatening condition that occurs when the body is unable to
regulate its temperature. The body’s temperature rises rapidly and the cooling
mechanism (sweating) fails. The high body temperature can lead to brain damage or
death if not treated promptly.
Signs and Symptoms:
 Hot, dry, flushed skin (cessation of sweating). Skin may be moist if heat stroke
was caused by exertion.
 Disoriented or unusual behavior; irritability
 Elevated temperature, usually above 104° F
 Increased heart rate
 Rapid, shallow breathing
 Elevated or lowered blood pressure
 Seizures
 Unresponsiveness
Treatment Heat Exhaustion/ Heat Stroke:
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1)
3. Remove person from the environment to a shady or air conditioned location.
4. Loosen or remove clothing. Put modesty aside.
5. Apply cooling measures: fan, cover with a damp sheet, or apply cool water,
paying close attention to the head, neck, armpits and groin, where arteries
pass close to the surface of the body. Shivering is the body’s way of
generating heat. If the person begins to shiver during the cooling process,
slow down or stop the cooling efforts, dry and cover the person.
6. Monitor body temperature and condition closely. If body temperature
increases, especially above 104° F, or if confusion, fainting or seizures
develop, person may have progressed from heat exhaustion to heat stroke.
Ensure EMS has been activated.
7. Provide cool water or sports drinks if person can tolerate them (no nausea,
vomiting, seizure, or confusion). Person must be responsive, coherent and
able to hold a glass without assistance.
Do not apply rubbing alcohol.
Do not give alcohol or caffeine drinks. DO NOT give salt tablets.
Note: Heat stroke can result from leaving a child in a car on a hot day. When the
ambient temperature is 93° F, the temperature inside a car can reach 123° F in just
20 minutes.
Tips to Prevent Heat-related Illness:110
 Know the signs and symptoms of heat-related illness, and how to respond.
 Drink fluids before, during and after activity.
Increase time spent outdoors gradually to allow time to acclimate to the heat
and humidity.
Perform the heaviest work or activity during the coolest part of the day.
Protect yourself from the sun with a hat, sunglasses or an umbrella.
Do not eat large meals before working in hot environments.
Avoid drinks that make you lose water, such as alcohol or drinks with caffeine.
Legal Issues
Most students in your basic First Aid and CPR courses will not be healthcare
providers and can be classified as lay providers. As lay providers they are not
formally medically trained, do not work in the healthcare industry, do not provide
direct patient care, and are not considered to have a ‘duty to act.’ Students in a
professional rescuer course may have a duty to act.
Professional responders, licensed healthcare providers or public safety first
responders (e.g. paramedics/EMTs, nurses, doctors, police or correctional officers,
lifeguards) have a duty to act. They have a legal obligation to respond to an
emergency while on duty, according to statute or job description. If off duty, they
would be responding voluntarily, and would generally be covered under the Good
Samaritan Law.
Personnel such as security officers, construction foremen and teachers are usually
required to have First Aid and CPR training as part of their job. They are considered
lay providers in most cases. If they are designated workplace responders, however,
they may have a duty to act, depending on statute and their job description.
Moral & Ethical Responsibilities
Even if a rescuer does not have a duty to act or a legal obligation to perform CPR
(e.g. lay responder, off-duty professional rescuer), he or she should be aware of
some moral and ethical responsibilities. It may help to clearly define the terms:
Moral: adj. concerned with right and wrong and the distinctions between them,
virtuous, good, capable of a right or wrong action, serving to teach a right action.
Ethical: adj. dealing with ethics, relating to morality of behavior, conforming with an
accepted standard of good behavior.
What those definitions mean to the students in your certification courses is that even
if they are not legally bound to help, they possess the skills to help someone in need
of First Aid or CPR. If it is safe to do so, the trained rescuer should assist those in
need. Students should be instructed that regardless of age, gender, race, ethnicity or
socioeconomic status, they should accept the responsibility to render care to fellow
human beings.
Once beginning emergency care, a responder should not abandon the victim. They
have a legal obligation to stay with the victim until help arrives.
It is the rescuer’s responsibility to update their skills and reinforce their training with
continuing education and re-certification courses. They should practice and review
their skills on a regular basis. First aid is only as effective as the person performing
it. Know the skills and practice them regularly.
Good Samaritan Law
Good Samaritan Laws are put into place to encourage the rescuer to act. Every state
has a version of a Good Samaritan Law. It is vitally important that you, the instructor,
are familiar with how the Good Samaritan Law is written in your state so that you are
prepared to answer questions about the law. Keep a copy of your state’s Good
Samaritan Law with your instructor manual.
If you need help finding your state’s Good Samaritan Law, there are many websites
available that locate laws and codes by key words. You can also visit your local
library or call EMS Safety Services for guidance in locating your state’s Good
Samaritan Law.
The Good Samaritan Law in most states is designed to protect rescuers from fear of
being sued when they choose to act in an emergency. Although anyone can be
sued, the Good Samaritan Law provides protection to rescuers as long as they
adhere to the stipulations within the law. Common elements of a Good Samaritan
Law include, but are not limited to, the following:
 Responding to help or an emergency situation on a voluntary basis.
o The rescuer does not have a ‘duty to act.’
 Not expecting compensation for rendering care.
 Providing care without gross negligence (carelessness, recklessness).
o Harm did not come to the victim as a result of the rescuer’s reckless
 Providing care with good faith (good intentions) and within the limits of your
 Not abandoning the victim after beginning care. Stay with the victim until help
In the instance of CPR, the patient is already clinically dead (cardiac arrest), so it is
very difficult to cause harm to that person.
Gaining Consent9
The rescuer must gain consent from the victim before beginning care. Everyone has
the legal right to refuse care. To provide care against someone’s will can meet the
legal definition of assault and battery; transporting someone to a hospital without his
or her consent can meet the legal definitions of kidnapping and false imprisonment.
When first approaching a victim, the rescuer should give his or her name, level of
training, and intentions, then request permission to begin care. For example, “My
name is ____, I’ve been trained in first aid, and you appear to be bleeding badly.
Can I help you?”
Types of Consent:
Expressed: The victim is a competent adult, informed of procedures and risks. The
victim has given consent for care.
Implied: Consent is assumed from the victim who is unresponsive or confused. This
is based on the assumption that the responsible person would consent to life saving
care. This is most often the consent gained in CPR-related situations.
Children/Minors: This also applies to mentally incompetent adults. Consent must be
obtained from the parent or legal guardian. If the parent/legal guardian is not
available for consent in a life-threatening situation, begin care (default to implied
The Right to Refuse Care9
Every mentally competent adult has the right to refuse care. It is not the place of the
first aid responder to force care on or make a decision for the victim. Even after you
begin care the person can, at any time, refuse further care. An example of this is the
person who becomes responsive and refuses further treatment.
Instruct students that they should not force care when it is refused. If they feel a
person needs care, they should first ensure their own safety. Keep an eye on the
situation from a distance, and contact the Emergency Medical Services (EMS) by
calling 9-1-1 or your local emergency response number.
The Right to Privacy
People have a right to privacy. Information belongs to the person. Keep personal
information private. Do not give the victim’s information out to bystanders or coworkers. It is acceptable to give information to advanced medical responders who
take over care, and to the person in charge of workplace safety.
Do Not Attempt Resuscitation113,114
Most states have state-wide out-of-hospital ‘Do Not Attempt Resuscitation’ (DNAR)
protocols, authorized by statute, regulation, or guidelines. Research your state’s
laws and protocols on DNAR in the out-of-hospital setting. Learn about your state’s
Advance Directives (e.g. living wills and medical power of attorney) from your
physician or attorney.
These decisions must be made and the advance directives or physician signatures
must be discussed and put in place before an emergency occurs. “Do Not
Resuscitate” orders written for a patient in the hospital are usually specific to that
setting. In most states a physician must write a specific ‘No CPR’ order for out-ofhospital cardiac arrest.
In some states a person with a DNAR order will wear medical jewelry that says “No
CPR.” In this situation, do not start CPR; call 9-1-1 and tell the dispatcher that the
unresponsive person is wearing jewelry that states, “No CPR.”
Muscle, Bone and Joint Injuries
The human body is made up of more than 600 muscles and 200 bones. Muscles are
firmly attached to bones through tendons, and provide active movement of the
skeleton and maintain its posture. A joint is the junction where two or more bones
meet, and is supported by ligaments, muscles and a fibrous joint capsule.
Although injuries to a muscles, bones or joints can occur at any age, some types of
injuries are more common at certain ages.
There are several types of musculoskeletal injury, including fractures, dislocations,
sprains, strains, and contusions. It is not always easy to differentiate between them.
Usually the only way to diagnose a fracture with certainty is by x-ray. An exact
diagnosis is not important when giving first aid. For the purposes of field treatment,
treat fractures, dislocations, severe sprains and strains equally.
Fractures and Dislocations115,116,117,118,119
A fracture is a break in a bone produced by excessive strain or force on the bone. It
is usually caused by a blow, a fall, a twisting movement, or even no apparent cause
(i.e. spontaneous fracture occurs without any external injury).
Types of fracture:
 An open fracture (compound) has bleeding and penetration of the skin by the
bone. A suspected fracture with bleeding should be treated as an open
fracture, even if the bone is not visible.
 A closed fracture (simple) leaves the skin intact.
 A stress fracture is a small fracture usually in a weight bearing bone of the
lower leg. It is an overuse injury that is caused when muscles fatigue and
transfer excess physical stress to a bone.
A dislocation is a separation or displacement of bones joined at a joint, with a
structural loss of joint stability. It may or may not be accompanied by a fracture
(fracture-dislocation). It is usually caused by an injury such as a hard blow or fall
that could occur during sports activities. Treat a dislocation as a fracture, and seek
medical attention immediately.
A subluxation (partial dislocation) can occur temporarily, and then the bones may
return to their original position. It is important to see a doctor for a subluxation
because the joint is now unstable and at risk for re-injury.
Signs and Symptoms:
 Swelling
 Bruising
 Deformity, angulation, shortening
 Pain
 Numbness
Inability to use the injured part
Exposed bone ends (open fracture)
Crepitus (crackling sound with movement)
A “snap” or “pop” heard at the time of injury
1. Keep the person still.
2. Assess response, breathing, circulation and appearance.
3. Activate EMS (call 9-1-1).
4. Observe for signs of hypovolemic shock due to internal bleeding, or a blue or
very pale limb. This would indicate a medical emergency.
5. Cover open wounds with a sterile dressing; apply gentle pressure to control
6. Apply an ice pack wrapped in a moist cloth. The cold decreases blood flow to
the injured area, limiting bleeding into the soft tissue and joint, and reducing
the amount of pain, swelling and bruising. Apply the ice pack up to 20 minutes
at a time.
7. Only splint the injury if emergency response is delayed or if you decide to
transport the victim yourself (e.g. for a finger injury).
8. Monitor circulation and sensation beyond the injury site.
9. Do not try to move a victim with a suspected fracture unless it is absolutely
10. Do not try to realign a broken bone or reduce a dislocation yourself. You may
damage the joint, muscles, nerves or blood vessels or even fracture a bone.
11. Do not give the victim food or fluids. This may delay any necessary surgery.
12. Do not walk on an injured leg until evaluated and cleared by an appropriate
medical professional.
Splints are applied to suspected fractures, dislocations and severe sprains. The
objective is to immobilize the joints above and below the injury. Applying a splint
reduces the movement of injured muscles and bones, and allows the person to be
transported with less pain and risk of further injury. It also reduces the risk of shock
by decreasing internal bleeding. A splint should not cause increased pain.
A splint can be made from a variety of rigid or firm materials, including cardboard, a
tree branch, a broom handle, or a tightly rolled blanket or magazine. An injured limb
can also be protected by “buddy taping” it to another part of the body.
Under normal circumstances, in both urban and suburban areas the rescuer
should simply immobilize the affected area instead of splinting it. Wait for EMS
personnel to arrive and splint the injury.
Splinting Procedure:
1. Explain the procedure.
2. Check sensation and skin temperature before and after splinting.
3. If necessary to control bleeding, expose the fracture site by cutting clothing
and removing shoes and socks (except for ankle/foot injuries). If you are
splinting an upper extremity injury, remove rings, watches or other jewelry.
Swelling may make it difficult to remove jewelry at a later time.
4. Cover open wounds with sterile dressings to control bleeding.
5. Select an appropriate splint that is longer than the bone it will support.
Measure the splint against the uninjured limb to estimate the correct size.
6. Pad the splint with soft material to relieve local pressure and ensure even
7. Carefully apply the splint. Do not straighten or manipulate the fracture site;
suspected strains, sprains and fractures are splinted in the position found.
8. Use tape or binding to secure the splint in place above and below the injury
site (e.g. tape, roll gauze, triangular bandages). It should be snug, but not so
tight that it restricts blood flow. Avoid placing bindings directly over the
fracture site.
The splinting methods below are for short-term, emergency use. Only apply a splint
to immobilize an injury during transport to seek medical care.
To immobilize a shoulder, gently bind the arm to the chest, with the strap passing
beneath the uninjured arm. High ankle shoes can serve as a splint-in-place.
Creating a Sling and Swath
A person with an arm or shoulder injury may need a sling to support and position the
limb after the application of a splint. A sling can be created out of almost any long
pieces of cloth, such as strips from a shirt or blanket. A swath is used to hold the
sling in place against the body and reduce the amount of movement.
Triangular bandages are a great addition to a first aid kit. They can be used as
slings, swaths, bandages, or for padding of gaps during the splinting process.
Create a Sling and Swath
1. Use a triangular bandage or other large piece of cloth cut or folded into a
triangle. For the adult victim the base of the triangle should be 4 to 5 feet long.
2. Place the injured arm into the bandage. The elbow is at the point of the
triangle and the wrist should be at its base with the fingers exposed. The sling
may need to be sized accordingly.
3. Wrap one end of the sling under the injured arm and the other end over the
front of the injured arm and around the neck so that the two ends come
4. Tie or pin the ends together so that the arm is bent at a right angle. Ensure
the knot is near the back of the neck, to the side (not directly on the spine).
5. Tie or pin the sling at the elbow so that the arm does not slip out of the sling.
6. Create a swath by using an additional triangular bandage or other long cloth.
Fold it into a long flat bandage 3 to 4 inches wide. Secure the sling in place by
tying the swath over the humerus (upper bone of the arm) and tying the ends
under the opposite arm. Ensure the swath is tight enough to restrict the
movement of the shoulder but not tight enough to restrict breathing or cause
Fractures in Older Adults120,121,122,123,124,125
Falls are serious for anyone, but they can have especially serious consequences for
older persons. Among Americans over age 65, more than one-third fall each year.
In 2009 about 2.2 million were treated in hospital emergency departments for fallrelated injuries, and more than 581,000 were hospitalized. More than 18,000 died
from fall-related injuries. Approximately 3-5% of older adult falls result in fractures.
Osteoporosis is a disease in which there is a gradual loss of bone density, resulting
in extremely fragile bones that break under minimal stress. More than 90% of hip
fractures are associated with osteoporosis in people older than age 65. Women lose
bone density more rapidly than men; 80% of hip fractures occur in older women. A
fracture may even occur without an associated fall due to weakening of the bones
from osteoporosis (pathological fracture). Half of all women and 25% of men older
than 50 will sustain a fracture due to osteoporosis.
Certain medications and chronic medical conditions can result in a weakening of
bone. Smoking, excessive alcohol consumption, and nutritional deficiencies can also
contribute. Lack of weight bearing activities, such as walking, along with prolonged
bed rest, will also result in bone loss.
To prevent falls and the progression of osteoporosis, it is important that older adults,
once cleared by their physicians, participate in regular physical activity and exercise
that can help improve their strength, flexibility and balance. Other factors that can
decrease their risk of falls include a medication evaluation, an eye exam, purchasing
proper footwear, and improving home safety (removing throw rugs, placing items
within easy reach, not using rolling chairs, etc.).
Identify common fractures/dislocations in older persons:
 Hip fractures: The leg is often turned outward in an unnatural position, with
pain and inability to move the leg. Call 9-1-1.
 Hip dislocation: Many older persons have hip replacement surgery. For
several weeks after surgery they are at risk for dislocating the new joint if they
do not follow specific movement restrictions or if they fall. The leg may be
turned inward or outward in an unnatural position, with pain and inability to
move the leg. Call 9-1-1.
 Pelvic fracture: There may be no visible deformity, but there is extreme pain
when attempting to walk, roll, or even move the legs. Call 9-1-1.
 Compression fracture of the back: The collapse of one or more individual
vertebral bones that may occur with no apparent cause. If the fracture is due
to osteoporosis, it is usually stable. It may be very painful, or may have no
symptoms at all. Get medical care for evaluation, pain management, and
osteoporosis treatment. If unable to move or walk, if pain is severe or caused
by injury, call 9-1-1. Do not move the victim.
Fractures can be devastating for an older person. Approximately 20% of people with
a hip fracture die within 1 year of their injury. About 25% of adults with hip fracture
must stay in a nursing home for at least a year after the injury.
After a fall, many older people develop a fear of falling. This causes them to reduce
their activities, which leads to loss of mobility and strength, which actually increases
the risk for falls.
Fractures in Children116
Children fall frequently, but the vast majority of children’s falls do not result in a
fracture. A child’s bones are softer than an adult’s bones. When a child does
sustain a fracture, it may be a greenstick fracture (one side of the bone is broken,
while the other side bends, such as would occur when trying to break a green tree
branch). Fractures in children generally heal faster than fractures in adults.
When a child sustains a fracture of a growth plate (the area of growing bone tissue
near the ends of long bones in children and adolescents), he or she may require
long-term follow-up to ensure that bone growth has not been interrupted.
Approximately 85% of growth plate fractures heal without any long-term
Sprains, Strains and Contusions126,127,128,129,130
A contusion is bruising resulting from a direct blow. It is caused when blood
vessels are damaged or broken. A sprain is a stretching or tearing of ligaments or
other structures in a joint, while a strain is a stretching or tearing of muscle or
tendon (a pulled muscle). A sprain or strain occurs when a structure is stretched
beyond its normal range of motion.
When the muscles controlling a joint are weak or “caught off guard” at the moment of
injury, a joint can be forced beyond its normal range of motion. Common injury sites
include the shoulder, elbow, finger, hip and ankle. Ankle injuries cause the most
common joint instability problems. Proper footwear can help support a joint and
prevent injury. Strengthening exercises can help prevent recurrent sprains.
Sprains and strains can be classified as mild (only slight stretching or tearing),
moderate (partial tear), or severe (complete tear). A mild injury will usually heal
within two weeks. An injury with moderate to severe symptoms should be seen by
your medical professional. Physical therapy, splinting, casting, or even surgery may
be indicated.
If a sprain remains swollen and painful for several days, consult a physician. Signs
and symptoms of a sprain or strain are similar to those of a fracture. Closed fractures
can often only be detected by x-ray.
Acute sprains, strains and contusions should be treated with the R.I.C.E.
Rest: Stop activity after an injury. Do not put weight on the injured area.
Ice: Apply an ice pack wrapped in a thin moist cloth to the affected area to reduce
swelling, bleeding and pain. Apply the ice 20 minutes on, and at least 20 minutes off
3-4 times a day for the first 2-3 days. The cold decreases blood flow to the injured
area, limiting bleeding into the soft tissue and reducing the amount of pain, swelling
and bruising. An ice pack can be made by placing ice in a plastic bag and covering
with a thin, moist towel or cloth. You may also purchase an instant cold pack, but
they are usually not as cold as an actual ice pack. Another option is using a bag of
frozen peas that will conform around the injured area, and can be refrozen and
reused (but not eaten).
Compress: Stabilize and support the injured area in the position found. Only apply
a splint if the patient must be moved, and if it does not increase pain.
Elevate: Raise the injured area above the heart, if it does not increase the pain.
This decreases blood flow to the area, reducing swelling and bruising.
 Do not apply ice directly onto bare skin, because it can cause frostbite.
 Do not apply heat to a new injury, because it will increase swelling and
 Victims with decreased sensation, diabetes or vascular disease should
consult their doctor before applying ice.
 Avoid injury by warming up before exercise.
 Keep your muscles and joints flexible with regular stretching. A daily
stretching program can help prevent injury during physical activity. Although
studies have not conclusively shown that stretching immediately prior to
activity reduces the risk of injury or improves performance, they have shown
that improving overall flexibility does help.
Easy bruising is very common with age due to thinning of the skin and weakening of
blood vessels. Often even a minor bump that you don’t even notice can result in a
large bruise. Prevent bruises by eliminating household clutter and wearing longsleeved shirts and long pants. Talk to your doctor about medications, supplements or
illness that could be contributing to the bruising. Easy bruising could be a sign of a
more serious condition, such as a blood disease or blood clotting problem.
Unexplained bruising can be an indication of domestic violence or abuse, especially
when the bruising is in an unusual location such as around the eye or face. Ask
about the cause of unexplained bruising.
Whiplash is a common injury that can occur when the soft tissues of the neck are
suddenly jerked or ‘whipped’ beyond their normal range of motion. This can occur
when a vehicle is hit from behind or stops suddenly in a crash. It may also occur
while playing sports, during a fight, when shaken (shaken baby syndrome), or during
roller coaster rides. Pain and stiffness in the neck may develop over the first few
days after injury, and may persist for several weeks or even months. Get medical
help for evaluation and treatment.
If neck pain is sudden, radiates to shoulders or arms, involves numbness, tingling or
weakness of the arms or legs, or any other signs of spinal injury, call 9-1-1. Treat the
person in the position found. Stabilize the head and neck together while waiting for
EMS responders.
Muscle Cramps132
A muscle cramp occurs when a muscle is locked into an involuntary contraction or
spasm lasting from a few seconds to several minutes. Symptoms can range from
muscle twitching to severe pain with a hard bulging muscle. The exact cause is
unknown, but it can involve muscle fatigue, overexertion, dehydration, exercising in
extreme heat, pregnancy, or inadequate stretching. They may also be associated
with certain diseases (e.g. circulatory or nerve problem) or medications.
1. Stop the activity that triggered the cramp.
2. Gently stretch the muscle until the spasm relaxes and the pain subsides.
3. Apply an ice pack wrapped in a moist cloth to the muscle to relax it.
Prevent muscle cramps with regular stretching, improving your fitness level, and
maintaining hydration. If muscle cramps persist, consult your physician to determine
a medical cause.
Ring Removal
Removal of a ring may be indicated due to extremity swelling. An application of mild
dish soap may help you gently remove the ring. If not, many EMS personnel carry
ring cutters in their first aid boxes. Your local hospital emergency department will
also have a ring cutter.
Neck and Spine Injuries
The spinal cord is a group of nerve tracts extending along the back, originating in the
brain and ending in the spinal nerves that go to the various parts of the body. It is
protected by the vertebral column, a series of bones (vertebrae) that extends from
the base of the skull to the tailbone. All the information going from the brain to the
limbs (e.g. movement) and from the limbs to the brain (e.g. sensation) travel through
the spinal cord.
The spinal cord can be damaged by a contusion (bruising), compression (pressure),
or laceration (tearing or severing nerve fibers). When a traumatic event damages
the cells within the spinal cord, it can result in loss of movement, sensation, and
other activities such as breathing and bladder control. An injury at a specific level of
the spinal cord may cause partial or complete loss of motor function (voluntary
movement) and sensation below the level of the injury. Although the spinal nerves
still exit the spinal cord between each vertebra and go to a particular muscle or
organ (e.g. bladder, diaphragm), there is no longer communication (messages being
sent or received) with the brain.
An injury to the neck is especially devastating. The neck contains the airway, major
blood vessels, and spinal cord tracts which innervate the respiratory muscles and all
four limbs. The result of a spinal cord injury at the neck (cervical spine) can be
quadriplegia (paralysis of both arms and legs), inability to breathe without a
mechanical ventilator due to paralysis of the diaphragm, and loss of bowel and
bladder control. A high enough injury can result in immediate death. A spinal cord
injury at the chest level (thoracic) or lower back (lumbar) can result in paraplegia
(paralysis of the legs and lower part of the body).
Between 12,000 – 20,000 people suffer spinal cord injuries (SCI) annually in the US;
up to 50% will die. Males sustain 80% of SCI. More than half of all victims are 15 to
35 years old. High-risk incidents include motor vehicle accidents (46%), severe blunt
trauma and penetration injuries (16%), diving and sports injuries (12%), falls (22%),
lightning strikes, head injuries, and any incident in which the victim is unresponsive
for an unknown reason. Use of a seat belt and airbag can reduce the risk of injury by
80%. Alcohol is involved in 25% of SCI.
If the victim of a traumatic injury sustains a vertebral fracture, the spinal cord may
still be intact. The initial care of a victim with a spinal injury may affect the rest of his
or her life. Improper handling of the victim can result in permanent paralysis or even
death. If there is a chance of spinal injury, assume there is one. If a victim has a
head injury, assume there is also a neck injury.
Do not move a victim of a severe injury unless:
1. You need to open or maintain an airway or perform CPR. If the person vomits,
carefully log roll him or her to the side, supporting the head, neck and back to
prevent twisting.
2. There is imminent danger. Move the victim using a drag or pull; keep the
head and spine completely supported and aligned. Improper movement of an
injured person can cause severe spinal cord injury.
Signs and Symptoms:
 Head, neck or back injury or pain
 Unresponsive trauma victim
 Numbness or tingling in extremities
 Weakness or paralysis in extremities
 Loss of bowel or bladder control
 Difficulty breathing
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (Call 9-1-1).
3. Maintain cervical spinal immobilization.
a. Use the palms of your hands to support the head in the position found.
b. Maintain an open airway.
4. Reassure the person; keep him or her calm and still.
5. DO NOT move the victim except for airway management, CPR or imminent
a. Move long axis (drag, pull).
b. Maintain a neutral position of the neck.
A poison exposure is contact with or ingestion of any substance that can produce
toxic effects. A poisoning occurs when an exposure results in bodily harm. One of
the main roles of a rescuer is to recognize that a poisoning may have occurred.
Poison exposure can be intentional or unintentional.
A poison is defined as any substance (solid, liquid or gas) that causes injury or even
death when it enters the body. There are four ways (routes of entry) through which
poisons may enter the body:
 Ingestion: swallowing
 Inhalation: breathing dust, gases, fumes or mists
 Absorption: through the skin
 Injection: hypodermic needle, bite or sting
In 2009, poison control centers received more than 4.2 million calls. Approximately
91% of poisonings occur at home. About half occur in children younger than six
years. Almost 2,000 people each day are seen in emergency departments for
treatment of poisoning.
The majority of poison exposures were unintentional (84%). Pediatric exposures
most frequently involved cosmetics and personal care products, cleaning
substances, analgesics (pain relievers), foreign bodies, topical agents and plants.
There is a greater rate of severe outcomes in older victims, and in intentional
exposures. Only 2% of the fatalities involved children younger than six years.
Analgesics and antidepressants are the drugs most frequently involved in fatal
Prevent poisonings
Since most poisonings involve children, the best way to address poisonings is to
prevent them. It takes only seconds for a poisoning to occur. Children may not be
old enough to realize that the things they eat may harm them. Most household
cleaners and chemicals are brightly colored. These items can appear like candy or
juice to a child.
Poisons Act Fast – So Must You!
General Signs and Symptoms:
 Throat pain; abdominal pain
 Nausea and vomiting
 Drooling or unusual odor on breath
Altered level of response; behavior changes
Difficulty breathing
Burns, redness or blisters around the mouth
Empty bottles or containers; disturbed plants
General Treatment:
1. Check for scene safety and clues.
2. Remove victim if necessary.
3. Assess response, breathing, circulation and appearance.
4. Place in a position of comfort.
5. Identify the poison, how much and when it was taken.
6. Contact EMS (call 9-1-1) for a victim who has an altered level of response or
is in distress.
7. Contact the poison control center for a conscious victim in no distress.
8. Locate Material Safety Data Sheets (MSDS) for chemical exposure.
9. If the person might vomit, roll him or her into a sidelying position to protect the
Do not give the victim food or drink unless instructed to do so.
Do not induce vomiting unless instructed to do so by the poison control center or a
medical professional.
Poison Control Centers
While waiting for EMS personnel to arrive, call the poison control center. They can
advise you on the preferred treatment and help you keep the person comfortable. If
EMS arrival is delayed, the poison control center may direct treatment. If the
recommended treatment is vomiting, keep in mind that a poison that burned while
going down will also burn while coming back up. Never induce vomiting unless
instructed to do so by a poison control center or medical professional.
The poison control center number is (800) 222-1222. When you call you will be
connected to a poison control center in your region. They are available 24/7/365, and
all calls are free and confidential.
Swallowed Poisons
Commonly ingested poisons include household cleaning products, plants, chemicals,
cosmetics, an overdose of medication, and illegal drugs. Collect any empty/spilled
containers, bottles or unknown plants to send with the person to the hospital. Make a
record of the victim’s age and weight, any medications he or she may be taking, the
time of the poisoning, and the amount you think was swallowed.
Since most poisonings involve children, it’s important to child proof your home:141
Lock dangerous items out of sight and reach (e.g. medicines, household
products and personal care products).
Keep products in their original containers.
Buy household products and medicines in child-resistant packages.
Return products to safe storage immediately after use.
Never call medicine “candy” or take it in front of children.
Check your home for lead-based paint. (For more information, contact the
National Lead Information Center at (800) 424-LEAD.)
Know the names of the plants in your house and yard. Remove poisonous
Keep important phone numbers by every phone (e.g. EMS, Poison Control
Center, police and fire departments, your physician).
Some communities supply brightly colored stickers that may warn children
away from hazardous substances. Contact your local poison control center to
find out more about child proofing your house.
Inhaled Poisons
Inhalation hazards include pesticides, fumigants, smoke from fires, as well as
chemical fumes, vapors and gases. Carbon monoxide and carbon dioxide are
particularly hazardous, as they are colorless and odorless. In the home fumes may
come from cleaners and solvents, wood, kerosene or coal stoves that are not
working properly, leaky gas vents, or a car running in a closed garage.
Signs and symptoms vary with each type of exposure. Some cause eye irritation
while others cause irritation of the respiratory tract. Additional symptoms may include
pale or bluish skin color, chest pain or tightness, dizziness, headache, confusion,
irritability, nausea or vomiting. Get the victim into fresh air right away. If the victim is
breathing without difficulty, call the poison control center. If the victim is having
trouble breathing or has other signs or symptoms or poisoning, contact EMS (call 91-1).
To prevent inhaled poisoning:
 Open windows and turn on a fan when using chemical products.
 Make sure combustion appliances (fuel burning) are professionally installed
and inspected annually.
 Do not mix chemicals or household products. For example, mixing bleach
and ammonia together creates chloramines, a poisonous gas.
 Do not burn charcoal or use gasoline-powered engines in confined spaces
such as tents, garages or poorly ventilated rooms.
 Place carbon monoxide and smoke detectors near the bedrooms in your
Confined Space Emergencies
Confined spaces may contain an accumulation of flammable or toxic gases, many
colorless and odorless. Hundreds of employees die each year in confined space
accidents. Rescuers can become victims themselves because they need to get close
to the victim in order to pull him or her out.
Follow OSHA prescribed permit entry. Avoid becoming a victim; do not enter any
confined space without proper equipment and training.
Absorbed Poisons142
Many substances can enter the body through the skin. The three most common
types of absorbed poisons are poison ivy, poison sumac, and poison oak.
Recognizing these plants is difficult for most people. The severity of the symptoms
will depend on the extent of the exposure and the victim’s sensitivity to the plant.
Exposure to any of these substances can cause itching, swelling, redness, burning,
blisters, difficulty breathing, fever, headache, and generalized weakness. Remove
exposed clothing carefully and wash skin thoroughly with soap and water ASAP.
Rinse the exposed area with rubbing alcohol to avoid spreading the oil. Contact a
physician for treatment.
Chemical Spill
If a chemical is spilled on the skin, use gloves to remove exposed clothing, then
rinse the skin with warm water for at least 20 minutes. Take care to avoid spreading
the contamination. Contact the Poison Control Center for further advice. Review the
Material Safety Data Sheet (MSDS).
Poison Oak142
Poison oak is probably the West's most common outdoor plant hazard. Recognizing
it can be difficult because the plant can take a number of forms: free standing shrub,
vine, or ground cover. "Leaves of three, let it be." The leaves that generally grow in
clusters of three are thin, shiny, and oak-shaped. Green in spring and early summer,
the leaves turn deep red toward fall, then drop off entirely revealing grayish branches
decorated with white berries.
The leaves, stems, and berries all contain a chemical compound call urushiol. Just
brushing against poison oak can get this oil on your skin. Within minutes the urushiol
will have entered the dermis (inner) layer of skin. A red rash will usually appear 1248 hours later. The same oil is found in poison ivy and poison sumac.
Most people have no reaction the first time they are exposed. Up to 30% of people
never develop sensitivity to the oil. Children under age seven are rarely sensitive.
It’s best to avoid any contact with poisonous plants. Be aware that the oil is spread
easily and can stick to almost anything, even when dry.
Injected Poisons
The bites and stings of various insects, snakes and marine animals can inject venom
into a victim. Although the bites and stings are generally not life-threatening, they
can cause an allergic reaction, which can develop into anaphylactic shock.
Medications and illegal drugs can also be injected with a hypodermic needle.
Substance Abuse139,143
Drug and alcohol emergencies are becoming increasingly common in today's
society. Almost 75% of all adult users of illegal drugs are employed.
It is often impossible to determine the cause of a patient's problem. Be observant for
syringes or drug paraphernalia, needle marks, the smell of alcohol on the victim’s
breath, empty pill or alcohol containers, and an altered level of response (e.g.
confusion, panic, agitation, threatening behavior).
It is not uncommon to encounter victims of drug overdose, alcohol poisoning or
alcohol withdrawal in respiratory arrest or with seizure activity. Follow general
treatment guidelines for poisoning, beginning with assessing response, breathing,
circulation and appearance. If it is likely that the person will vomit, turn him or her to
the side. If the person has an altered level of response, activate EMS. Give any
drugs or medications found on scene to the EMS responders.
Rescuers must always concern themselves with the increased potential for violence,
as these patients are often uncooperative and combative. Calm an agitated or
threatening person. Ensure an escape route if the person becomes violent.
Alcohol Abuse
Over 30 million people in the U.S. age 12 or older reported driving under the
influence of alcohol in 2009.
Lead Poisoning144
Lead poisoning is of great concern to health officials, since it affects nearly every
system in the body. It may have no obvious symptoms, or it may result in slowed
growth, damage to the brain and nervous system, behavioral and learning problems,
and impaired hearing. More severe cases can result in seizures, coma and death.
In the U.S., approximately 250,000 children between the ages of one and five have
blood lead levels greater than the CDC recommended level. Those at highest risk for
lead poisoning are children under the age of six, children in low-income families, and
persons living in housing built prior to 1978 (when lead-based paints were banned
for use in housing).
Children are exposed to lead primarily through lead-based paint and leadcontaminated dust found in older buildings. Other sources of lead poisoning are from
certain hobbies (stained-glass), work, drinking water (lead pipes, brass fixtures), and
home health remedies. Lead poisoning can be prevented by keeping children from
coming into contact with lead, and treating those who have.
Foodborne Illness145,146
There are 76 million cases of foodborne illness annually in the United States. The
primary causes of foodborne illness are bacteria (e.g. Salmonella, Listeria, E. coli,
Clostridium botulinum), viruses (e.g. hepatitis A) and parasites (e.g. Giardia lamblia).
They can be found in a wide range of foods. Practice these four steps to food safety:
1. CLEAN: Wash hands and surfaces often.
 Wash your hands, cutting boards, dishes, utensils, and counter tops
with hot, soapy water before, during and after preparing food.
2. SEPARATE: Don’t cross-contaminate.
 Always keep raw meat, poultry, seafood and their juices away from
other foods.
3. COOK: Cook to proper temperatures.
 Use a food thermometer to make sure foods are cooked to a safe
internal temperature.
4. CHILL: Refrigerate promptly.
 Be sure to refrigerate foods within two hours. Set your refrigerator no
higher than 40° F and the freezer at 0° F.
Positioning and Moving a Victim
During most emergency situations you should not move the victim. EMS responders
will assess and stabilize for transport. Only move a victim to provide essential care,
to reach another person who is seriously injured, or if there is immediate danger:1
Types of Immediate Danger:
 Fire or smoke
 Explosives, danger of explosion, or other hazardous materials
 Traffic
 Structural collapse, unstable surface
 Downed electrical wires
 Any other environmental danger
Victim Positioning
Recovery Position3,23,147
When victims are placed in the recovery position, they are placed on their side using
the log roll technique to minimize spinal movement. The airway of a person who is
unresponsive and in a supine position (on the back) can be easily blocked by the
 The tongue falling back and covering the trachea (windpipe)
 Vomit, mucus and other secretions pooling in the throat
By placing the victim on his or her side, the tongue falls forward and fluids are
allowed to drain. Use the recovery position for a victim who is unresponsive and
breathing normally when:
 Fluids, blood or vomit may block the airway
 A rescuer must leave to summon help
 Any victim is unresponsive and the rescuer cannot manage the airway
Consider these principles when utilizing the recovery position:
1. The victim should be in a true sidelying position as much as possible, not too
far prone (face down) or too far supine (face up). The head should be slightly
down to allow fluids to drain, and the lower arm in front of the body.
2. The position should be stable, and may vary between victims.
3. Avoid any pressure on the chest that impairs breathing.
4. It should be possible to turn the victim onto his or her side and to return to the
back easily and safely, with consideration for a possible spine injury.
5. Good observation of and access to the airway should be possible.
6. The position itself should not harm the victim.
To place a victim in the recovery position, use the log roll to avoid further injury. One
rescuer can use the log roll, but it is easier with two. Only move a potential trauma
victim if you cannot otherwise keep the airway open (leave to get help).
Use the modified H.A.IN.E.S. recovery position (High Arm IN Endangered Spine)
when an unresponsive person is breathing normally and you must leave to get
help, or when fluids or vomit may block the airway. This is the best recovery position
if a neck or back injury is suspected because it significantly reduces the amount of
lateral flexion of the head and neck. In the modified H.A.IN.E.S. position, the head is
supported by the victim’s arm.
1. Grasp the arm furthest from you and gently lift it above the person’s head.
Place the arm nearest you by the person’s side. Bend the knee furthest from
2. With one hand, stabilize the base of the skull and place your forearm under
the shoulder. Place your other hand under the hip and arm nearest you.
3. Carefully roll the person away from you. Do not push the head or neck. Bend
the top knee so both knees are flexed to stabilize the victim.
4. If you must leave to get help, place the person’s hand, palm down, under the
head near the armpit.
If the victim remains in the recovery position longer than 30 minutes, turn the victim
to the opposite side to avoid blood vessel and nerve injury.
A victim who is obviously pregnant should be placed on her left side to avoid
complications caused by the weight of the baby pressing down on vital blood
Positioning a Responsive Victim
 Shock Position: Position a person lying down, face up if he or she has signs
of shock, or feels dizzy or faint.
 Sitting up: A person who is having difficulty breathing can usually breathe
easier in this position. If a person can’t get out of bed, prop him or her up with
pillows or blankets. A person with severe shortness of breath may sit upright
in a rigid position, supported on his arms (tripod).
 Position of Comfort: Help a person into the position that is most comfortable.
A person can often find the position that reduces pain, nausea, or shortness
of breath.
Lifting and Moving Principles
Remember the following principles of lifting:
 Know your capabilities; ask for help with a heavy or awkward load.
 Use as much of your palms as possible for a safe lift.
 Keep your back straight, tighten your abdominals, and bend your knees.
 Lift with the strong muscles of the thigh and buttocks, not with your back.
 Position your feet shoulder width apart for balance, with one foot slightly in
front of the other.
 Lift with the victim close to your body.
 Do not twist your back; pivot with your feet.
Lift and carry slowly, in unison with others.
Before you move a victim, let him or her know what you’re going to do.
Emergency Moves14
If an emergency move is required due to immediate danger, consider:
 Moving the victim (especially quickly) can worsen a spinal injury.
 Pulling the victim in the direction of the long axis of the body to protect the
spine as much as possible.
 Never pull the victim’s head separate from the neck and shoulders.
Drags and Carries
Drags and carries generally do not provide cervical spine stabilization. Use
only when rescuer and victim are in immediate danger and an emergency move is
Ankle Drag: Grab the victim by the ankles and drag to safety.
Blanket Drag: Place the victim on a blanket using the log roll technique and drag to
This can also be performed as a clothes drag by pulling the victim’s clothing in the
neck and shoulder area, and supporting the victim’s head and neck with your
Armpit-Forearm Drag: Kneel down behind the victim’s head and neck. Reach under
the armpits and interlace your fingers. Support the head and neck, stand with your
knees and drag the victim to safety. This technique is good for short distances over a
rough surface.
Shoulder Pull: Grasp the victim under the armpits, support the head on your
forearms and drag.
Clothes Drag: Grasp the neck and shoulders of the shirt or jacket, support the head
with your forearms and drag. Make sure the clothing does not press on the airway.
Human Crutch: Help the victim to walk by supporting the injured leg and helping
him or her walk on the good one. Do not walk the victim if he or she becomes
lightheaded or sweaty when standing, has chest pain or difficulty breathing, has a
suspected spinal injury, or a seriously injured leg. 14
Firefighter’s Carry: If the victim’s injuries permit, place him or her over your
shoulder. This carry is good for lone rescuers who have to travel long distances.
Pack Strap Carry: Similar to the firefighter’s carry, but reserved for victims whose
injuries will not permit the use of the firefighter’s carry. Place the victim on your back
with an arm over each shoulder. Secure your hold by crossing the person’s arms and
grasping the wrists.
Seat Carry: (requires two rescuers) Grasp hands or use a four-handed technique by
inter-linking the rescuers’ forearms and creating a ‘seat’ for the victim. The victim
should hold on to the rescuers’ shoulders. This is the easiest two-person carry when
no other equipment is available.
Cradle Carry: Cradle the victim in your arms. Use for children or small adults.
Non-Emergency Moves14
Non-emergency moves are used to transfer a patient to a stretcher or board. There
is no immediate danger, so there is time to select the right equipment. Use these
moves when spinal or head injury is not suspected. It is helpful to practice before
using these techniques.
Direct Ground Lift: No suspected spinal injury
1. Line two or three rescuers up on one side of the person.
2. Kneel on one knee, preferably the same knee for all rescuers.
3. Place the person’s arms on his or her chest, if possible.
4. 1st Rescuer is at the head in charge of calling signals:
a. Place one arm under the neck and shoulder and cradle the head.
b. Place the other arm under the lower back.
5. 2nd rescuer:
a. Place one arm under the person’s knees.
b. Place the other arm above the patient’s buttocks.
6. If a 3rd rescuer is available:
a. Place both arms under the waist.
b. Other two rescuers slide arms up to the mid-back or down to the
buttocks as appropriate.
7. On signal, lift the person to their knees and roll in toward their chests.
8. On signal, stand and move the person to the stretcher.
9. To lower the person, reverse the steps.
Extremity Lift: No suspected extremity injury
1. 1st rescuer kneels at the person’s head.
2. 2nd rescuer kneels at the side of the person by the knees.
3. 1st rescuer places one hand under each of the person’s shoulders, slips
his/her hands under the arms and grasps the person’s wrists.
4. 2nd rescuer slips her/her hands under the patient’s knees.
5. Both rescuers move up to a crouching position.
6. On signal, the rescuers stand up and move with the patient to a stretcher.
Transfer a Supine Patient from a Bed to a Stretcher: Direct Carry
1. Prepare stretcher: adjust height, lower rails, unbuckle straps.
2. Position stretcher perpendicular to bed with head end at the foot of the bed.
3. Rescuers stand between the bed and stretcher, facing the patient.
4. 1st rescuer slides arm under patient’s neck and cups patient’s shoulder.
2nd rescuer slides hand under hip and lifts slightly.
1st rescuer slides other arm under patient’s back.
2nd rescuer places other arm under patient’s calves.
Slide patient to edge of the bed and lift toward the rescuers’ chests.
Rescuers rotate, and place the patient gently onto stretcher.
Transfer a Supine Patient from a Bed to a Stretcher: Draw Sheet
1. Loosen bottom sheet of bed.
2. Prepare stretcher: adjust height, lower rails, unbuckle straps.
3. Position stretcher next to bed.
4. Rescuers stand next to each other, with stretcher between them and the bed.
5. Reach across stretcher & grasp sheet firmly at patient’s head, chest, hips,
6. Slide patient gently onto stretcher.
Equipment for Moving Patients14
Although most first responders are not equipped with devices for moving patients, it
is helpful to be familiar with the equipment EMS responders may bring to the scene.
First responders who assist their local EMS agency should practice with them to
become familiar with the types and operation of the following:
Wheeled Ambulance Stretcher (cot or gurney):
 Can be raised or lowered, head can raise, sometimes foot can raise
 Can be rolled by two or four people with rescuers at the head and foot ends
 Can be carried by two or four people:
o Best with four rescuers, one at each corner
o With two rescuers, face each other from the head and foot of the
Portable Stretcher:
 Use when a wheeled stretcher cannot be moved into a small area
 Carry in the same way as a wheeled stretcher
Long Backboard:
 Use for trauma patients to protect neck and spine
 Use for lifting patients from small spaces or up onto a stretcher
 Immobilize head and neck; secure patient with straps before moving
 Can be used as CPR surface
Short Backboard:
 Use to immobilize the head, neck and spine of a patient found in a seated
position (e.g. automobile or confined space)
 Some are simple boards with straps; others wrap around the patient and
secure the head, neck and torso. (Kendrick Extrication Device, or KED)
 Once extricated, patients stay attached to the short backboard and are then
secured to a long backboard.
Stair Chair:
 Use to carry a patient in a seated position
Good for small spaces, stairs, and patients with difficulty breathing
Can be tilted back and rolled or carried
To carry, rescuers face each other, similar to a stretcher
Not used for suspected trauma patients
Scoop Stretcher:
 A rigid device that separates into right and left halves
 Rescuers scoop each half under the patient and reconnect the ends.
 Helpful for moving patients out of small or tight spaces
 Straps can be attached
 Not used for suspected trauma patients
Respiratory Emergencies
Acute (sudden) shortness of breath (SOB), a symptom of respiratory distress, is a
medical emergency. There can be many causes, including heart attack, asthma,
collapsed lung, pulmonary embolism, congestive heart failure, allergic reaction,
choking, emphysema, bronchitis, and respiratory illness. Electrocution, poisoning, or
an injury to the head or trunk can also cause respiratory distress. Generally, the
treatment for respiratory emergencies is the same. Fast recognition of the
emergency together with prompt activation of EMS (9-1-1) is critical. Delay can be
Signs and Symptoms:
 Breathing rate: Too fast or too slow; agonal breathing (gasping, irregular, or
only a few breaths per minute)
 Noisy breathing: Wheezing, gurgling, high-pitched whistle-like sound
 Sitting upright: Tripod positioning, upright, leaning forward, chin lifted, mouth
 Labored breathing: Using shoulder and back muscles to assist breathing
 Broken dialogue: Speaking in short sentences or one word answers,
pausing for breath
 Color: Ashen, pale, cyanotic (blue skin, especially around the lips and
fingernail beds)
 Cough, fever
 Dizziness, confusion
 Chest pain: Caused by injury, heart attack, collapsed lung or pulmonary
 Children: Nasal flaring, rib retraction (pulling inward of the ribs with breathing)
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Position of comfort, usually sitting up.
4. Loosen tight clothing.
5. Monitor status closely until EMS responders arrive.
Medical Illnesses resulting in Respiratory Distress
 Heart Attack (see separate section)
 Asthma (see below)
 Allergic reaction (see separate section)
 Choking (see separate section)
 Congestive heart failure (CHF): A condition in which the heart gradually fails
in its ability to deliver blood to the tissues of the body. The result is a buildup
of fluid in the legs, ankles and feet, and a backup of fluid into the lungs,
leading to SOB. CHF can be caused by heart attack or heart disease.149
 Chronic obstructive pulmonary disease (COPD): A group of lung diseases,
including chronic bronchitis and emphysema, which limit the flow of air into
and out of the lungs. Approximately 80% of all cases are caused by heavy,
long-term cigarette smoking. Other causes include repeated infections, such
as pneumonia, and inhalation of toxic agents, such as industrial gases. The
main signs and symptoms are SOB, chronic cough, fatigue, weight loss, and
excess mucus production (bronchitis). Although COPD cannot be cured, it can
be treated. A patient may use an inhaler or supplemental oxygen to help
breathe better. People who quit smoking will also stop, or at least slow, the
progression of emphysema. Exercise (with medical clearance), proper diet,
adequate rest, and stress management will also help prevent exacerbation of
Respiratory Illnesses
Croup is usually seen in children ages 3 months to 3 years, with age 21 months
being the most common. Croup is caused by viral agents and is characterized by a
barking cough, stridor (a high-pitched sound during obstructed breathing), wheezing,
mild retractions and fever.
Signs and Symptoms:
 Difficulty breathing
 Inability to swallow
 Tripod position
 Hoarseness
 Retractions (pulling inward of the ribcage)
 Barking cough
 Fever
1. Assess response, breathing, circulation and appearance.
2. High humidity therapy (Fill bathtub or sink with hot, steamy, water.)
3. Use humidifier if available.
4. Give ibuprofen and use cooling measures for fever. If fever should spike
greater than 102° F, notify a physician.
Respiratory Syncytial Virus (RSV) is a common virus that causes cold-like
symptoms in adults and older children, but can be more serious in babies. It is more
prevalent in the infant/toddler age group. It commonly occurs in the fall/winter
Signs and Symptoms:
 Low-grade fever
 Slight cough
 Profuse, thick, clear nasal secretions
 Watery eyes
 Labored, rapid breathing; shortness of breath
1. Bed rest
2. Encourage fluids (to thin the secretions and prevent dehydration).
3. Suction nose with bulb syringe to clear nasal passageway.
Pneumonia is a respiratory condition that affects millions of people of all ages in the
U.S. each year. It can be especially serious for older adults or those with chronic
illnesses. Pneumonia can be caused by various agents (e.g. bacterial infections, viral
infections, aspiration). The infection can destroy lung tissue and cause fluid build-up
in the surrounding normal lung tissue. Pneumonia reduces the lungs’ ability to
exchange oxygen for carbon dioxide, lowering the blood oxygen level. The person
may breathe faster to compensate. Over 52,000 Americans die each year of
pneumonia. If you suspect that you have pneumonia, see your doctor promptly. It
can be positively diagnosed with a chest x-ray. Pneumonia can be prevented with
Signs and Symptoms:
 Fever
 Fatigue
 Rapid, shallow respirations , shortness of breath
 Cough, runny nose
 Chest pain
 Sweaty, clammy skin; chills
1. Get medical care for proper antibiotic therapy.
2. Bed rest
3. Encourage fluids.
4. Give ibuprofen and use cooling measures for fever. If fever should spike
greater than 102° F, notify a physician.
Pertussis, also known as whooping cough, is caused by a bacterial source known
as Bordetella Pertussis. Pertussis has an incubation period of 5-21 days. This
childhood disease is transmitted by droplet spread of infected persons, direct
contact, or also indirectly when one comes in contact with freshly contaminated
objects. The greatest risk of infection is during the initial stage of pertussis, before
the onset of its characteristic "sudden attacks" of coughing.154
Signs and Symptoms:
 Initial Prodromal stage: fever (fever may spike as high as 104°F between day
4 and 5. Notify physician of any fever greater than 102°F).
 Malaise
 24 hours of runny nose, cough, and conjunctivitis.
After 1-2 weeks, symptoms worsen.
 Prolonged coughing attacks
o Coughing may end with a high-pitched “whoop” sound when you inhale
the next breath.
o Persistent, hacking cough
1. Bed rest during the febrile period. Ibuprofen for fever; avoid chilling.
2. Keep skin clean and dry. Use tepid bath.
3. Use cool mist vaporizer for cough.
4. Encourage fluids and soft, bland foods.
5. Clean eyelids with warm saline solution to remove secretions and crust.
If you suspect that someone is having a respiratory emergency, call 9-1-1 without
Asthma is a chronic disease in which the main air passages of the lungs become
inflamed. During an asthma attack, the muscles around the airways tighten and extra
mucus is produced, progressively blocking the airway. This results in narrowing of
the bronchial airways and less airflow to the lungs.
Approximately 25 million Americans suffer from asthma; 9 million of them are
children. More than half the people with asthma have an asthma attack each year in
the United States. Thousands of people die each year from asthma. It affects a
higher percentage of low income, minority, and inner-city populations, and can
develop at any age.
The incidence of asthma has increased significantly in the past 20 years. It is now
the most common chronic childhood illness. The exact cause is still unknown, but
possible factors that can increase your risk include air quality (pollution, secondhand
smoke or occupational chemicals), building ventilation, health issues such as obesity
and lack of physical exercise, respiratory infections in childhood, low birth weight,
having at least one parent with asthma, and gastroesophageal reflux disease
Although there is no cure for asthma, it is treatable. Medical treatment includes
quick-relief or “rescue” medicines to relieve asthma symptoms that flare up, and
long-term control medicines. It’s also important to avoid things that could worsen
your asthma symptoms.
Triggers that can cause or worsen an asthma attack include the following:
 Strong odors (perfumes, cooking fumes, chemicals)
 Exercise or physical exertion
 Respiratory infection (e.g. the common cold) and sinusitis
 Change in the weather (temperature, humidity, wind, barometric pressure)
 Inhaled substances (talcum powder, chalk dust)
 Emotional stress and anxiety
 Allergens (e.g. pollen, pet dander, dust mites, cockroach droppings, mold)
 Irritants (e.g. dust, tobacco or wood smoke, air pollution)
 Sulfites (food preservatives)
Medication allergies
Occupational exposure to chemical fumes, gases or dust
Asthma attacks can be controlled by taking medicine and avoiding the triggers that
cause an attack. Many asthmatics carry inhaled bronchodilators that open narrowed
air passages and ease breathing.
An episode can occur with little warning. It’s important to recognize the symptoms
and respond quickly. By treating attacks early, the severity of the attack is usually
lessened. Early activation of 9-1-1 saves lives!
Signs and Symptoms:
 Labored, rapid breathing
 Coughing (sudden, non-productive “tight” cough initially; progresses to rattling
and productive, with clear, frothy sputum)
 Audible wheezing
 Shortness of breath (speak in short, panting phrases)
 Chest tightness
 Anxiety, apprehension, restlessness
 Upright, rigid posture with arms locked and supporting body weight (tripod
 Cyanosis
 Flared nostrils
 Sweating
 History of asthma attacks (May have a medically prescribed asthma inhaler.)
1. Assess response, breathing, circulation and appearance.
2. Help person locate the inhaler and self-administer it, if patient indicates that
he or she is having an asthma attack and needs help.
3. Determine the attack trigger.
4. Call 9-1-1 if no relief from the inhaler.
5. Position of comfort, usually sitting up.
6. Calm and reassure patient.
If you are a caregiver of a child who is a known asthmatic, make sure the parents
leave the child’s medications with you, along with specific instructions on how and
when to administer them. (There may be various ways to administer these
medications, such as orally, by injection, or via inhalers or nebulizers.)
Many people with a history of asthma or allergic reactions carry medication to take in
the event of a respiratory emergency. The victim uses a prescription inhaler by
squeezing the device and propelling a measured dose into the mouth. The patient
inhales while delivering the dose to get the medication into the lungs. Prescription
inhaled medications relax the smooth muscle tissue of the bronchial tubes and
opens them up, making it easier to breathe.
Only assist a person with an inhaler if the prescription is in his or her name and the
medication is not expired. Ensure that the victim is responsive and cooperative and
can hold and squeeze the inhaler him or herself prior to assisting with the inhaler.
Using a Quick-Relief Inhaler:158
Help the person follow the steps to use a prescription quick-relief inhaler.
1. Locate the inhaler and confirm it is prescribed to the patient and the expiration
date has not passed.
2. Shake it vigorously a few times.
3. Remove the cover and attach the spacer if there is one.
4. Instruct the person to fully exhale.
5. Place the inhaler in the person’s mouth and press down on the inhaler
canister as the person inhales slowly and deeply.
6. Instruct the person to hold her breath for 10 seconds.
7. Repeat with a 2nd dose after a few breaths.
When treating a child, the use of a “spacer” with the inhaler is often recommended.
 It allows the full dose of the inhaled medication to flow down the child’s
trachea into the lungs, and prevents the medication from sticking to the back
of the throat.
 One end of the spacer is attached to the inhaler and the other end can be
affixed to a mask for small children or go directly into the mouth of a larger
Inhaled medication is safe to use. Side effects can include increased heart rate,
shaking and nervousness. The heart rate may decrease as the airways are opened
up and breathing becomes easier. The side effects from an inhaler are more a
nuisance than dangerous.
Encourage fluids. An asthmatic child’s hydration status is put at risk from excessive
sweating and hyperventilation. Be sure that fluids are warm or room temperature, as
cold fluids often trigger a reflex bronchospasm.
Identify a patient’s attack triggers, and try to avoid them in the future (except
exercise). Call 9-1-1 immediately if you suspect a severe asthma attack or if an
inhaled treatment isn’t working.
Responding To Emergencies
What is an Emergency?
An emergency is an unexpected occurrence that demands serious attention.
Emergencies can happen anywhere and usually when you least expect them. Be
prepared for an emergency before one happens.
Without an adequate assessment of scene safety, responders can quickly change
roles from rescuers to victims, adding confusion and the need for more resources to
an already difficult situation. Get your students thinking about:
 Letting someone know where he or she is going before entering an
emergency scene.
 Ensuring that EMS has been called.
 Sizing up potential hazards.
 Sizing up the number of victims and a general idea of their condition and what
 What resources they have available to them.
 Remembering treatment priorities.
 The fact that safety on any emergency scene is not guaranteed, and that an
emergency scene can quickly change from safe to unsafe.
The most important actions to take during an emergency are to remain calm, stay
aware of your own safety, and activate the EMS system or your workplace internal
Emergency Response Plan when appropriate.
How do I get help?
Dial 9-1-1 or your local emergency response number. If you are not sure what
number to call, check in the front of your local telephone directory. When you dial 91-1, it’s free, even from a cell phone with no current contract. About 70% of 9-1-1
calls are made from wireless telephones.159
Many businesses have a different procedure to activate EMS, such as calling the inhouse operator. Make sure all employees know how to activate EMS while at work.
Post the emergency response number prominently next to every telephone, first aid
kit and AED.
When should I get help?11,160
Call 9-1-1 or your local emergency response number for anyone who is seriously ill
or injured. Examples include:
 Unresponsive, change in level of responsive or mental status
 Difficulty breathing or no breathing
 Bleeding that is severe or uncontrolled, or from body openings (e.g. mouth,
nose, ears)
 Chest or abdominal pain or pressure
 Severe pain
Sudden weakness, dizziness, change in vision or speech
Serious burn or injury
Suspected broken bone
Vomiting or coughing up blood
Head, neck or back injury
Suicidal or homicidal feelings
Signs of heart attack, stroke, or shock
Suspected poisoning
Don’t delay calling 9-1-1! Statistics show that a person has a better chance of
surviving an emergency when EMS is activated early. If you postpone calling 9-1-1,
the seriousness of the injury or illness and the risk of death can increase.
If you are not comfortable with a situation, or you are not sure if you should call 9-11, err on the side of caution. Call 9-1-1 and the dispatcher will ask questions to help
determine if it is an emergency.
Do not assume someone else will activate EMS. If you ask someone else to call 9-11, have the person report back to you. Do not transport someone in your own car to
the hospital if he or she has an injury or illness that could be aggravated by transport
or that may become life-threatening. EMS responders can usually transport a victim
to the hospital faster than you can, and provide essential care on the way. Delay =
What happens when I call 9-1-1?3,161
When you activate EMS:
 You are connected to a law enforcement or fire department/emergency
medical dispatcher (EMD).
 While the dispatcher is talking with you, he or she is simultaneously sending
help your way.
o Many people get frustrated when calling EMS because they think the
dispatcher is taking too much time to send help to the scene.
o Emergency Medical Dispatchers often work in tandem: one talks with
the caller, while the other dispatches the units. Help is coming while the
caller is giving valuable information that will be passed on to the
professional rescuers en route to the scene.
 Let the dispatcher drive the call. Be prepared to provide the following:
o Your name
o Location of emergency
o Telephone number that you are calling from
o What happened (fall, auto crash, etc.)
o Hazardous conditions
o Number of persons needing help
o Condition of the victim (awake, breathing, injured, dangerous position)
o What aid is being given (CPR, AED use, controlling bleeding, etc.)
o History (recent major medical event, chronic medical condition)
o Any other information requested
o Do not hang up unless instructed to do so by the dispatcher.
The dispatcher may give you instructions to aid in helping the victim, such as
compression-only CPR.
Remain calm, follow instructions, and always hang up last.
REACT to an Emergency
EMS Safety uses the acronym REACT to help students remember how to respond to
an emergency.
R – Recognize the emergency
Pay attention to sights, sounds and situations that are unusual. Look and listen for
any of the following: screams or panicked facial expressions; a person who is
grimacing, having trouble breathing, clutching his or her chest, or who has slurred
speech; a stopped car in the road containing a person who is not moving; severe,
uncontrolled bleeding; and any problem involving pregnancy.
Remain calm and in control of your feelings. When you know you’re going to respond
to an emergency, your body releases adrenaline and your heart rate and blood
pressure go up. Before it takes over, take a moment to gather your thoughts and
establish your priorities. The first priority is to be safe! Taking a moment to focus and
prioritize can help protect your life and put what you’re about to do into perspective.
E: Environment:
Size-up the scene before you enter it. What are the potential hazards you face?
Common hazards include:
Traffic: Use your vehicle, hazard lights, reflectors and bystanders to control
traffic around the scene. Watch for jagged metal and broken glass. Don't turn
your back to oncoming traffic. Park your vehicle to protect the scene.
Fire or smoke: Stay low to avoid smoke inhalation, focus on escaping and
calling 9-1-1. If possible, drag the victim to safety. Never enter a smoke-filled
Wet, icy or unstable surface or structure: Slips, falls, vehicle movement,
and structural collapse can cause additional injuries to bystanders and
rescuers. Avoid walking onto a frozen lake or pond if the stability of the ice is
Downed electrical wires: Do not enter the scene; maintain a safe distance. If
downed lines are near your car, stay inside the vehicle.
Hazardous materials/chemicals/gasses: Unusual smells, hissing sounds,
liquids, hazardous containers; dead birds, animals, and fish could indicate a
biological or chemical hazard.
o Leave the area and report it immediately.
o Refer to Material Safety Data Sheets (MSDS) where available. They
provide a listing of chemicals used at a specific location and can help
The types of chemicals likely to be present and their properties.
Effects of exposure to the chemicals listed.
Treatment for exposure to the types of chemicals listed.
Open water, swift/strong currents: Do not attempt a water rescue without
professional training and equipment. It only takes a foot of swift moving water
to move a car downstream.
Confined spaces: A confined space is any space where gas or noxious
fumes can become trapped, such as a cave, sewer, drainage culvert, or
someone's garage. Look for clues such as more than one victim with no
apparent injury. Do not enter a confined space without proper equipment and
The victim: Blood or body fluids are commonly present at accident scenes.
Use Personal Protective Equipment when helping a victim to protect from
bloodborne and airborne pathogens. Do the victims or bystanders appear
agitated or hostile? Consider waiting for help if you are unsure of the safety of
the scene.
Plan your exit before you enter an emergency scene. Identify two possible exits.
Always let someone know where you are going and what you intend to do.
Continually reassess the scene for danger. If the scene doesn’t look safe, do not
enter it. Secure the area and call for help.
Size-up the victim. How many victims? Are many people showing similar
symptoms? Be alert to multiple victims with similar symptoms, as that could indicate
a toxic or low oxygen environment.
 What appears to be their general condition? Assess level of distress or lack of
 Can you identify the cause of the illness or injury? This can help identify the
potential for severe injury.
A – Assess the victim
Assess the victim for responsiveness, breathing, and serious or life-threatening
illness or injury that may require CPR, bleeding control, or EMS response.
C – Call for help
Shout for help and call 9-1-1 or your emergency response number to get
professional help on the way if there is danger or if the victim is unresponsive or
seriously ill or injured. With a serious medical emergency, transport to a hospital in
the first hour (the golden hour) is critical to survival.
Activate your workplace Emergency Action Plan (OSHA Publication 3088).162
T – Treat the victim
Prioritize treating problems related to breathing and circulation first. Treat the person
in the position found, unless there is danger or the person needs to be repositioned
for essential care or a position of comfort.
Interacting with EMS Personnel9
A smooth transfer of care from a first aid provider to EMS responders is important in
order to provide the best care and avoid wasting valuable time. Although a first aid
responder’s initial reaction may be to step back when EMS personnel arrive, actually
he or she should continue care until formally relieved by EMS personnel. The first aid
responder should work together with EMS personnel during the transfer of care.
Before EMS responders arrive:
 Send a bystander out to meet EMS.
o Turn on outside lights.
o Secure your pets.
o Unlock your front door.
When EMS responders arrive:
 Continue care while EMS responders prepare equipment and additional
rescuers arrive.
 EMS personnel will notify the first aid responder when ready to assume care.
 Be ready to assist EMS personnel with additional patient care tasks if asked:
o Continue to stabilize a suspected neck or back injury.
o Continue performing chest compressions; relieve other rescuers.
o Provide AED shock if indicated by the AED prompt.
o Continue to apply pressure to a bleeding wound.
o Help lift a patient to a stretcher.
o Any other task within the first aid provider’s level of training.
 Communicate to EMS:
o The time the event occurred, and what time you began care.
o The treatment given to the victim.
o Information gathered during interviews of the victim, family and
o Information from your initial assessment.
o A printed list of medications if available.
o A child’s Emergency Information Form (from school or childcare facility)
After an emergency:
 Give EMS any contaminated dressings, PPE, and used epinephrine pens.
 Keep the victim’s information private.
 Restock the first aid kit.
 Report the incident to your supervisor at work; complete any required
Rescuer Stress163,164
Giving care in an emergency may have physical, mental, and emotional
consequences for the rescuer. Each rescuer will respond differently to stress,
depending on his or her experience and personality, and also on the seriousness
and outcome of the incident.
It’s normal to feel stress after an incident. The response usually lasts just a few days.
If a rescuer is unable to cope with the stress produced by the incident, the effects
may last for weeks or even months and affect a person’s health, family life, and work
performance. The signs and symptoms of incident stress may include the following:
Physical Response
 Rapid breathing or heart rate
 Trembling
 Sweating
 Nausea, diarrhea
 Headache, muscle ache
 Fatigue
 Difficulty sleeping
 Increased or decreased appetite
Mental Response
 Cannot stop thinking about the event
 Confusion, difficulty concentrating
 Nightmares
Emotional Response
 Anxiety, worry, guilt, fear, anger
 Depression, crying
 Restlessness
 Change in behavior or interactions with people
To keep post-traumatic stress from developing, don’t ignore signs of stress. Take
care of yourself by eating properly, avoiding alcohol, drugs and caffeine, exercising,
and getting enough rest. Talk about your feelings with someone who has had a
similar experience. Don’t judge yourself for your actions, and get professional help if
A seizure is an abnormal electrical discharge in the brain. The symptoms displayed
will depend on the cause of the seizure and the part of the brain that is affected. It
may affect only one part of the body (focal seizure), or may affect the whole body
(generalized seizure). Some seizures involve unusual sensations, visual
disturbances or staring spells that can easily go unnoticed. Seizures are a relatively
common medical disorder. They can occur at any time or place.
Many seizure conditions are kept in check with medication, but the body may
develop a tolerance to the medication and the person will experience another
seizure. In addition, most seizure medications become ineffective when mixed with
alcohol. Many people may take their medication inconsistently, which also makes it
A seizure may last from a few seconds to several minutes. Most seizures will stop
by themselves after a period of time. A physician is needed to determine the cause
of first time or repeated seizures.
About 10% of the U.S. population will have a seizure during their lifetime. Almost 3
million Americans currently have epilepsy, with an additional 200,000 developing
seizures and epilepsy each year.
Seizures have a beginning, middle and end:
1. Aura – A premonition of an impending seizure. It can be a strange feeling, a
particular taste, smell or sensation. If someone tells you he thinks he is going
to have a seizure, believe him. A seizure victim may or may not be aware of
the beginning of the seizure.
2. Ictus – The actual seizure.
3. Post-ictal – The recovery period for the brain; a period of lethargy and
extreme exhaustion following a seizure. It is normal, and you should not try to
awaken the person. As the person regains consciousness, he may be
extremely confused and combative. Actual symptoms vary according to the
type of seizure. At this time the person may not be able to protect his own
airway; rescuers should ensure that the airway is open.
Types of Seizure165,166
There are several different types of seizure. A partial seizure (focal seizure)
affects only a portion of the brain. Symptoms may include abnormal sensations,
personality or emotional changes, nausea or sweating, muscle contractions of a
specific body part, or other localized symptoms. The person may or may not lose
A generalized seizure (petit mal or grand mal seizure) affects all or most of the
brain. A petit mal seizure, also known as an absence seizure, is characterized by
a sudden lack of conscious activity or other abnormal change in behavior. The
victim stops all activity and speech, and then resumes one to several seconds later.
The seizures may be infrequent, or may occur very frequently. They occur most
often in people under age 20, usually in children ages 6-12. Since the seizure can
appear as a staring episode, it is often thought that a child is simply daydreaming.
The cause of petit mal seizures is usually unidentifiable.
The most common seizure requiring first responder intervention is the grand mal
seizure, also known as a tonic-clonic seizure. This is the type that most people
associate with the terms “seizure,” “convulsion” or “epilepsy.”
The following is the typical sequence of events during a grand mal seizure:
1. The seizure begins with the tonic-clonic phase, as the patient becomes
unconscious and the entire muscular system becomes involved. The
patient stiffens his arms and legs and arches his back; twitches and jerks
are common.
2. The person is unresponsive for the duration of the seizure.
3. The person’s skin may turn a bluish color due to a lack of oxygen during
the seizure. Breathing is often irregular or stops temporarily, and oxygen
does not reach the skin cells in adequate amounts. After the seizure the
person resumes breathing, but may need assistance maintaining an open
4. The person may bite his or her tongue or cheek, and be incontinent (loss
of bowel or bladder control).
5. After the seizure, the person may remain unresponsive or be confused
and weak.
Causes of Seizure167,168
Causes of seizure include brain tumor, brain injury, stroke, drug overdose (especially
cocaine or stimulants), alcohol or drug withdrawal, poisoning, low blood sugar
(hypoglycemia), infection (brain abscess or meningitis), a sudden lack of oxygen to
the brain, or a heat-related emergency. Sometimes the cause of a seizure is
unknown (idiopathic). The most common cause of seizure is epilepsy.
Epilepsy is a chronic disorder that involves recurrent seizures of any type. It is
diagnosed when a patient has had two or more seizures. The normal pattern of brain
cell (neuron) activity is disturbed, resulting in strange sensations, emotions or
behavior, and sometimes muscle spasms, seizures, and loss of consciousness.
Epilepsy (seizure disorder) can affect people of any age. It is most likely to develop
in early childhood and old age. Risk factors include head injury or other conditions
that cause damage to the brain (e.g. stroke), and a family history of epilepsy. It is
controlled through medication and surgical techniques in about 80% of patients.
Factors that may contribute to worsening seizures in a person with normally well142
controlled seizures include pregnancy, illness, certain prescribed medications,
skipping doses of medication, use of alcohol or recreational drugs, or lack of sleep.3
Febrile seizures are triggered by a rapid rise of body temperature usually to over
102° F. They are most common during the first two years of life, but can be seen in
children up to four or five years of age. The brain stem, which regulates body
temperature, does not mature until age four. This results in a child’s body
temperature rising quickly when he or she becomes ill. About 3-5% of children
between 9 months and 5 years will have at least one febrile seizure.169
A febrile seizure can be as mild as the child’s eyes rolling or limbs stiffening, or may
be a grand mal seizure. If a febrile seizure is suspected, follow seizure treatment
guidelines, beginning with assessing response, breathing, circulation and
appearance. Cool the febrile child by removing all clothing and sponging with
lukewarm water. Stop the cooling process if shivering or goose bumps become
evident. Most febrile seizures are harmless. There is no evidence that febrile
seizures cause brain damage.
Signs and Symptoms of Seizure:
 Muscle twitches, rigidity, violent rhythmic muscle contractions
 Staring, eye movements
 Lip smacking, mouth movements, drooling, tongue biting
 Head turning, purposeless movements
 Abnormal sensations, hallucinations
 Nausea
 Dilated pupils
 Sweating, flushed skin
 Incontinence
 May or may not lose consciousness and awareness
Treatment During the Seizure:
1. Place victim on the floor; remove nearby objects and furniture.
2. Protect the victim’s head from injury with a small pillow or other soft object
such as a blanket or jacket. Ensure that you do not close the victim’s airway
or restrict movement by raising the head too high.
3. Activate EMS (call 9-1-1).
4. Loosen any tight clothing, especially around the neck.
5. Ask spectators to leave.
6. Time the seizure.
Do not put anything in the victim’s mouth. The object may break and obstruct the
patient’s airway.
Do not restrain the victim.
Do not move the victim unless he or she is in a dangerous location.
Treatment After the Seizure:
1. Assess response, breathing, circulation and appearance. A person having a
seizure might be injured, inhale food, fluid or vomit into the lungs, or not get
adequate oxygen.
2. If potential spinal injury, treat head and neck as a unit to prevent further injury.
3. If fluids or vomit in the mouth, place in recovery position. Turning the person
on his or her side will help expel any vomit and keep the airway open.
4. Cool a febrile seizure patient.
5. Ensure EMS has been activated.
6. For a febrile seizure patient, give the normal dose of ibuprofen or
acetaminophen when the child is completely awake.
Do not give food or drink until the person is completely awake and alert.
After a generalized seizure the person will be sleepy for one hour or longer and may
not remember the seizure episode. A physician should evaluate all seizure victims.
Even if the person is known to have recurrent seizures or epilepsy, medications may
need to be adjusted or other instructions given. Record details of the seizure: date,
length of time, type of symptoms, which body parts were affected, behavior after the
seizure, and any other pertinent information.
Fainting (syncope) is a brief loss of consciousness usually caused by a momentary
lack of blood supply to the brain. Awareness of self and surroundings should recover
spontaneously. Fainting is a common problem, and accounts for 3% of patient visits
to emergency departments.
Fainting can be caused by dehydration, temporary low blood pressure or low blood
sugar, or may be related to environmental, emotional or physical stress. A change in
position from lying to sitting or sitting to standing can cause postural hypotension
(orthostatic hypotension), which is a decrease in blood pressure resulting in
inadequate blood supply to the brain. Fainting can also occur after urinating,
defecating or coughing (vasovagal reaction). Since fainting may be related to
medications or a serious heart or other medical condition, it is important to contact
your physician for evaluation.
If the signs and symptoms of fainting do not pass relatively quickly (1–2 minutes),
treat the loss of consciousness as a medical emergency and activate EMS. Since
people who lose consciousness may vomit, ensure that the airway remains
If you feel lightheaded or faint, lie down. If you can’t lie down, then sit down with
your head between your knees to get the blood flowing to your brain. Do not stand
up until you feel better. Be aware that if you do faint while seated with your head
between your knees, you may sustain head, neck or other injuries from a fall.
If someone else faints, position the victim on his or her back. Monitor the airway and
ensure that it remains open.
Signs and Symptoms:
 Lightheadedness
 Blurred vision
 Nausea
 Pale, sweaty skin
 Brief period of unconsciousness
1. Use shock position until dizziness passes.
2. Loosen restrictive clothing.
3. Activate EMS if victim remains unresponsive or is injured.
4. Treat any injuries sustained if the victim fell when fainting.
Shock Management
The body must have two basic things to survive: oxygen and glucose (sugar). Both
of these are carried by the blood to nourish the body’s tissues. Shock is a lifethreatening condition that occurs when there is inadequate blood flow (perfusion) to
the vital organs and body tissues. Perfusion is dependent on heart rate (pump), fluid
volume (blood), and a container for the blood (vessels). Interference with any of
these components can affect perfusion.
Shock requires immediate medical treatment, or the victim may die. The goals of first
aid care are to treat the underlying cause of shock, maintain body temperature, and
get medical help. Early intervention through bystander first aid can prevent shock or
keep it from getting worse. Treat shock before it progresses.
Types of Shock:
Hypovolemic: Fluid or blood loss of at least 1/5th of the normal blood volume.
Causes may include the following: internal bleeding from the gastrointestinal
(GI) tract or other source; external bleeding from trauma; inadequate blood
volume due to vomiting or diarrhea; fluid loss due to burns.
Cardiogenic: Heart-related. There is adequate blood volume, but the heart
cannot effectively pump the blood due to heart attack, heart failure, trauma to
the chest, or another cardiac condition.
Anaphylactic: Allergic reaction that involves the entire body (systemic).
Once a person has been exposed to an allergen, a subsequent exposure can
trigger a sudden, severe, life-threatening reaction in which the airways
constrict, causing difficulty breathing, and the blood vessels dilate, resulting in
decreased blood pressure. Examples include allergies to food, drugs, or bee
Neurogenic: Nervous system injury. The injury may cause vasodilation and
pooling of blood, with subsequent decrease in blood pressure (e.g. spinal cord
Septic: Severe blood stream infection (e.g. blood poisoning)
Psychogenic: A sudden dilation of blood vessels due to extreme emotion.
(e.g. fainting spell).
Signs of shock are not always obvious, and may even appear hours later. Signs and
symptoms may vary according to the cause. Suspect shock in cases of severe
external bleeding. Internal bleeding may be hidden, but can also cause shock.
When a victim displays early signs of shock, do not delay calling for emergency help.
The victim’s condition can deteriorate very rapidly. Early medical care can minimize
damage to vital organs such as the brain and kidneys, or even save a life.
Signs and Symptoms:
 Pale, cool, moist skin
Weak, rapid pulse
Rapid, shallow breathing
Very low blood pressure
Nausea and/or vomiting
Emotional unrest or confusion
Dizziness or faintness
Chest pain
Dull, vacant eyes; dilated pupils
Excessive thirst
Decreased urine output
Signs and symptoms of allergic reaction (wheezing, hives, itching, skin
redness, abdominal cramping)
An increased heart rate can indicate that the person’s heart is trying to compensate
for decreased blood flow to vital organs.
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Lay the victim down. This will improve blood flow to vital organs in the core of
the body.
4. Control external bleeding; treat fractures as indicated.
5. Maintain body temperature. Normal body temperature is 98.6 F. It may require
warming a cold patient or cooling a hot patient. If cold, cover with a blanket;
replace wet clothing with dry. Insulate the victim from the ground if needed
(e.g. place a blanket underneath the victim).
6. Loosen tight clothing.
7. Monitor status every 5 minutes.
8. Do not give the person anything to eat or drink. This may delay any
necessary surgery, or cause vomiting.
Elevating the legs when there are signs of shock has not been proven through
research to be beneficial as a first aid maneuver, so it will not be taught in a basic
first aid course.23 There is also the risk of the first aid provider causing harm to the
victim by missing signs of a spine, pelvic or leg injury.
A stroke (cerebrovascular accident or CVA) is a general term that describes an
injury to the brain caused by a disruption of blood flow to a region of the brain. A
stroke is just like a heart attack, but occurs in the brain. The term “brain attack” has
been used to signify the importance of early recognition and treatment of stroke
The brain relies on oxygen and sugar (glucose) to live. When blood flow to the brain
is interrupted, brain cells in the affected area begin to die. The severity of a stroke is
determined by the size and location of the area affected by the lack of oxygen. If the
stroke is not fatal, the person may have permanent disability.
Every 40 seconds someone has a stroke in the U.S. Stroke is the third leading cause
of death in the United States and most other countries, and is the leading cause of
brain injury in the U.S. About 800,000 Americans suffer a first or recurrent stroke
each year. More women than men have strokes, primarily due to the longer life
expectancy of women, and the increased risk of stroke with increasing age.
Annually more than 136,000 strokes are fatal, with more than half of them occurring
out of the hospital. There are over 7 million stroke survivors in the U.S., many of
whom have permanent stroke-related disabilities.69,172
Recognition of stroke
symptoms by family members and rapid medical intervention is critical to reducing
death and disability. Certain treatment options are only available to a stroke victim
within a few hours of the onset of symptoms. Like a heart attack, delay equals cell
Clot vs. Bleed69
There are two categories of stroke. An ischemic (clot-type) stroke results from the
blockage of a cerebral artery. A hemorrhagic stroke usually results from the rupture
of a weakened portion of a blood vessel wall that is overstretched and bulging due to
hypertension (aneurysm) or a malformation of blood vessels. The result is bleeding
into brain tissue. It is important to note that both types can be fatal.
Hemorrhagic Stroke
Although both types of stroke can be deadly, clot-related stroke rarely leads to death
within the first hour, while hemorrhagic stroke can be fatal at onset. When a rupture
in a cerebral artery occurs, the onset of signs and symptoms occurs quickly and with
little warning. Hemorrhagic stroke accounts for approximately 13% of all strokes.
The most common cause of hemorrhagic stroke is hypertension (sustained high
blood pressure). Emergency surgery is usually required to resolve this lifethreatening condition.
Clot-Type Stroke
A clot-type (ischemic) stroke is caused by a traveling clot (embolus) or a blockage
(thrombus) that forms in a cerebral artery. Clot-type strokes are the most common
type of stroke, and are responsible for about 87% of all strokes. 69
Transient Ischemic Attack (TIA)
A TIA, often termed a minor or baby stroke, is a temporary lack of oxygen to the
brain that results in transient stroke symptoms. The cause is the same as that of an
ischemic stroke. The symptoms of a TIA usually resolve without intervention within
the first 60 minutes, with all symptoms gone within 24 hours.
TIAs are considered a warning sign of an impending stroke. About 10% of TIA
victims will develop a stroke within 90 days, and up to 13% will die within a year. TIA
victims should be evaluated by their physician to identify ways to reduce the risk of a
major stroke, yet only half actually report a TIA.69 Medications, surgery and lifestyle
changes can reduce the risk of subsequent stroke in patients with TIA.
Risk Factors Associated with Stroke69,174,175
Similar to a heart attack, some risk factors of stroke are controllable, while others are
beyond our control. We all should be aware of the risk factors and do what we can to
prevent or reduce our risk of stroke. Combined risk factors significantly increase the
prevalence of arterial disease and the occurrence of stroke.
Controllable Risk Factors
Reducing the controllable risk factors associated with stroke is paramount to living a
long and healthy life. Consult your doctor before beginning an exercise program or
significant lifestyle changes. Your doctor can identify your risk factors, and then
develop a plan to reduce your risk. Efforts at reducing risk factors can be focused on
the following activities:
Smoking: Smoking is the number one preventable cause of serious illness such as
heart disease, stroke and lung cancer. It reduces the amount of oxygen in your
blood, and increases heart rate and blood pressure.
Physical Activity/Obesity: Physical activity affects blood pressure, reduces
cholesterol levels, helps control weight, reduces the risk of diabetes and reduces
stress. Obesity (30 pounds or more overweight) is a significant risk factor for heart
attack and stroke. It is caused primarily by eating more calories than are burned
through daily activity. The excess calories are stored as fat. Maintain a healthy
weight with a varied, healthy diet, more appropriate portions, regular exercise and
increased daily activity. Consult your doctor prior to beginning an exercise program.
Diet: Foods that are high in saturated fat, trans fat and cholesterol contribute to heart
attack and stroke. Healthy foods (a variety of fruits, vegetables, whole grains, low in
saturated fat) reduce risk. High salt intake can lead to high blood pressure. Eat a
varied, healthy diet with plenty of fruit and vegetables.
Excessive Alcohol: Studies indicate that one or two drinks a day may increase
“good” cholesterol (HDL); however, heavy drinking can lead to high blood pressure,
heart disease and stroke.
High Blood Pressure and High Blood Cholesterol: Hypertension and high blood
cholesterol levels are direct contributors to heart attack and stroke. Keep levels low
through regular checkups with your doctor, exercise, a healthy diet and medication
as needed.
A good blood pressure is 120/80 mm Hg. If it’s over 120/80 mm Hg, have it checked
more often and report your findings to your doctor. High blood pressure is
considered to be 140/90 mm Hg or higher. Sustained high blood pressure
(hypertension) is known as the “silent killer,” as it occurs over years without signs or
symptoms. Hypertension causes damage to the blood vessels and increases risk of
heart attack and stroke.
High levels of cholesterol are associated with heart disease. Low Density
Lipoproteins (LDL) carry cholesterol to the tissues and arteries. High Density
Lipoproteins (HDL) carry cholesterol to the liver to remove it from the body. When
there is too much LDL circulating in the bloodstream, plaques (cholesterol and other
materials) build up on the inside of the artery walls, leading to narrowing of the inside
of the artery and hardening of the artery wall.
Good levels of cholesterol: <100 mg/dl LDL; >60 mg/dl HDL; <200 mg/dl total
Diabetes: Diabetes leads to vascular disease, which automatically increases the risk
of heart disease and stroke. With medical care, diabetes can be detected and
controlled. With a healthy diet, exercise, and healthy weight, type 2 diabetes can
often be prevented.
History of TIA: Recent or repeated ‘baby’ strokes.
Non-Controllable Risk Factors
Age: The older we get, the higher our risk of heart disease and stroke.
Sex: Each year more women than men suffer from a stroke.
Hereditary: A family history of heart disease or stroke is a strong indicator of
increased risk. For persons with a family history of heart disease or stroke, it is even
more important to identify and control the other risk factors.
Race: African Americans are more likely than Caucasians to have high blood
pressure, and tend to have strokes earlier in life and with more severe results.
Recognition of Stroke
The onset of stroke symptoms is usually sudden and can encompass a range of
signs and symptoms. Not all signs and symptoms need to be present. The types of
symptoms experienced during a stroke can vary depending on the portion of the
brain affected (i.e. if the speech center is affected, the victim’s slurred speech may
be the most prevalent sign of a stroke).
The brain is the nerve center for the body; impulses from the brain control nearly
every aspect of our body. When brain cells are injured by a stroke, the injury affects
the part of the body controlled by that portion of the brain. The brain is divided into
two hemispheres, each of which controls the opposite side of the body. The
symptoms of a stroke commonly affect only one side of the body, but may be present
in both sides.
Families of those at risk for stroke should be educated on the signs and symptoms of
stroke. Early medical intervention is critical.
Signs and Symptoms of Stroke
 Sudden weakness or numbness of the arm or leg, usually on one side of the
 Facial droop or paralysis, usually on one side
o Ask the stroke victim to smile or show his or her teeth.
o A drooping cheek or corner of the mouth is an indicator of stroke.
 Difficulty speaking
o A stroke may affect the speech center of the brain.
o Slurred, garbled or confused speech is a sign of stroke.
 Difficulty swallowing
o Drooling
o Coughing when attempting to eat or drink
 Altered level of consciousness
o Confused, unresponsive, lethargic
o Remember that hearing is the last sense to go when we become
unconscious. Rescuers should refrain from discussing the severity of
the patient’s condition or from making inappropriate comments.
 Sudden dizziness or severe headache with unknown cause
 Unsteadiness, sudden falls or other sudden lack of coordination or balance
 Visual disturbances such as the loss of vision in one eye
Quick Stroke Assessment176
Use S-T-R, the first three letters of stroke, to remember common signs of stroke.
S: Smile. Ask the person to smile. Look for a lopsided or uneven smile.
T: Talk. Ask the person to say a simple statement, such as “You can’t teach an old
dog new tricks.” Listen for slurring or incorrect use of words.
R: Reach. Ask the person to close his or her eyes and raise both arms up. Look for
uneven movement or strength.
A victim of stroke will often have sudden weakness on one side of the body, or
difficulty speaking or using words correctly. Suspect stroke if any of these signs are
present, and call 9-1-1 immediately. Give the time of the onset of signs and
Delays in Calling 9-1-1178
Rescuers should err on the side of caution when considering the signs and
symptoms of a stroke. If the victim shows any of the signs and symptoms of stroke,
call 9-1-1 (activate EMS).
Some people who recognize stroke symptoms may still not call 9-1-1. A recent study
found that almost 40% of people who recognize at least one stroke symptom would
choose to give first aid, call their doctor, stay with them until they feel better, or drive
them to the hospital instead of calling 9-1-1.
The correct action is always to call 9-1-1 for even one stroke symptom. EMS
responders will be available to help if the victim’s condition gets worse, can get to the
hospital fast, and will often contact the hospital to prepare them for the suspected
stroke victim.
Treatment of Stroke
Call 9-1-1 at the earliest onset of stroke symptoms. Do not assume that a victim is
having a TIA and wait for symptoms to resolve. Early recognition of the symptoms of
a stroke is essential to reduce associated death and disability. Recent advances in
the treatment of stroke have produced new medications that are incredibly effective,
but only work in the early hours of a stroke.
When you suspect a stroke, take the following actions:
1. Call 9-1-1 (activate EMS).
2. Protect the airway.
a. May have trouble controlling the tongue or managing secretions.
b. If fluids or vomit in the mouth, place in the recovery position to allow
fluids to drain.
3. Calm and reassure the victim.
4. Note the time that symptoms began.
If the person is unresponsive:
1. Check for breathing.
2. If no breathing or only gasping, begin CPR.
Fibrinolytic Therapy – The use of “Clot-Busters” 69
When clot-busting medication, or rtPA (recombinant tissue plasminogen activator), is
administered to the victim of a clot-type stroke, it is known as fibrinolytic therapy.
Protocols suggest that fibrinolytic therapy has to be administered within three hours
of the onset of symptoms in order to be most effective at limiting neurological
damage. Sadly, fewer than 10% of appropriate patients can receive fibrinolytic
therapy because most victims reach the hospital too late.
Because of the narrow window of time between the onset of stroke symptoms and
the effectiveness of fibrinolytic therapy, 9-1-1 should be called without delay if a
stroke is suspected or a person is exhibiting stroke symptoms.
Since there is a risk of hemorrhage associated with the use of fibrinolytic therapy,
clot-busting medications cannot be administered to someone with a hemorrhagictype stroke, as it would worsen the bleeding into the brain tissue.
Fibrinolytic therapy can reduce the effects of a stroke by reducing or eliminating the
clot at the source. It is administered through an intra-venous line and circulates
through the blood stream. It will locate the clot and attempt to dissolve it. Receiving
clot-busting medication could make the difference between lifelong disability or even
death and a complete resolution of the stroke and its symptoms.
Stroke-Prepared Hospital
Due to the time sensitive nature of stroke, the development of stroke systems of care
with improved public awareness has been an important part of decreasing mortality
and disability from stroke. The greatest improvement has been in the area of the
‘stroke-prepared’ hospital.
A stroke-prepared hospital will have expertise in the following:
 Rapid triage, evaluation and management in the Emergency Department
 Fibrinolytic therapy and other strategies
 Rapid admission to the appropriate acute hospital unit
Further progress is needed in early recognition of stroke symptoms by the public,
early activation of EMS, rapid EMS dispatch, and pre-hospital notification and patient
transport to a stroke-prepared hospital. This “Stroke Chain of Survival” can have a
significant impact on survival of stroke with decreased disability.69
Racial and Ethnic Disparities in Recognition and Care of Stroke
Despite improvements in prevention, recognition, and medical care of stroke, there
remains a significant gap between minorities and Caucasians in stroke care.
Improvement is needed in many areas: compliance with prevention, such as control
of hypertension and diabetes; community education of stroke signs and the need for
immediate care; cultural competence among EMS and healthcare providers; access
to insurance coverage and care.177
Traumatic Injuries
Trauma is defined as "an injury or wound to a living body caused by the application
of external force or violence." Acute trauma may occur when a sudden application of
force or violence causes immediate damage to a living body. The most common
cause of injury-related death in the US is motor vehicle accidents; gunshot wounds
are the 3rd leading cause.183
Gunshot Wounds179,180,181
There are more than 200 million privately owned firearms in the US. There were
more than 30,000 deaths and 70,000 injuries by firearms in 2005.
One third of households with children or adolescents contain firearms, and one third
of those firearms are not stored safely.182 Most young children are strong enough to
fire a gun, despite popular belief to the contrary. More than half of the unintentional
firearm-related deaths among children occur in the home of the child, a relative or
The most important factor when dealing with gunshot wounds (GSW) is scene
safety. Once the scene has been secured, you can turn your attention to caring for
the victim.
Consider the following aspects of GSW:
 Causes laceration, crushing and shock wave-type injuries.
 Can damage vital organs or major blood vessels.
 May cause exit wounds that are larger and bleed more than entrance wounds.
 Can ricochet off bones, causing more damage.
1. Call 9-1-1 for EMS and law enforcement.
2. Ensure scene safety.
3. Assess response, breathing, circulation and appearance.
4. Spinal immobilization if potential spinal injury.
5. Check for entrance and exit wound.
6. Control bleeding.
7. Keep the victim still.
8. Treat for shock.
9. Do not disturb potential crime scene evidence.
The definitive treatment is surgery to repair the damaged organs. Many GSWs are
part of a crime scene; remember as much detail as you can and disturb as little of
the area as possible.
Crush Injuries184,185
Crush injuries occur when blunt force is applied to the body for extended periods of
time (e.g. a car accident victim whose legs are trapped under the dashboard, or a
structural collapse during an earthquake). Common injuries include fractures,
lacerations, bruising, bleeding, and compartment syndrome (increased pressure or
swelling in a section of muscle resulting in severe pain, decreased blood flow, and
eventually tissue death if pressure is not surgically relieved).
The person’s outcome is determined by the length of time the tissue is compressed
and deprived of blood. Although the injury is localized, the whole body can be
affected as muscle tissue breaks down and its toxic components are released into
the body.
Emergency scenes that involve crush injuries are typically dangerous; secondary
collapse should be considered a major hazard.
1. Ensure scene safety.
2. Activate EMS. (Call 9-1-1).
3. Assess response, breathing, circulation and appearance.
4. Severe Bleeding Treatment protocol
5. Spinal immobilization
Impaled Object14,37
An impaled object injury occurs when the object that causes a wound remains
deeply embedded in the skin. Treatment is focused on controlling bleeding while
securing the object in place. In most cases the impaled object should not be
removed. Removing the object may cause more damage and could increase
1. Assess response, breathing, circulation and appearance.
2. Activate EMS. (Call 9-1-1.)
3. Expose the wound. Remove the clothing covering the wound if possible.
4. Apply direct pressure to control bleeding.
a. Apply pressure on either side of the object.
b. Do not apply pressure directly on the impaled object.
5. Stabilize the object in place.
a. Use a bulky dressing or clean cloths and tape.
b. If the object is impaled in an extremity and EMS is delayed, immobilize
it with a splint.
c. Secure at least ¾ of the object in place.
6. Calm and reassure the victim.
Do not apply pressure directly on the impaled object.
Do not attempt to remove an impaled object.
 Removing the object may cause severe bleeding and more damage to the
underlying area.
 Leaving the object in place may slow the bleeding, and could help identify
organ involvement by the depth and angle of injury.
 A physician will ultimately remove the object in a controlled environment.
Do not attempt to shorten an impaled object.
 Motion of the impaled object may damage surrounding tissues.
 Consider cutting the object only if extremely cumbersome and transport is
 Leave the manipulation of the impaled object to EMS professionals, in most
Stabilizing an Impaled Object:
1. Apply direct pressure at the wound edges to control bleeding.
2. Build up bulky dressings, bandages or clean cloth around the object.
3. Stabilize at least ¾ of the object.
4. Secure in place with adhesive tape.
5. Assess circulation below the bandage to ensure it is not too tight; reapply if
any change in circulation, sensation or motion below the bandage.
Impaled Object in the Cheek
One of the only times a rescuer should consider the removal of an impaled object is
when it is embedded in the cheek. When a foreign object is impaled in the cheek it
should be removed, because massive bleeding with cheek injuries is associated with
airway obstruction.
Removing an Object Impaled in the Cheek:
Gently feel the inside of the cheek to determine if the object has penetrated all the
way through. If so, carefully pull the object out from the same side it entered. If there
is difficulty removing the object, leave it in place; do not force the object out. When
the object has been removed, pack the inside of the cheek (inside the mouth,
between the teeth and cheek) with sterile gauze. Apply counter pressure with a
dressing and bandage secured over the outside of the wound. Position the victim so
that blood will drain out of his/her mouth if bleeding is significant.
An amputation is a partial or complete loss of a body part due to an injury or
accident. Bleeding may be minimal due to retraction of the blood vessels.
1. Assess response, breathing, circulation and appearance.
2. Activate EMS (call 9-1-1).
3. Apply direct pressure to the site of bleeding.
4. Treat for shock.
5. Wrap amputated part in dry sterile gauze. Put gauze in plastic bag. Put plastic
bag into second bag filled with ice.
DO NOT Do not let ice come in direct contact with the amputated part or immerse it
in water.
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