INTRODUCTION TO FIRST AID

First Aid is the immediate care given to a person who is injured or

suddenly becomes ill. First Aid includes recognizing life threatening
conditions and taking action to keep the injured or ill person alive and in
the best possible condition until medical treatment can be obtained.

First Aid does not replace the physician. One of the first principles of first
aid is to obtain medical assistance in all cases or serious injury.

The principle aims of first aid are as follows:

- To care for life-threatening conditions

- To minimize infection

- To make conserve the victim strength as comfortable as possible.

- To transport necessary the victim to medical facilities, when

necessary

First aiders should know how to supply artificial ventilation and

circulation, control bleeding, protect injuries from infection and other
complications. When first aid is properly administered, the victim's
chances of recovery are greatly increased.

First aiders must be able to take charge of situations, keep calm while
working under pressure.

Evaluating the Situations.

When a person is injured, someone must take charge, administer first

aid and arrange for medical assistance. First aiders should take charge
with full recognition of their own limitations and while caring for life-
threatening conditions, direct others briefly and clearly as to exactly
what they should do and how to secure assistance.

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PRIMARY SURVEY
Several conditions are considered life-threatening, but three in particular
requires immediate action.

- Respiratory arrest.

- Circulatory failure.

- Severe bleeding.

Respiratory arrest and/or circulatory failure can set off a chain of events
that will lead to death. Severe and uncontrolled bleeding can lead to an
irreversible state of shock in which death is inevitable. Death may occur
in few minutes if -an attempt is not made to help the victim in these
situations. The first aider should perform the primary survey to
determine the extent of the problem as soon as the victim is reached, and
if any of the life threatening conditions are found, begin first aid
procedures without delay.

In checking for an adequate breathing, an open airway must be

established and maintained. If there are no signs of breathing, artificial
ventilation must immediately be given.

If a victim experiences circulatory failure, a person trained in

cardiopulmonary resuscitation (CPR) should check for a pulse, and if
none is detected, start CPR at once.

A careful and thorough check must be made for any severe bleeding.
Serious bleeding must be controlled by proper methods.

In making the primary survey, the first aider must be carefull not to
move the victim any more than is necessary to support life. Rough
handling or any unnecessary movement might cause additional pain and
aggravate serious injuries that have not yet been detected.

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SECONDARY SURVEY

When the life-threatening conditions have been controlled, the secondary

survey should begin. The secondary survey is Head to Toe examination
to check carefully for any additional unseen injuries that can cause
serious complications. It is conducted by examining for the following:

- Scalp lacerations and contusions. Without moving the head, check

for blood in the hair.

- Skull depressions. Gently feel for possible bone fragments or

depressions.

- Loss of fluid or bleeding from ears and nose, which indicates

possible skull fracture and damage to the brain.

- Spine fracture, especially in the neck area. Gently feel and look for
any deformities. If a spinal injury is suspected, stop the secondary
survey until the head can be stablized.

- Chest fracture and penetrating (sucking) wounds. Observe chest

movement. When the sides are not rising together or one side is not
moving at all, there may be lung and rib damage.

- Abdominal spasms and tenderness. Gently feel the abdominal area.

- Fractures in the pelvic area. Check for grating, tenderness, bony

protusions and depressions.

- Fractures or dislocations of the extremitis. Check for discoloration,

swelling, tenderness and lumps.

- Paralysis of the extremitis. This condition indicates spinal cord

damage. Paralysis in the arms and legs indicates a broken neck.
Paralysis in the legs, but not arms indicates a broken back.

- Wounds underneath the victim which are often over looked,

especially if the victim is found on his or her back. Check for any
non protusions or bleeding.

- Burns, visually examine the victim.

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GENERAL PRINCIPLES
Besides being trained in proper FIRST AID methods, all first aiders
should know what first aid equipment is available. The equipments
should be checked periodically. The following procedures are generally
applicable:
- Take charge: instruct someone to obtain medical help and
others to assist as directed.
- Make a primary survey of the victim.
- Care for all life-threatening conditions.
- Care for all injuries in order of need.
- If several people have been injured, decide upon priorities in caring
for each victim.
- Keep the injured person lying down.
- Loosen restricting clothing when necessary.
- Keep onlookers away from the victim.
- When necessary, improvise first aid materials using the most
appropriate material available.
- Cover all wounds completely.
- Exclude air from burned surfaces as quickly as possible by using a
suitable dressing.
- Remove small, loose foreign objects from a wound by brushing
away from the wound with a piece of sterile gauze.
- Do not attempt to remove embedded objects.
- Place a bandage compress and a bandage over an open fracture
without undue pressure before applying splints.
- Support and immobilise fractures and dislocations.
- Leave the reduction of fractures or dislocations to a doctor.
- Never move a victim, unless absolutely necessary, until fractures
have been immobilised.

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- Test the stretcher before use, and carefully place an injured person
on the stretcher.

- Carry the victim on a stretcher without any unnecessary rough

movements.

FOR EASY REMEMBERANCE

F - First

I - Inform

R - Render

S - Simple

T - Treatment

A - Avoid

I - Immediate

D - Danger/Death.

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 STRUCTURE AND FUNCTIONS OF THE HUMAN BODY

The human body is a very complex multicelluar organism, the

maintenance of its life depends on numerous physiological and
biochemical activities.

The complexity varies from organism to organism and have a better

understanding, there is a gross need to have a working knowledge of its
structure.

STRUCTURE AND FUNCTION

Structure simply means the way something is put together. Anatomy is

the study of the structure of the body and the position of the various
organs. Physiology describes the mode of action and function of the
organs and systems of the body.

The CELL is the fundamental

building unit of the human
body. Basically a cell is a unit
of living matter - a unit of
structure and function. The
single cell organism -
AMOEBA - is the smallest
functional unit thus being the
simplest kind of organism
that can be exist
independently. Examples of
cell types: nerve cells, muscle
cells, epithalial (surface) cells.

For survival, every species, simple or complex must be able to perform

certain functions. The amoeba can carry out all the necessary functions
because all parts of the cell are easily exposed to the external
environment.

It's not so simple in the human body which consist of countless cells,
(multicellular). So it is not possible for all the cells to be in close contact
with the environment, therefore specialised cells have evolved leadling to
specialisation in function and structure, eg. the cells which make up the
muscular structure are different from those cells that make up the
stomach because the former function is to contract and the latter to
produce digestive juice.

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Groups of cells which look the same and tend to perform similar
functions are discribed as TISSUES.

The body consists of four main types of tissues –classified according to

size, shape and functions.

1. Epithelial tissue of epithelium

2. Connective tissue.

3. Muscular tissue.

4. Nervous tissue.

EPITHELIAL TISSUE : two functions to perform they protect

the body and form secretions. Protection is provided by the covering and
lining membranes for the free surfaces inside and outside the body. The
second function of the tissue is the formations of glands in order to
produce secretions which are necessary for the proper functioning of the
body.

CONNECTIVE TISSUE : this support and binds together all

other tissues. These cells undergo transformation at different places to
serve it's function. The cells of the bone, adipose tissue or fat and
cartilage cells belong to this group.

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MUSCULAR TISSUE ; specilised for contraction and is able to
produce movement. Muscle cells are long and thin, so that the
shortening that occurs during contraction maybe effective. There are
three types of muscular tissues -Voluntary, Involuntary and Cardiac.

NERVOUS TISSUE : is especially designed to receive stimuli from

inside or outside the body and when stimulated to carry impulses to
other tissues.

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These tissues are further grouped together to form ORGANS. An organ is
a group of tissues arranged in a certain way to carry out a specific task
eg. the kidneys, heart. These organs are grouped together to form
SYSTEMS. A system is a group of organs which together carry out one
of the essential functions of the body. However, some of the cells are so
specilalised that none of the systems can exist on its own. Therefore all
the system are grouped together to form the HUMAN BODY.

1. THE SKELETAL SYSTEM : provides a framework which gives

support and protection to the soft tissues and allows movement at
the joint.

2. THE MUSCULAR SYSTEM : effects movement of the body as a

whole. Both those systems are sometimes called the
LOCOMOTOR .system ( SKELETAL + MUSCULAR).

3. THE CIRCULATORY SYSTEM: is the transport system of the

body. It carries oxygen and nourishments to the tissues and waste
products away.

4. THE RESPIRATORY : allows exchange of gases between the

body and the environment.

5. THE DIGESTIVE SYSTEM : is concerned with digestion and

absorption of food and elimination of waste products.

6. THE URINARY SYSTEM: main excretory system of the body.

7. THE NERVOUS SYSTEM: creates awareness o f the environment

and makes it possible for the body to respond to change.

8. THE ENDOCRINE SYSTEM: produces hormones which

control a variety of functions in the body.

9. THE REPRODUCTIVE SYSTEM: responsible for the survival of the

species of the same kind.

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 BASIC ANATOMICAL LAYOUT OF THE BODY.

Man or HOMO SAPIEN is the highest evolved member of the group

MAMMALIA. This group consists of warm blooded vertebrates with hairs
on their body. The skin contains sweat glands and sebaceous glands. In
the females of this species, the sebaceous glands along the ventral side
are modified to form mammary glands, from which they earn the name
mammalia. The human body can be divided into the head, neck, thorax,
chest, abdomen and limbs.

Definition of Terms Used in Anatomy.

In order to achieve uniformity of description an anatomical position has

been choosen and defined. The body is erect, facing the observer, with
the arms at the sides and the hands facing forwards.

The following terms are commonly used:

Superior : upper or above
Inferior : lower or below
Anterior or ventral : towards the front
Posterior or dorsal : towards the back
Distal : furthest from the source
Proximal : nearest to the source
External : outer
Internal : inner

The median or saggittal line is an imaginary vertically through the

midline of the body from the crown of the head to the ground between
the feet, dividing it into right and left halves. Lateral means furthest from
the median line; medial means nearest to the median line.

A horizontal section divides the body into superior and inferior portions.

A saggital section divides the body into right and left portions parallel to
the median line.

A coronal section divides the body into anterior and posterior portions.

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CAVITIES OF THE BODY

The body has two major cavities, each subdivided into lesser cavities. The
ventral cavity, within the trunk, is divided into:

1. The Thorax or Thoracic cavity.

2. The Abdomen or Abdominal cavity which is continuous with

the pelvic cavity.

The dorsal cavity is subdivided into:

1. The cranial portion, containing the brain.

2. The spinal portion, containing the spinal cord

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REGIONS OF THE ABDOMEN
For purpose of description the abdomen is divided into regions by two
transverse and two upright lines.
Important organs found in the respective regions are:
Right Hypochondrium - LIVER
Epigastrium - STOMACH
Left Hypochondrium - SPLEEN
Right Lumber - KIDNEY SMALL INTENSTINE
Umbilical region - KIDNEY
Left Lumber - APPENDIX
Right Iliac Fossa - BLADDER
Hypograstrium - SIGMOID

Left Iliac Fossa - COLON

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THE SKELETAL SYSTEM

This system is made up of 206 bones, joined together to provide a strong

movable living framework for the body. It is built on an external
framework of bones called the SKELETON. Actually, bone is a
specialised type of connective tissue which is reinforced by calsium to
give it strength and solidity.

The skeletal system may be divided into an axial portion, consisting of

the skull, vertebrae, the chest bones and pelvic bones and appendicular
portion consisting of limbs.

The system has four main functions.

1. It support and protects the surrounding soft tissues and vital

organs.

2. It assists in body, movements by giving attachment to

muscles and providing leverage at the joints.

3. It manufactures red blood cells in the red bone marrow.

4. It provides storage for mineral salts-phosphorus and calcium.

Type of Bones

These are four types of bones:

1. Long bones 2. Flat bones

3. Irregular bones 4. Short bones.

Long bones - consists of shaft and two extremities. The

central cavity is called the medullary canal which contains yellow
bone marrow. The extremities consist of a mass of spongy bone
containing red bone marrow. The bone is covered by a tough sheat
of fibrous tissue called periosteum. eg. humerus.

Flat bones - two stout layers of compact bone joined by a

layer of spongy bone, these bones are also covered by periosteum,
eg. head, shoulder and pelvic girdle. Where they give protection to
the delicate organs.

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 Irregular bones - consists of mass of spongy bone covered by a
thin layer of compact bone. They are also covered by periosteum,
except on the articular surface. eg. spinal column.
Short bones - composed of an outer layer of compact bony
substance, internal to which cancellous bony material, eg. bone of
the vertebral column.
Bones of the Head
The student is advised that it is not possible to study adequately the
bones of the skeleton without access to an entire skeleton and to
disarticulated bones which can be handled and examined closely.
The skeleton can be divided into:
1. The bones of the head.
2. The bones of the trunk.
3. The bones of the upper limb and shoulder girdle.
4. The bones of the limb and pelvic girdle.
The Bones of the Cranium
The cranium is a box -like cavity contains and protects the brain. It has
a dome shaped roof called calvaria or skull cap and its floor is known as
the base of the skull. The cranium consists of fifteen bones:
1. One frontal bone
2. Two'parietal bones
3. One occipital bone
4. Two temporal bones
5. One ethmoid bone
6. One sphenoid bone
7. Two inferior nasal conchae
8. Two lacrimal bones
9. Two nasal bones
10. One vomer

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The frontal bone is a large flat bone forming the forehead and most of the
roof of the orbit. There are rounded prominences, called the frontal
tuberosities, one on each side of the midline, which vary in size from one
individual to another and which together form the forehead. The bone
contains two irregular cavities called the frontal sinuses which lie one
over each orbit and which open into the nasal cavity. The sinuses
contain air and are lined with mucous membrane which is continous
with the mucous membrane lining the respiratory tract. They add
resonance to the voice and they serve to lighten the skull, but the
mucous membrane may become infected, causing a condition known as
sinusitis.

The parietal bones form the sides and roof of the cranium: they articulate
with the frontal bone, the occipital bone and with each other to form the
sutures or joints of the cranium. On the internal surface are small
grooves to carry the blood vessels supplying the brain and the
impression of the folds or convolutions of the surface of the brain can be
seen. At birth there are membranous gaps in the skull at the angles of
the parietal bone which are called fontenelles.

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The occipital bone forms the back of the skull. It carries a marked
prominance, the external occipital protuberance which gives attachment
to muscles. Below this there is a large oval opening, known as the
foramen magnum, through which the cranial cavity communicates with
the vertabral canal. On either side of the foramen are two smooth oval
processes called the occipital condyles for articulation with the first
cervical vertebra. This joint allows the nodding movement of the head.
The temporal bones are situated at the sides and base of the skull.
The Bones of the Face.
The bones of the face are:
The maxillae
The mandible
The zygomatic bones
Two palatine bones
The hyoid bone
MAXILLAGE - largest bones of the face -form the upper
jaw and contains the maxillary sinuses.
MANDIBLE - only movable bone of the head, forms the
lower jaw.
ZYGOMATIC - irregular bones -form the prominence of
the check.
PALATINE - irregular bones -form part of the hard
palate.
HYOID - is U- shaped and lies at the base of the
tongue.

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The Bones of the Trunk

The bones of the trunk are:

The sternum.

The ribs.

The vertebral column.

The Sternum

The sternum is a long flat bone

which runs down the front of the
thorax close under the skin. Its
upper end supports the clavicles
and it also articulates with the first
seven pairs of ribs. The bone is in
three parts - the manubrium, the
body and the xiphoid process.

The Ribs

The ribs are arched bones which

are connected behind with the
vertebral column. There are usually
twelve pairs, the first seven of
which are attached to the sternum
by the costal cartilages and are
known as the true ribs. The
remaining five are called false ribs.
Of these the upper three are joined
to the cartilage of the rib
immediately above and the lower
two are free at their anterior ends
and are known a floating ribs.

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The ribs form the curved walls of
the thorax, sloping downwards
towards the front. They increase in
size from above downwards
towards the front. They increase in
size from above down wards so that
the thoracic cavity is roughly
coneshaped.

Each rib is curved and the under

surface is grooved for the passage
of intercostal arteries, veins and
nerves. The vertebral end possesses
ahead, a neck and a tubercle. The
head has two smooth facets which
articulate with the bodies of the
corresponding vertebrae.

The tubercle had a small oval facet

for articulation with the transverse
process of the corresponding
vertebra.

The vertebral column

Consists of irregular bones called

vertebrae. The column provides a
central axis and also protects the
spinal cord. The main support of
the head and trunk.

The vertebrae are divided 5

groups:

1. 7 cervical vertebrae

2. 12 thoracic vertebrae

3. 5 lumbar vertebrae

4. 5 sacral vertebrae

5. 3- 5 coccyx

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The vertebrae and spinal curves

The five lumbar vertebrae are the largest

vertebrae and have no facets for articulation
with the ribs. The spinous processess are
large and strong and give attachment to the
muscles.

The five sacral vertebrae are fused together to

form a large bone, the sacrum, which is
tringular in shape and forms a wedge
between the two hip bones with which it
articulates. The pelvic surface of the bone is
concave and the interior projection at the
upper ends is known as the sacral
promontory. The vertebral foremen found in
the other vertebrae is here called the sacral
canal and from it four openings allow for the
passage of nerve roots.

The coccyx is a small tringular bone which consists of four vertebrae

fused together. It articulates with the sacrum and the joint allows slight
movement backwards and forwards which increases the size of the pelvic
outlet during child birth.

The vertebral column is the main support of the head and trunk as well
as giving protection to the spinal cord. When viewed from the side it has
four curves; the thoracic and pelvic curves are termed primary curves as
they are present during fetal life. The cervical and lumbar curves are
secondary as they appear or are accentuated when the child begins to
hold up its head and sit up (cervical) and when it begin to stand and
walk (lumbar) .

There is only limited movement between any two adjoining vertebrae but
there is considerable movement in the vertebral column as whole. The
intervertebral discs cushion any jarring which may occur; as for example
jumping from a height and landing on the feet. The curves of the spine
enable it to bend without breaking, but a blow on the column is more
likely to cause a fracture or a dislocation because the vertebrae are so
firmly united to one another.

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Bones of the upper limb

The scapula
The clavicle -(shoulder gridle)
The humerus
The radius
The ulna -(Forearm)
8 carpal bones
5 metacarpal bones
14 phalanges

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Bones of the lower limb

The hip bone -which forms parts of the pelvis

The femur
The patella -knee cap
The Tibia
The fibula -leg
7 tarsal bones
5 metatarsal bones
14 phalanges

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 THE MUSCULAR SYSTEM
It is made up of countless
muscles, attached to the bones,
which allows movement,
muscles from the flesh of the
body and are responsible for
movement from place to place,
for the. power to reach and hold
objects. For this reason the
skeletal, articular and muscular
systems together are known as
the LOCOMOTOR SYSTEM.

Types of muscle
There are three types of
muscles:
1. Voluntary (striated)
2. Involuntary (smooth)
3. Cardiac muscle.
The muscle is a tissue in which chemically stored energy is coverted
mechanical work.
1. Voluntary Striated : Muscles which are attached to
bones are called skeletal muscles. They are also called
voluntary muscles because they can be moved at will by the
central nervous system. The skeletal muscle is composed of a
group of muscle fibres called fasiculi bound together by
connective tissue.
2. Involuntary (Plain smooth) : This type of muscle is
not attached to any bone and is not under voluntary control.
3. Cardiac : This type of muscle tissue is found
exclusively in the wall of the heart. It is not under the control
of the cell.
Important muscles
1. Hamstrings are made up of The Biceps Femories, Semitendinous
and Semimembranous.
2. Calf is made up of the Gastronemius and the Soleus.

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Functions

The function of the muscle is to contract and when it contracts it pulls. It

contracts when it is stimulated by one of the following means.

Electrol

Mechanical

Chemical

Thermol

In the human body the necessary stimulus (chemical) is supplied by the

reflexous which pass to the muscle and break up into minute nerve
endings each one of which stimulates a single muscle fibre. When the
muscle fibre contracts it follows the all or none law which means that it
contracts to its full capacity, or it does not contract at all.

In order to contract when it is stimulated a muscle fibre must have an

adequate blood supply to provide sufficient oxygen and nutritioinal
materials and to remove waste products.

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 THE CIRCULATORY SYSTEM

INTRODUCTION AND DEFINITION

Metabolism in a unicellular animal was an easy process carried out by a

simple mechanism of DIFFUSION. When the organism became
multicellular, channels had to be devised to reach the inner core of the
cells. A fluid was required to carry oxygen and materials to the cells and
take away the end products of metabolism.

As the animal form developed further, the fluid becomes blood and the
blood could be propelled through the vascular channels only by a pump -
the HEART.

The heart serves as a pump to force the blood through the vascular tree.
The simplest pump need only to disperse it - this system exists in lower
forms of live -fishes. With the evaluation of the lung we have a three
chambered heart of the frog and finally the human heart which is four
chambered (where the oxygenated and deoxygenated blood does not mix).

Basically, it is well organised transport system of the . body, where blood

is being circulated within a closed system under different pressure
gradients. The volume of blood in our body is limited (5 liters or 10 pints)
but the same blood has to be used over again. In other words, blood
must circulate.

The heart which serve as a pump and the vascular tree (vessels) is also
referred to as the cardio-vascular system.

The cardio vascular system that contains the blood is composed of the:

1. HEART.

2. ARTERIES.

3. CAPILLARIES.

4. VEINS.

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GENERAL STRUCTURE OF THE HEART

The heart of an adult is not much larger than the fist.

Position : It is the centre of the chest normally pointing towards

the left.

The heart is surrounded by:

IN FRONT -the sternum (breast bone)

BEHIND -the thoracic spine (back bone)
BELOW -the diphragm
SIDES -both the lungs

Heart and great vessels

STRUCTURE

The heart is a hollow organ. Its tough muscular wall (myocardium} is

surrounded by a bag covering (pericardium} and is lined inside by a thin,
strong membrane (endocardium).

A wall (septum} divides the heart cavity into the "right heart" and "left
heart". Each side of the heart is divided again into upper chambers
(called atrium} and lower chambers (ventricles} .

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VALVES OF THE HEART

The functioning of the heart is dependent on the existence of valves

which allow the passage of blood only in one direction. The mouths of the
pulmonary artery and aorta are guarded by (SIMILUNAR) valves which
allow the passage of blood only into the vessels and do not permit any
backflow (regurgitation). TRICUSPID valve separate the right atrium and
right ventricle. BICUSPID valve separates the left atrium from the left
ventricle. It is also known as the MITRAL valve.

ACTION OF THE VALVES

The atrio-ventricular valves (tricuspid and bicuspid) open towards the

ventricles and close towards the atrium. The semilunar valves open away
from the ventricles and close towards the ventricles. So when the atrium
contract the atrio-venticular valves open and blood passes into the
ventricles. When the ventricles contract, atrio-venticular valves close but
semilunar valves open. This prevents regurgitation of blood into the
atrium, but allows blood to flow out of the ventricles. In this way
circulation becomes one way.

RELAXATION ( heart fills ) CONTRACTION ( heart ejects )

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THE PROPERTY OF THE HEART MUSCLES
Functionally there are two types of muscle in the body - VOLUNTARY
(skeletal) and INVOLUNTARY (smooth). The CARDIAC muscle has some
of the properties of both these types. The most important characteristic
of the cardiac muscle is that the fibres branch and rebranch and these
again join together to form a continous protoplasma mass called a
'SYNCITIUM'.
The cardiac muscle just like the other muscle contract whenever the
muscle is excited. but the cardiac muscle also obeys the 'ALL OR NONE
LAW', i.e. when an external stimulus is applied to the muscle, the muscle
does not contract unless the stlimulus is strong enough but with a
threshold stimulus the cardiac muscle responds with a maximal
contraction. Any increase in the stimulus will not produce a more
powerful contraction. The cardiac muscle contracts with a maximum
force or does not contract at all.
THE CONDUCTING MECHANISM OF THE HEART ( RHYTHM )
The property of rhythmicity which the cardiac muscle exhibits is unique.
It beats at a specific rate because of this property, .the rate in man being
about 70- 80 beat per minute. This property is best seen, in a specialised
area of the heart muscle called the SINO-AURICULAR NODE (S.A.NODE)
which is the best pacemaker of the heart.
The inpulses which orginate from the S.A. NODE is carried forward
through a special conduction tissue to reach the ATRIO-VENTRICULAR
(A.V.NODE) which sits on top of the inter ventricular system. The
'BUNDLE OF HIS' carries the impulses from the A.V. NODE across the
ventricular septum. The bundle of his splits into the branches at the
bottom of the septum to supply the two ventricles. The main branch split
into smaller branches and end of the myocardium as PURKINGE
FIBRES.

32
The refactory period (rest period) of the heart is long. This period extends
throughout the whole period of contraction. Any stimulus, however
strong will fail to elicit a response if it falls within the period. This long
refactory period ensures enough time for recovery of the cardiac muscle.
This is the reason why cardiac muscle cannot be fatigued (get tired) .
THE MECHANISM OF CIRCULATION
The basic function of the heart is to pump blood both to the body and to
the lungs. Oxygen is required continously by all the body cells to carry
out the normal functions, Carbon dioxide is produced as a waste product
and must be eliminated from the body.
Therefore, the heart is really a double pump. One pump (the right heart)
receive blood which has just come from the body after delivering
nutrients and oxygen to the body tissues. It pumps this dark, bluish -
red blood (de-oxygenated) to the lungs where the blood gets rid of the
waste gas (carbon dioxide) and picks up a fresh supply of oxygen which
turns it into bright red again (oxygenated) , the second (left heart) pumps
it out through the great-trunk artery (aorta) to be distributed by smaller
arteries to all parts of the body.
In greater detail
The four chambers .of the heart perform four different functions. The
right auricle receives venous (deoxygenated) blood from the great veins,
namely the superior and inferior vena cavas and directs it into the right
ventricle. From the right ventricle it pumps it blood through the
pulmonary arteries to the lungs. The blood after oxygenated is returned
to the left auricle and in turn sent it to the left ventricle which is a very
thick walled, pumps the oxygenated blood through the aorta to the
systematic circulation, through the entire body. In this way circulation
goes on.

33
Systemic circulation therefore begins in the left ventricle and ends in the
right atrium. Pulmonary circulation starts in the right ventrilcle and
ends in the left atrium. The right side of the heart deals with reduced
blood (deoxygenated} while the left is concerned with the oxygenated
blood.

The technical terms are used in the functioning of the heart.

SYSTOLE means to contract and DIASTOLE means to relax.

Therefore it can be seen that.

Blood gets deoxygenated (loses oxygen) in the tissues and reoxygenated

(gain oxygen) in the lungs. Hence, circulatory system has become divided
into two functionally opposite parts:

1. SYSTEMETIC CIRCULATION (passing through the tissues).

2. PULMONARY CIRCULATION (PASSING THROUGH THE LUNGS).

The two systems meet only in the heart.

The heart at rest pumps approximately 70 times a minute or

approximately 100,000 times each day for life. Each time the heart beats,
it ejects about 70ml of blood, therefore the heart pumps about 5 liters of
blood each minute.

During the exercise the heart can pump up to 35 liters each minute. The
total blood volume of 6 liters (Note that with a total blood volume of 6
liters and the capability of the heart to pump much more than each
minute if there is a large leak in the system due to severe bleeding and
the heart continues to function).

Each cardiac muscle contraction or heart beat is preceded and initiated

by an electrical impulse which arises from the natural pacemaker
(S.A.NODE) in the heart and is transmitted to the heart muscle by a
specialised conduction system (BUNDLE OF HIS AND PURKINGE
FIBRES).

After the heart muscle is stimulated by this electrical impulse, it

contracts (Systole). This contraction is followed by a period during which
the electrical system and the heart muscle are recharged (diastole) and
made ready for the next beat.

34
The heart has its own intrinsic electrical pacemaker. Even if the heart is
removed from the body, it will continue to beat, if properly maintained.
However, nervous impulses from the brain and various substances in the
blood influence the pacemaker and conduction system to alter the heart
rate.

The two ventricles and atrium contract at the same time, therefore, the
same amount of blood passes out of the ventricles at the same time
during contraction (systole) and the same amount of blood enters the
heart relaxation (diastole). Any change from this can cause heart failure.

When the blood is pumped by the heart, the arteries and veins carry the
blood to and from the capillaries and the heart. It is at the capillary level
that exchange oxygen and carbon dioxide occurs between the blood and
the tissues, in both the lungs and the rest of the body, including the
heart muscle itself.

FACTORS THAT MAINTAIN CILRCULATION

1. Pumping action of the heart -this is the main force of circulation.

2. Elastic recoil of the arteries -this pumps the blood forward.

3. Pressure gradient - blood pressure gradually from the left to the

right of the heart e.g. Big arteries 120mm. Hg. capillaries 15mm
Hg.

4. Respiration- on breathing the intrathoracic pressure decrease and

venous return increases.

5. Muscular exercise - when muscles contract they squeeze the

capillaries and veins and thus help venous return.

6. Effect of gravity -above the level of the heart it helps venous return
but below it works against it.

BLOOD VESSELS

1. ARTERY : The term artery means a vessel which carries

blood away from the heart. The vessel is muscular and is better felt
than seen (because they are deep structure) .The aorta divides into
a number of big arteries each one of which divides into smaller
arteries. Each small artery gives rise to a branch of arterioles and
to form the capillaries.

35
2. VEIN : The veins in our body can be easily seen with our naked
eyes because they lie just below our skin, but the pressure in the
vein is not as high as the arteries and therefore the veins are better
seen than felt. The veins carries all the deoxygenated blood from
the body and takes it to the heart. Veins divide into venules.

3. CAPILLARIES: They are the link between the arterioles and

venules.

THE LYMPHATIC SYSTEM

The basic components of the system are the lymph nodes and the lymph
vessels. This vascular channel transport lymph. The lymph is clear,
transparent, faint yellow fluid that is collected from the tissues
throughout the body, flows in the lymphatic vessels (through the lymph
nodes) and is eventually added to the venous circulation.

FOETAL CIRCULATION

PECULIARITIES IN THE CIRCULATION

1. The two ventricles have got common function of circulating blood to

the peripher. The thickness of both the ventricles is almost the
same but following birth both the system are separated and then
the left ventricles become thicker because it maintains the systemic
circulation.

2. The respiratory function of the lungs is absent and the lungs

remain as a solid organ. Most of the blood coming from the right
ventricle is shunted through the patent ductus arteriosus to the
descendeing aorta. After birth the duct closes and the respiratory
function is resumed. So in foetal life, right and left heart work in
parallel but in adult life they work in series.

3. Placenta takes the important part in maintaining the respiration,

execretion and nutrition of the foetus.

4. Through the foramen ovale connection between the inferior

venacava and left auricle is present, to avoid mixing with
deoxygenated blood in the right auricle and also to supply well
oxygenated blood to the brain and heart. After birth the foramen
ovale is fused.

36
COURSE OF CIRCULATION

Blood leaded with nutrients leaves the placenta through the umbilical
vein and ends in the liver. Here part of the blood is shunted to the
inferior vena cava through the ductus venousus and the rest is mixing
with the portal blood. The blood then enters the left auricle through the
foramen ovale and a small portion remains in the right auricle. From the
left auricle the blood enters the left ventricle and then to the aorta.

Most of the blood coming from the superior vena cava enters the right
auricle and goes into the right ventricle. From here the blood is expelled
into the pulmonary artery. The resistance of the collapsed lungs is high
and therefore the pressure in the pulmonary artery is much higher than
the aorta, so most of the blood in the pulmonary artery through the
ductus arteriosus into the aorta.

CHANGES IN THE CIRCULATION AFTER BIRTH

1. Closure of the foramen ovale.

2. Closure of the ductus arteriosus.

3. Closure of the venosus.

4. Changes in the cardiac muscle.

37
 RESPIRATORY SYSTEM
INTRODUCTION

Oxygen is as important for the survival of the cells as is the carbon

dioxide that is produced by tissue metabolism, that must be carried
away from the site of production. The arterial blood carries the oxygen to
the cells and the venous blood carries the carbon dioxide from the cells
to the lungs. This is known as INTERNAL RESPIRATION. The
mechanism by which the lungs remove the carbon dioxide from the blood
and absorb oxygen is known as EXTERNAL RESPIRATION.

ANATOMY OF THE RESPIRATORY SYSTEM

Diagram representing the respiratory system

The respiratory system has four components (parts) :

1. AIRWAY - from the outside of the body to the inside .

2. LUNGS - a pair of lungs with its basis lung units - the

ALVEOLI.

3. NEUROMUSCULAR APPARATUS - consisting of the respiratory

centre and muscles respiration.

38
4. VESSELS - arteries, veins and capillaries.

AIRWAY

The airway is composed of the following parts:

A. UPPER AIRWAY:

1. Nose and Mouth

2. Pharynx

3. Larynx or Voice box

B. LOWER AIRWAY:

1. Trachea or wind pipe

2. Bronchi - one to the right and one to the left lung

3. Branches of the bronchi which terminate in the basic lung

unit the alveoli.
Air is drawn in through the nasal cavities. The nasal cavities open into
the pharynx. The nasal passages with the presence of hair play and
important part in filtering and air-conditioning the air.
1. The dust particles and bacteria become caught in the nasal
mucus and are removed.
2. The air is cooled and is made moist.
3. The sense organ of smell being situated in the nose, the odour
of the air can easily be known.
Thus purified, the air passes down the pharynx, larynx (voice box),
trachea and enters the lungs and reaches the alveoli, where the gaseous
exchange takes place.
The trachea divides into two bronchi -one for the right lung and one for
the left lung. The right bronchus is almost in line with the trachea. The
lung surface is covered by a membrane called VISCERAL pleura and it is
continous with the PARIETAL pleura which lines the rib cage. The
potential space between the pleura is called the intra-pleural space and
the pressure in sub-atmospheric.

39
LUNGS

In our body we have a pair of lungs situated in the thoracic cavity (chest
cavity) .The lungs are spongy organs composed of tubes {bronchioles) and
air sacs (alveoli)., blood vessels and a supporting framework of
connective tissue. The right lung has three lobes and the left lung has
two lobes.

The lungs are surrounded in front by the sternum (breast bone) behind
by the vertebral column (spine) below by the diaphragm and on the side
by the ribs and muscles (intercostal muscles).

Diagram of the Diagram showing the interchange

capillary network surrounding of gases in an alveolus and the
the alveoli blood in a capillary .

The basic lung units, the ALVEOLI (single is called ALVEOLUS) are
millions of tiny air sacs lined by a membrane, on the other side of which
is fine network of capillaries. At this level blood and air are separated by
only a minute distance. This is where carbon dioxide and oxygen
exchange takes place.

NEUROMUSCULAR APPARATUS

This is composed of the respiratory centre in the brain, the nerves to the
muscles of respiration and the muscles of respiration themselves. The
major muscles of respiration (breathing) are the large sheet-;like
diaphragm attached to the margin of the lower ribs extending from front
to back and separating the chest cavity from the abdominal cavity, the
muscles between the ribs (the intercostal muscle) and some of the
muscle of the neck and shoulder girdle.

40
VESSELS

The arteries carry blood from the heart, the capillaries surround the
alveoli, and the veins carry blood back to the heart.

PHYSIOLOGY OF RESPIRATION

The function of the respiratory system is to bring oxygen from the

outside air into the blood and to eliminate carbon dioxide. The cells of
the body are continously in need of oxygen to function and as a result of
using this oxygen, carbon dioxide is produced. Unless carbon dioxide is
eliminated from the body it will lead to death.

The circulatory system transports oxygen from the lungs to the cells of
the body and transport carbon dioxide from the cells to the lungs for
elimination.

The main stimulus to breathe is simply the level of carbon dioxide in the
blood. As the level rises, the respiratory centre in the brain sends an
increasing number of signals by way of nerves to the muscles of
respiration.

The breathing rate and depth are increased until the level of carbon
dioxide falls and breathing slows. There is a continous feedback at all
times between the carbon dioxide level and the rate depth of breathing.

At the level of the alveoli, oxygen from the air passes into the blood
through the alveolus and capillary walls and carbon dioxide passes in
the opposite direction.

Atmospheric air at sea level contains about 21% oxygen, 79% nitrogen
and negligible carbon dioxide. During respiration, only about a quarter of
the oxygen in the inhaled air is taken up by the blood in the lungs, so
that exhaled air still contains significant oxygen (about 16%), as well as a
small amount of added carbon dioxide (5%) and water vapour. Exhaled
air therefore contains adequate oxygen to support life.

41
MECHANISM OF RESPIRATION

Diagram of the changes in the capacity of the thoracic

cavilty (and the lungs) during breathing.

Respiration includes two processes: INSPIRATION (INHALE) AND

EXPIRATION (EXHALE). Inspiration is the active process, while
expiration is passive.

Inspiration involves the expansion of the chest cavity by:

1. The downward movements of the diaphragm towards the

abdominal cavity so as to increase the longitudinal length (height);

2. The elevation of the ribs upwards and forward by contraction of the

intercostal muscles (so as to cause an increase in the
anteroposterior width diameter of the chest cavity) .

The lungs expand and the pressure within the lungs becomes less than
that outside of the chest. Thus, air moves into the airways and lungs.

Expiration Involves:

1. The upward movement of the diaphragm (so as to cause the

shortening of the chest cavity) .

2. The depression of the ribs (causing a decrease in the

anteroposterior diameter of the chest cavity) .

42
This upward movement of the diaphragm and descend of the ribs
decreases the capacity of the chest cavity. The elastic lung passively
becomes smaller, and the air within moves toward the outside to a lower
pressure.
The average adult normally breathes about 12 times per minute, children
15 times and infants 20 times per minute. This rate of increases during
stress, exercise, injury or illness.
The oxygen which we inhale is carried around the body by the red cells in
the blood. Blood is circulated in a continuously, repeated cycle by the
contraction and relaxation movement of the heart. The heart rate will
increase accordingly to carry the extra oxygen around the body.
SUMMARY
Natural respiration is an automatic action that continues rhythemically
and without voluntary effort. Inspiration and expiration are caused by a
combination of muscle action affecting the ribs and by the movement of
the diaphragm (a domeshaped muscular partition surging upwards
under the lungs, separating the chest and abdominal cavities). These
actions such air into the lungs during inspiration. During expiration the
size of the chest cavity is reduced by relaxation of the muscles of the
chest, diaphragm and elasticity of the lungs.
The heart pumps venous blood to the lungs where it exchange the
carbon dioxide for oxygen and after returning to the heart, this
oxygenated blood is then pumped through the body.
Natural respiration is controlled by the repiratory center in the brain.
This control mechanism is affected by the, relative amounts of oxygen
and carbon dioxide in the body. In general, if the carbon dioxide is
increased there is a corresponding increase in the depth and rapidity of
breathing to restore the normal oxygen - carbon dioxide balance in the
blood.
Therefore, respiration content is dependent upon:
1. Adequate oxygen content in the air.
2. Clear air passages in the nose, mouth, (Pharynx) throat, larynx and
wind pipe.
3. Active rhythmic muscle action in the chest and diaphragm to draw
air into the lungs.
4. Adequate circulation of blood to carry oxygen from the lungs to the
brain and other important organs, and return this blood to the
lungs.
43
 WOUNDS AND HAEMORRHAGE
DEFINITION:

A wound is defined as a breach (break) in the continutity of tissues

produces by external violence. There maybe loss of continuty in deeper
structures such as muscle and nerve as well as in skin.

It is important to exclude injuries to other parts of the body, for example

the head and chest in wound patients who are unconscoius. Wounds
themselves may be multiple are careful search is required. The back half
of a patient is just as vulnerable to wounds as the front half.

Classification of wounds

Wounds maybe closed or open.

Contusions haematomas and abrasions are example of closed wounds.

Open wounds take the form of Incised (tidy) wounds, Lacerated (untidy)
wounds and Puncture wounds which may be penetrating i.e. without and
exit.

CLOSED WOUNDS

Contusion - a soft tissue injury without interruption of the

skin surface, small blood vessels are torn and extravasation of blood
produces swelling and discolouration. If the bleeding extends to discolor
the skin, a bruise or ecchymosis is the result.

Haematoma - results when there is a more marked loss of blood

which collects between fascial places, e.g. subperios teal, submuscular,
intramuscular, subtaneous.

Treatment - treatment should start immediately. All

soft tissue injuries should be treated with REST, ICE,
COMPRESSION ELEVATION (R.I.C.E ).

Rest : Lesions heal with the rest but such advice maybe
inappropriate to many people. Activity must be modified and/or reduced
perhaps using splints, strapping or padding.

44
ICE : Alters the vascular response (vessels constrict) and reduces
pain.

Compression : Pressure bandaging is the most appropriate.

Abrasion - Superficial layers of the skin is scraped away and small

bleeding points in the dermis are exposed as well as nerve endings. The
abrasive substance is normally sand, rough surfaces etc.

Treatment - Any foreign material should be removed to

prevent scarring and infection. The wound should be throughly cleaned
with antiseptic (water & soap). If possible cover abrasions with dry sterile
dressing.

OPEN WOUNDS

Incised Wound produced by a sharp cutting edge, often produced by a

blow over a body prominence causing the over laying skin to split - edges
are normally clean out and bleeds freely. Normally it heals without
scarring.

Incised Wound

45
Lacerated Wound (Jagged) produced by a tearing or crushing force -the
continuity of the skin is breached and the tissues round the wound are
traumatized and devascularised. The wound edges are irregular. If not
treated properly it can lead to bad scarring.

Lacerated Wound

Puncture Wounds care should be taken to look out for injury to deeper
organs. Prone to infection if any foreign body is lodged inside. If foreign
body is still sticking out, do not remove e.g. stab wound.

Punctured Wound

46
Penetratinq and Perforating. Perforating wound has an entrance
and exit. Penetrating wound has an entry only e.g. gunshot.

Bites. Each one. of us gets bitten by some insect. or the other

during our lives. It is paramount importance to differentiate between a
poisonous and non-poisonous bite.

If it is localised, pain over an area gives the first indication that we have
been bitten by something. The pain is caused by the 'venom' which
causes local irritation and pain.

The best treatment of all poisonous bites is to cleriate the pain-by using
ice and wash the bite over with soap or any antiseptic.

The bites that need special mention area:

a. Bee stings

b. Dog bites

c. Snake bites

Bee sting. Can be extremely painful and can cause anaphylactic

shock. Treat with ice over the bite and the shock accordingly (refer
shock).

47
 Dog bite. This bite can be dangerous if the dog is a rabid dog. It
can cause rabies. A rabid dog is usually filthy looking and normally
salivates a lot. It is known to die after it has bitten its victim. Apart
from the general first aid treatment of washing the wound, the
patient needs to be seen by a doctor.
Snake bites. The majority of snakes found are harmless with
the exception of the king cobra, the mambas, the poisonous snakes
do not generally attack man spontaneously and bite only in
deference or because they been disturbed or trodden upon.
Precautions that can be taken before qettinq bitten
1. Wear suitable clothing when out in the jungle or when coming near
jungle.
2. Don't walk around barefoot or with sandals especially at night.
3. Don't walk around at night without a light. Most poisonous snakes
are more active at night then by day.
4. Don't place your hands on ledges, down holes or under rocks where
and unseen snake maybe hiding.
5. Don't disturb snakes -never pick them up unless you are certain
they are harmless.
Treatment.
Examine the patient:
1. Marks of Bites - characteristically, the double fang
mark with or without additional teeth marks points to the bite
of a venomous snake. The bite of non-poisonous snake is
usually U – shaped impression of snake teeth marks.

Sketches showing a) the outline of a poisonous snake bite with fang marks and
b) the bite of a non-poisonous snake, with no fang marks but 2 rows of bite marks.

48
 2. Local reaction - The more rapid and severe the reaction
the greater the degree of poisoning.
3. Local pain - In the presence of fang marks local pain,
with or without swelling usually means that the snake was
poisonous. If in spite of fang marks nothing, happens then
either the snake was non-poisonous or poisoning did not take
place.
4. Systemic symptoms can be more disturbances, bleeding,
shock, vomiting etc.
Treatment of Bites
Considerable controversies still exist over this first management of
snakebites but first aid management would involve.
1. If possible, kill the snake for identification.
2. Immobilize the injured part - venom is absorbed by the
lymphatic system and lymphatic drainage is greatly accelerated by
movement. Total immobilization is advisable if possible.
3. Use of tourniquet - The application of a tourniquet is
probably only of value if carried out within 2- 10 min. of the bite. It
should be tightened enough to occlude lymphatic and venous
drainage and should be released for 30 sec. every 20 min. and not
continued for longer than 20 min.
4. Incision and suction - most authorities are not against
incision as an effective therapeutic reason. Suction is only likely to
be effective in the very earliest stages after the bite and the value of
this suction is also in doubt.
5. Cold - The use of local cold ice or water is advocated to
diminish pain and reduce local reaction and slow down absorption
and action of the venom.
6. Rush the victim to hospital for anti-venom therapy.
General effects of wounds - The most important general effect
is caused by:
1. Blood loss - External - can be obviously seen
Internal - not easily seen out can be
Ascertained from signs e.g.
described in detailed in SHOCK.

49
2. Infection - Proper toilet (as described earlier)

Medication.

Aim of Treating Wounds - All wounds should be carefully

examined. Every attempt should be made to prevent secondary
infection.

1. Preserve tissue vitality -the main aim by cleaning wound with

soap and water – if possible running water.

2. Remove foreign body - only remove them if loose and already

dislodge.

3. Proper blood supply & maintenance.

How to achieve Hoemostasis (stop bleeding)

Whenever there is bleeding, the first aim should be to stop it. This can be
obtained in many ways.

1. DIRECT PRESSURE

To apply adequate pressure over the part of the injury and

maintain it till proper help is sought. It is also necessary to elevate
that injured part so that it is above the level of the heart.

2. INDIRECT PRESSURE

This is a difficult procedure. Here pressure is applied over an artery

supplying blood to that particular area.

50
 HAEMORRHAGE
Hemorrhage means a loss of circulating blood volume from the vascular
system 60% -70% of the blood is accommodated in the low pressure
venulas and veins and in the splanchic system. 10% loss is compensated
by venoconstriction. More than 10% is compensated by vasoconstriction.

TYPE OF HEAMORRHAGE

A.

1. ARTERIAL : bright red, coming from high pressure circulation, it

spurts out like a jet in accordance with the pulse.

2. VENOUS : darker red and escapes as steady flow because it is

from the low pressure area.

3. CAPILLARY : bright red and comes in a rapid ooze

B.

1. PRIMARY : occurs at the same time of injury or operation.

2. REACTIONARY : May follow primary haeorrhage within 24 hours

and is mainly due to slipping of a ligature, dislodgement of a clot.

Precipating factors are:

(a) Increase of blood pressure on recovery from shock

(b) Restlessness, coughing and vomiting which raises the venous

pressure.

Take care of penetrating wounds.

3. SECONDARY : occurs after 7 -14 days and is due to infection and

soothing of part of the wall of the artery.

Predisposing factors: pressure of a drainage tube

: a fragement of a bone

: a ligature in an infected area

51
 1. Make patient sit with body forward.

2. Pinch the area the cartilage meets the bone with the thumb
and index finger.

3. Open mouth and breath.

4. Keep pressure over the area 10 minutes where bleeding

should stop.

5. You can also apply a cold compression over the nasal region
at the same time.

6. Take patient to the hospital.

C. INTERNAL OR EXTERNAL

Concealed: fractures, rupture of spleen, rupture of ectopic

pregnancy.

Revealed: haematomas, malaena, etc.

SIGN OF HAEMORRHAGE

Accute blood loss:

External bleeding is obvious.

Internal bleeding : increasing palor and sighing

respirations (air hunger)

These signs are accompanied by :

cold clammy skin

empty veins
thirsty
tinnitus
blindness
Pulse volume -thready
Fall in blood pressure
- not to be relied
upon B.P can be normal
in internal bleeding

52
HAEMORRGHAGE IN SPECIAL REGIONS AND TREATMENT

EYE : Any bleeding occuring from the eye - cover eye with
sterile gauze and take to hospital.

EAR : Bleeding ear due to head injury or bleeding can occur

due to any injury in the ear.

Cover the ear or pack softly with gauze and take to

hospital.

MOUTH : It must be ascertained from where the bleeding is

comming from e.g. tooth, gums, tongue, lips. Apply
pressure whenever possible and take to hospital.

NOSE : Bleeding from the nose is called epistaxis. The tendency

is to bleed from the area where the cartilage meets with
the nasal bone. It has many blood vessels.

RECOVERY

Commences within a few hours of haemorrhage by the withdrawal of

fluids from the tissues into the circulation. There is heamodilution.
Plasma proteins are replaced by the liver.

Red blood cells recovery takes 5 - 6 weeks.

Chronic blood loss: e.g. bleeding piles, fibroids, carcinoma of caecum,

peptic ulcer, no. volume loss decrease in red cells ("microcytic
hypochromic anemia") result in anemias and hypoxia, requiring and
increased cardiac output. This results in high output cardiac failures.
The treatment of choice is packed cell transfusions.
FIRST AID TREATMENT OF BLEEDING
1. Keep calm and quickly assess the patient generally - rule out any
other injury, take his pulse.
2. Identify yourself to the patient and reassure him and keep
comforting him.
3. Loosen all his tight clothing.
4. Attend to the site of the wound -if the bleeding is clean, apply a
pressure bandage and elevate the part of the body so that it is above the
level of the heart, in doing so make sure the patient is comfortable. If
there is any loose foreign body then remove it.

53
5. If he is bleeding very profusely then you can identify the pressure
point of the particular artery and apply pressure against the
nearest bony prominence along with pressure bandage.
6. Only if it is absolutely necessary apply a tourniquet - the
application must be tight enough so that the venous and the
arterial blood supply is stopped. If this is not done then the
bleeding will not 'stop. After every 15 minutes, the tourniquet must
be released for 5 minutes, and reaplied again. On reaching the
hospital, the doctor must be personally told that the patient is on a
tourniquet.
7. Keep the patient warm and let him rest.
CHEST INJURIES
Injuries to this part of the body can be serious and if not careful can be
easily missed. In addition to the other injuries already mentioned to the
chest that need to be mentioned are pneumotorax and haemothorax. It
simply means that due to a puncture in the pluera, air or blood or both
accumalates in the pleural spare thus causing the lung tissue to
collapse. It is important for the first aider to recognise this condition.
Such a patient presents with severe respiratory embarrassment due to:
1. Compression of the lung by the haemothorax/pneumothorax.
2. Obstruction to the major bronchi in breathing secretions.
The patient will have difficulties in breathing and will appear cyanosed
(blue).
Immediate management - Needs hospital management.

IF PATIENT'S CONDITION DECLINES AFTER

SEALING PUNCTURE WOUND, OPEN THE
SEAL IMMEDIATELY

54
ABDOMINAL INJURIES

Abdominal injuries can be obtained by external injuries e.g. seat belt

injury, being punched in the abdomen.

When to suspect abdominal injury

1. Tenderness over the abdomen.

2. Vomiting.

3. Blood per rectum.

4. Distension.

5. Increasing pallor.

6. Deteropration of vital signs.

How to manage - Not to give anything through the mouth and take to
hospital after treating for shock.

Tetanus

Both human and animal faeces contain Clostridium which in

unfavourable circumstances forms spores.

Deep puncture wounds are those most liable to develop tetanus. The
wound need not be larger than prick thorns, wounds occuring on farms,
playing field, roads, drains etc. are likely to be contaminated with
tetanus.

Generally, protection against tetanus can be provided by maintaining a

proper treatment of the wounds, removing all foreign material. It is
imperative to have a anti-tetanus toxoid taken after an injury.

55
 FRACTURES AND INJURIES TO JOINTS

DEFINATION :
A fracture may be a complete break in the continuity of a bone or it may
be an incomplete break or creak
CLASSISFICATION:
Fracture may be subdivided according to their causes, into three groups:
1. Fractures caused by sudden injury.
2. Fatigue or stress fractures
3. Pathological fractures.
1. FRACTURES CAUSED BY SUDDEN INJURY: These fractures form
the largest group. They occur through bone that was free from
disease. Such fractures can be caused by DIRECT violence (fracture
of the clavicle with a fall on an outstreched hand) .
2. FATIQUE FRACTURES : These fracture do not occur from a single
episode of stress but due too repeated stress. These are normally
confined to bones of the lower limbs. The majority of these
fractures occur in the metatarsal.
3. PATHOLOGICAL FRACTURES: The term "pathological" is applied
to a fracture through a diseased bone.
TYPE OF FRACTURES
There are two types of fractures:

1. OPEN (COMPOUND)

2. CLOSED (SIMPLE)

CLOSED (SIMPLE): A fracture is

closed or simple when there is no
communication between the side of
the fracture and the exterior of the
body.

56
OPEN (COMPOUND) : A fracture is
compound or open, when there is a
wound on the skin surface leading
down to the end of the bone
protudes from the surface of the
skin.

PATTERNS OF FRACTURES
The pattern of a fracture is referred to the line of fracture on the bone.
This line of fracture is directly due to the line of force of injury.

It would be reasonable to support that

1. if the force is perpendicular to the bone you could get transverse
fracture;
2. if the force is not perpendicular to the bone you could get an
oblique or spinal fracture.
Other common patterns are:
- Comminuted fractures : when the fractured bone has
more than two fragments
- Impacted fractures : When bone fragments are driven
so firmly together that they
become stuck to one another.
- Compression fractures : when a bone is compressed
(normally occurs in vertebrae)
- Greenstick fractures : occur only in children because
their bone are supple and the
fractured ends do not break
away.
A definite way to know the pattern of a fracture would be to do a
radiological examination (X'ray).

57
SIGNS AND SYMPTOMS OF A FRACTURE

The presence of a fracture can always be suspected from the history and
clinical examination of a victim but to be exact an x'ray must be taken.
The following feature, though not in themselves diagnostic, are fairly
constant and should always arouse suspicion of a fracture.

1. Visible or palpable deformity

2. Local swelling
3. Visible bruising (ecchymosis)
4. Marked local tenderness
5. Marked impairment of function
6. Abnormal mobility
7. Crepitus or granting when the injured part is removed.

Clinical evidence of a fracture must always be confirmed with an x'ray.

The other signs to look out for are:

1. Skin wound - rule out a compound fracture by looking for

any wound that may be communicated with the fracture site.

2. State of the circulation - the part of the limb distal to be fracture

site must be examined for any block in the supply of blood to that are:-
The colour of the limb should be pink but other should arose some
suspicion of trouble. The limb should also be warm. Feel for the arterial
pulses.

EXPLANATION

1. Visible or palpable deformity:

It may not be possible to appreciate the deformity (change in shape)

unless palpalation (to feel with hand) is done.

2. Local swelling:

There is bound to be local swelling at the site of the fracture

because when the bone breaks, blood vessels also rupture and
certain amount of bleeding occurs. The size of the swelling will
depend on the amount of bleeding.

3. Visible bruising:

The bleeding finds its way under the skin at the site of the fracture.

58
4. Marked local tenderness:

The nerve endings also become sensitive because of the injury and
any amount of pressure on the site of injury will give rise to pain
(symptom).

5. Marked impairment of function:

The fractured rib mayor may be able to perform as before of the

injury.

6. Abdominal mobility:

On the other hand the site of injury may be able to move in

directions and could not move before the injury.

7. Crepitus:
This is the sound produced by two broken ends of bone rubbing
against each other. This should never be done or demonstrated.
COMPLICATED FRACTURE
Open and closed fractures can become complicated when nerves or
organs get injured by the broken ends of the bones. E.g. Fracture of the
humerus may involve the radial nerves end, therefore the person may not
be able to extend (lift up) his wrist. This inability is a comnplication of
this fracture.
TREATMENT OF FRACTURES
Before definitive treatment of a fracture is undertaken, attention must be
directed to first aid treatment, to the clinical assessment of the patient
with special reference to the possibility of associated injuries or
complications, and to resuscitation. Therefore, the BASIC LIFE SUPPORT
of the Patient must be looked into first (refer to notes on basic life
support).
Prompt treatment prevents further damage which is caused in two ways.
First any unnecessary movement across the injured area causes further
damage. Secondly, more blood and oedema are forced into the injured
tissues thus increasing pain, swelling and further complications.
The emergency treatment of fractures lies in the maxim
‘ SPLINTTHEM WHERE THEY LIE’. Before a patient is moved
the fracture must be immobilised. Immobolisation can be main

59
tained with the use of wooden splints, walking sticks, folded newspaper,
bandaging two limbs together or in the upper limb by bandaging the arm
to the chest or putting the forearm in a sling. (Improvisisation is
necessary here).

There are reasons for immobilising a fracture.

1. To prevent displacement or angulation of the fragments during

transportation.

2. To prevent movement that may interfere with union and cause

further bleeding.

3. To relieve pain and prevent shock.

RATIONALE OF IMMOBILISING
It is imperative that all fractures be adequately supported and
immobilised in a proper and efficient way.
It would be helpul for the First Aider that all movements in our body take
place at the joints and with attachments of muscle around the joints,
locomotion is possible when a fracture occurs, it can be reasonably
assumed that the site of fracture may act like a joint and it will also move
whenever the corresponding joints move.
Therefore, whenever a fracture site is immobilised it is important to make
sure that the two corresponding joints related to the fracture are
supported and immobilised, e.g. if the shaft of the tibia gets fractured,
the corresponding knee joint and ankle joint must be immobilised along
with the site of fracture.
With this immobilisation
1. PAIN is reduced because the broken ends of the bone do not move.
2. SHOCK is reduced by controlling the bleeding.
3. FURTHER INJURY will be prevented because the limb is well
supported.
All then will help towards healing of the fracture.
TYPE OF SPLINTS

Splinting is a common word used to describe the support and

immobilisation of a fracture site.

60
The support can either be some internal support which is available on
the injured person e.g. a healthy limb.

To immobilise, bandages can be used or some of improvisation can be

done.

Splints can be made from wood, magazines, umbrellas etc ( it is

important to note that any object which has regidity can act as a splint).

Bandages can be made out of belts, ties, scarves, shoe-laces or even

handkerchives.

It may always not be possible to have. the above equipment and injuries
normally take place when they are least expected.

I would always teach my first aiders to attempt immobilizing a fractures

with whatever they have on them or the victim. That means
improvisation to its maximum. It is always effective to use the normal
limbs as a support and immobilise the fracture with bandages or
improvised material.

Therefore:

1. Make ready the necessary equipment - splint and bandages.

2. If using external splints they should be long enough to include the

corresponding joints.

3. Splints should be well padded or if using the healthy limbs - pads

should be placed between joints to avoid pain due to rubbing of the
joints.
4. Reef knots should be tied on the splint or on the normal limbs.
5. Proper support must be given while splinting.
6. Speed is Not important but it is important to have an effective
support.

Please Note

In open fracture the treatment is the same aspect to prevent infection

cleaning and covering the wounds as soon as possible is advocated and a
ring pad to be used if there is any foreign body protuding.

61
COMMON FRACTURE SITES AND THEIR MANAGEMENT

Fractures can occur in any site of a bone but it is commonly seen that
certain sites are more prone to fracture than others.

Broadly fracture sites can be divided into:

1. Upper limb.

2. Lower Limb.

3. Spine and others.

Upper limb

The common sites are collar bone (clavicle) shaft of humerus, lower end
of humerus (supracondylar), upper end of radius/ulna and lower end of
ulna/ radius.

Management

In my experience I can safely say that any one sling can be used to
manage any of the fractures, namely small arm sling, large arm sling and
triangular arm sling.
For easy rememberance
For forearm fractures - large arm sling
For arm fracture - trangular arm sling
For any other fracture of - small arm sling
the upper limbs
Lower limb
Common sites are along the femur, tibia/fibula and knee cap (Patella),
around the ankle.
Management
It is easy and safe to use five bandages for all the fractures. Three
bandages for the three joints (hip, knee, ankle) and the other two for
above and below the fracture site. (Application will be discussed in detail
under the practical lessons).

62
FRACTURE OF SPINE

In fracture of the spine it is important to get to know the mode of injury

(how the injury occured} .The fracture normally occurs if the person falls
from a height. It is not possible - the victim will complain of

1. Pain
2. Unable to move arms or legs.
3. Tingling sensations or numbess in arms or legs.

Management

No movement to be allowed. Make sure his head, spine and legs kept in a
straight line. Wait for professional help. All spinal fractures must be
transported on hard boards only. The ordinary stretcher MUST NOT be
used.

CRUSH INJURY

This usually occurs due to industrial accidents. Immediate first aid

should be given and quick transportation to hospital is necessary. If the
victim is dismembered (loss of limb} it is important to bring the limb
along, placed in cold surroundings. (e.g. ice pack, cold water} .

SUMMARY OF FRACTURE TREATMENT

1. Keep calm and use common sense.

2. Assess the patient's condition and injuries.
3. Provide a clear airway.
4. Attend to other external trauma which might lead to shock.
5. Treat the fracture, immobilise and elevate if necessary.
6. Reassure the patient.
7. Transport to hospital.
FOR FURTHER READING

HEALING OF A FRACTURE
A bone is always divided into the HEAD, NECK, SHAFT
and BASE. The outer ends of a bone are called the METAPHYSIS

63
and the inner shafts the DIAPHYSIS. Before the bone attains maturity
the part in between these two parts is called the EPIPHYSIS. The bone is
covered by a thin layer of epithelium called the PERIOSTIUM.

The repair of bone takes place in five stages:

1. Stages of haematoma - when the bone fractures, it injures the
nearby vessels and a haematoma is formed between and around
the fracture surfaces. The haematoma is limited to the area around
the farcture by the periostium and muscles.
2. Stages of subperiosteal and endosteal cellular-proliferation- the
cells from the deep surface of the periostium start growing close to
the fracture. These cells will lay down the intercellular substance,
which surrounds each fragment. At the same time there is cellular
growth from within the bone marrow. It grow from one fractured
side to the other.
3. Stage of callus - as the intercellular substance matures, it gives
rise to osteablasts, These osteoblasts lay down collagen and
popsaccharide tissues, in which the calcium salts are deposited to
form the immature bone of the fracture - CALLUS.
4. Stage of consolidation- the callus mature further to consolidation
the fracture site.
5. Stage of remodelling - the fracture site tries to return to its
original shape.
INJURIES TO JOINTS AND SPORTING INJURIES (SOFT TISSUE) :

There are many types of joints in our body (discussed under anatomy)
Two ends of bones articulate with each other to form a joint.

DISLOCATION

DEFINITION : A dislocation is a complete displacement of both

the articulating surfaces of a joint. An incomplete displacement is clled a
SUBLUXATION. Dislocation can take place in any joint of the body, but
is commonly seen in the shoulder joint, hip joint, elbow joint and
temporo-mandibular joint of the jaw. The signs and symptoms and
treatment (first aid) are basically the same as that of a fracture. The only
clue to differentiate it from a fracture would be if the signs occur around
a joint :

64
SOFT TISSUE INJURY
Soft tissue injury involves the muscles, ligaments and tendons. Soft
tissue injury may occur on their own or in association with a fracture or
dislocation.
Injuries to muscles, tendons, ligaments, capsules, fascial and skin
readily bleed and tissue fluid rapidly accumulates. Immediate attention
must be directed towards limiting or preventing these complications as
well as arresting further soft tissue damage.
SPRAIN : This occurs in the ligaments of the body. A ligament can
be sprained, partially torn or completely torn.
If there is severe swelling and abnormal mobility then a tear should be
suspected.
Sign and Symptoms - localised tenderness.
- tenderness
- spasm occurs in the affected muscle
- a lump may be palpable
Common muscles involved -Hamstring (back of thigh) calf, quadriceps
(front thigh muscles).
GENERAL TREATMENT
The regime is called the RICE rule :
R - rest
I - ice
C - compression
E - elevation
A cold compression is applied to the injured part for 15 minutes and limb
is elevated for 20- 60 minutes on the amount of swelling. This can be
repeated many times with 5 minutes break.
The simpliest method is to place ice cubes in a thick towel or an ice
solution in a rubber bottle and place it over the injured part. Never apply
ice directly to the injured part for it may cause burns. The injured part is
then strapped with a crepe or ordinary bandage and rested.
It is worth remembering that recent injuries cannot be cured by heating,
massaging, stretching or manipulating. Any of these activities will make
swelling worse and will delay healing.
All this is done during rehabilitation which does not fall under the
purview of first aid.

65
 DRESSING AND BANDAGES

Definition : a dressing is a protective covering which is placed over a

broken area of skin (wound)
Functions of a dressing
1. Control bleeding - this is achieved 'by the direct
pressure of the dressing over the bleeding point. If the dressing gets
stained it should be re enforced with another dressing over the
previous dressing. This process must be repeated until there is no
more staining - this would mean sufficient direct pressure has been
applied to stop the bleeding.
2. Prevent infection - using a sterile gauze will keep off any
other germs from getting to the wound.
3. Absorb any discharge- if would is fresh it will absorb the blood
and keep the wound dry.
Principles of dressing a wound
1. All principles should be large enough to cover the area of the
wound and probably extend beyond it. It should be placed directly
on the wound.
2. Any form of lotion should not be used unless it is absolutely
necessary.
3. If an antiseptic is used, using the swab to remove as much
moisture as possible.
4. Swab from the wound out, never swab in towards the wound, since
this sweeps micro-organism which are harmless on the intact skin
into the wound, where they can do harm.
5. Dry the area using wool swabs.
6. If strapping is used to hold the dressing in position, it should be
applied so that the patient can move freely.
7. Whenever a dressing is being performed, it should be carried out as
gently as possible.
8. Personal hygiene when dressing a wound must be maintained
whenever possible.

66
TYPE OF DRESSING

1. ADHESIVE DRESSING - these are commonly known as

"plasters". Basically they consist of an absorbant gauze held in
place by an adhesive backing. It is best to have the adhesive
backing which is waterproof.

Always make sure the skin around the wound is clean and dry
before applying an adhesive dressing, otherwise it will not stick.

Method of Application

1. Remove the other wrapping and hold the dressing, gauze-side

down by the protective strips.

2. Peel, but do not remove the protective strips and without

touching the gauze, place the gauze on the wound.

2. GAUZE DRESSING

These consist of layers of gauze which form a soft, pliable cover. It

can be secured by a plaster or bandage if pressure is required.

Method of Application

1. Remove the wrapping and place gauze directly over the

wound.

2. Secure the gauze with a bandage or plaster.

3. Carefully pull of the protective strips and gently press the end
down.

It is advisable to use gauze which is sterile.

* Do not use cotton wool. lint, wooly or fibrous material to protect a

wound, the fiber can become embedded in it.

67
How to remove a dressing

There is a tendency for dressings to get adhered easy, moisturize the

dressing with the antiseptic and the remove the dressing.

IMPROVISED DRESSINGS

At times of emergencies prepared dressings may not be available.

Improvise using whatever suitable materials are available e.g. a clean
handkerchief, a fresh towel, a piece of linen, a pad of clean paper
handkerchiefs.

Improvised dressings should be covered and hold in position using

whatever materials are available at the time e.g. string, scarves etc.

BANDAGES

Definition : a bandage is apiece of band of any material used to

cover, support, immobilize or exert pressure to apart of the body.

Functions of a bandage

1. To maintain direct pressure over a dressing to control bleeding.

2. To hold dressing or splints in position.

3. To provide support for a limb or joint thus restricting movement.

4. To prevent swelling by providing compression.

5. Used in preparing a stretcher to lift casualties.

6. In times of need, used as padding.

Principles in applying bandages.

1. Bandages can be applied with the casualty sitting or laying down.

2. Always face the casualty when bandaging.

3. When bandaging the injured part will be well supported and placed
in a comfortable position.

68
4. If casualty is laying down, pass all bandages under the natural
hollows of the ankles, knees, back and neck: To get them in
position, gently pull them backwards and forwards and move them
up or down the body.
5. Bandages should be firm enough to hold the dressing, control the
bleeding or prevent from movement, it should not be too tight so as
to interfere with the circulation.
6. Check the bandaging frequently. To ensure that the bandages are
not becoming too tight because the tissues may swell.
7. Expose the finger and toe nails when bandaging a limb so that the
colour of the nails can be regularly checked (if it turns blue -
bandage is too tight.
8. Always use the reef knot to secure a bandage.
In controlling bleeding -knot must be over the dressing.
In immobilising -knot must be over uninjured part and infront.
If both sides involved -knot must be in the centre of the body.
9. Adequate padding must be used over bony prominencies and hollows.

TYPE OF BANDAGES
Triangular Bandaqes
These can be made by cutting in half diagonally a piece of material not
less that 1 yard square.
POINT

END END
BASE
The triangular bandage has a point with ends, two sides and a base
(it is an isosceles triangular).
69
STORING TRIANGULAR BANDAGES

1. Fold the bandage with the point touching the base and repeat this
folding until the fold is narrow (folded 4 times).

2. Turn the ends of the bandage into the middle till they meet, Repeat
this folding until a convenient size is reached.

Broad Fold Bandage

This bandaging is used for immobilizing limbs during transportation or

for securing splints or dressing.

Narrow Fold Bandage

This is useful for securing a dressing at a point.

70
REEF KNOT

Methods

1. Hold the ends of the bandage in both hands. Take the left and
place it over the right end and turn it under and pull slightly.

2. Hold the ends again and place the right end over the left and turn it
under and pull the knot firmly.

3. Tuck the ends of the bandage carefully in so that the bandage looks
neat.

- This is an effective knot because it will not slip.

- It lies very flat and therefore is a comfortable knot.

- It is extremely easy to unite.

71
SLINGS

This are used to immobilize any part of the upper limb when there is a
fracture bleeding or in chest injuries.

There are 3 slings that must be learned.

1. Small arm sling

2. Large arm sling

3. Triangular arm sling

IMPROVISED SLINGS
If no triangular bandages are available, slings may be improvised in
several ways to provide adequate support e.g. shirt, jacket, belt, scarf etc.

72
ROLLER BANDAGES

This type of bandage is used

1. to keep dressing in position

2. to apply pressure to control bleeding

3. to support a sprain or a strain.

The advantage of using this bandage is to hold dressing lightly but firmly
in place because they mould to the shape of the limb, they maintain an
even pressure.

Material used

Standard roller bandages are made of cotton, gauze or linen and usually
supplied in roll.

Application

The initials rolled part of the bandage is called the head and the unrolled
part the tail.

Before applying, the bandage should be tightly rolled and of suitable

dimensions.

Position yourself in front of the injured part and support the injured part
in position in which it is to remain.

To bandage a left limb hold the bandage in your right hand and vice
versa. Always work from the inner side outwards and from below the
injury upwards.

73
 ASPHYXIA

DEFINATION AND INTRODUCTION

Asphyxia is a condition occuring when there is not enough oxygen

available for the cells in our body (improper oxygenation of cells). This is
a potentially fatal condition.

Life depends on an adequate supply of air to the lungs. When the

quantity and/or quality of this air are interfered with, there is danger of
asphyxiation. Although some parts of the body may be deprived of
oxygen for up to several hours and recover fully, the brain is able to
tolerate the absence of oxygen for only a few minutes (4- 6 minutes)
Beyond this short time permanent damage to the brain may occur – even
death.

CAUSES OF ASPHYXIA

Asphyxia may be of two types:

1. GENERAL - intake of air into the body of interfered with e.g.

drowning.

2. LOCAL - when blood suply to apart of our body is cut off

e.g. tourniquet.
Essential conditions of asphyxia are:
1. There must be both carbon dioxide excess as well as oxygen lack;
2. The improper oxygenation must be continued.
The phenomenon of asphyxia has been divided into THREE STAGES.
The whole phenomenon from the onset to death, takes about five
minutes.
GENERAL CAUSES
1. Obstruction of air passage by:
a. foreign body (solid or liquid) -vomitus, tongue, food, etc.
b. drowning- liquid in the air passages;
c. strangulation or hanging- compresion of the windpipe;

74
 d. smothering (suffocation) -by pillows or plastic bags;

e. being buried alive -compression of the chest, e.g. earth,

crowds;

f. medical conditions e.g. fits preventing adequate breathing,

angioneurotic oedema ( swelling of the tissue);

g. injury to the chest walls or lungs e.g. - pneunothorax.

2. Contamination of air by poisonous gases (mainly gases, engine

exhaust fumes, dense smoke) -this will prevent the use of oxygen in
the body and also the amount of oxygen in the blood will be
reduced.

When we breathe in the engine fumes (carbon monoxide -

poisoning) it is also carried in the blood by the red blood cells.
Therefore, this will prevent the use of oxygen in our body.

Whereas, if we breathe in smoke - the intake of oxygen will be

reduced and therefore there will be less oxygen in the blood.

3. Interference with the function of the respiratory centre by:

a. electric shock.

b. poisons.

c. diseases e.g. paralysis caused by stroke or injury to the spinal

cord.

GENERAL SYMTOMS AND SIGNS

1. Difficulty in breathing - when the air passage is blocked (complete

or partial) this will happen and the person will be gasping for air.

2. Breathing increases (Tachyapnoee) - the rate, depth of breathing

increases to overcome this difficulty so as to prevent only shortage
of oxygen in our body.

3. Breathing may become noisy with snoring and gurgling - this

happen because the air has to pass through a smaller opening in
the air passage.

75
4. Blueness of face, lips, ears and nail beds – this blueness is called
cyanosis - it happens because there is excessive carbon dioxide in
the blood.
5. Frothing at the mouth - this happens because air bubbles
through the accumulated saliva.
6. Confusion and unconscious - this is caused by the decreased in
blood supply to the brain.
7. Breathing may stop.

STAGES MANIFESTATION (Symptons & Signs) CAUSES

First stage or stage rate and depth of breathing increases (both The stimulation is
of hyperpnoea inspiration and expiration) the animal becomes due to carbon
(increased breathless. The expiration become more dioxide excess only.
breathing 1min). pronounced

Second stage or The stages of hyperpnoea is followed by 1. Further

stage expiratory unconsciuosness Expiration become more accumilation of
convulsion pronounced and with each expiration the body carbon dioxide.
Duration 1 or 2 enters into a convulsion. Saliva is secreated. and
mins. vamitting occurs. Maximun excitation is seen in 2. Oxygen lack
this stage. stimulates the
respiratory
centre.

3. Lactic acid
Produces
acidosis

Third stage or slow Expiratory convulsions stop and are replaced by Due to the direct
deep inspiration or slow deep inspirations. With each inspiration the effect of oxygen on
stage of central animal stretches itself out, open its mouth wide respiratory centre.
depression. gasping for breath. The interval between each The three factors
Duration 2-3 mins inspiraticn becomes longer, the animal takes a few above fail to excite
gasping breaths and dies the center anymore.

GENERAL TREATMENT

AIM : The obvious thing to do would be to attend to the cause

of asphyxia or remove the casualty from the cause. This will remain
or restore the casualty's breathing.

1. Remove the cause of asphyxia.

2. Open the airway.

76
3. If casualty is not breathing, perform CPR immediately.

4. When breathing and pulse returns, place the casulaty in the

Recovery Position.

5. Regularly check the breathing, pulse and levels of responsiveness.

6. Seek medical aid as soon as possible.

MANAGEMENT OF SOME ASPHYXIA CASES

1. CHOKING :
CAUSE
Occurs when the airway is partially or totally obstructed by an
object (tongue, food, vomitus etc). However, choking can be caused
by muscular spasm.
Adult normally choke on food which is swallowed in a hurry and
children choke on objects they like putting in their mouths.
SIGN AND SYMPTOMS
1. Refer to general signs and symptoms.
2. Casualty will be unable to speak or breathe and may grasp
his throat.
3. Veins on the face and neck will become prominent and the
face will be flushed (red).
4. After awhile the mouth and lips will appear blue.
5. Possible unconsciousness.
TREATMENT
Refer to the end of the chapter.
2. DROWNING:
CAUSE
By water entering the air passages, however only small amount of
water can enter the lungs. The water can also cause the throat to
go into spasm thereby constricting the air passage (DRY
DROWING).

77
If the casualty has been in the water a long time there is a danger of
hypothermia (low temperature), so it is important to keep the casualty
warm.

SIGNS AND SYMPTOMS

1. Refer to general signs and symptoms.

2. Casualty may be frothing from the mouth or nose.

TREATMENT

AIM : To get air into the casualty's lungs as fast as possible, even
while in the water.

Institute Artificial Ventilation.

Send to hospital immediately.

1. Remove any foreign matter from the mouth .

2. In shallow water, support casualty's head with one hand and the
body with the other hand and perform Mouth to Mouth Ventilation
(Refer Resuscitation). If in deeper water, give occassional breath of
air while towing the casualty ashore.

3. When on firm surface perform CPR (Refer Resuscitation).

4. If casualty recovers put in Recovery Position.

5. Keep casualty warm -if possible remove wet clothing.

6. Remove to hospital - maintaining the treatment position.

3. STRANGULATION/HANGING

CAUSE

When pressure on the outside of the neck squeezes, the airway

shut and blocks off the flow of air to the lungs.

Hanging - when the body suspended by the neck by the nose.

Strangulation - involves cutting off the air supply by a tight

constriction around the neck e.g. neck tie.

78
 SIGN AND SYMPTOMS
Refer general symptoms and signs.
1. Congestion of the face and neck with the veins becoming
prominent.
2. The constriction mark may be visible around the area where
it has been applied.
3. May find a suspended body.
TREATMENT
Remove the cause.
Apply CPR.
Send to hospital.
4. SMOTHERING (SUFFOCATION):
CAUSE
Result when air is prevented from reaching the air passage by an
external obstruction e.g. plastic bag, soft pillow etc. It can also
result when the available oxygen in the air is reduced, thereby
causing suffocation e.g. smoke inhalation, poisonous gases etc. Fire
uses up oxygen in the air, therefore in a smoke filled room oxygen
level is low. Smoke also causes the throat to go into spasm.
SIGN AND SYMPTOMS
1. Refer general symptoms and signs.
2. Obvious external object over nose or mouth or pressure of
stale air in a confined space.
TREATMENT
1. Immediately remove an obstruction or remove casualty to
fresh air.
2. If casualty is conscious and breathing normally - observe and
reassure.
3. If unconscious but breathing normally, put in recovery
position.
4. If has difficulty or no breathing, perform Artificial Ventilation.
5. Send to hospital.

79
5. SWELLING OF THROAT TISSUES (OEDEMA):

CAUSE

Embedded foreign body (fish bone). Allergic reaction leading to

Oedema of tissues (ANGONEUROTIC) e.g. drugs.

SIGN AND SYMPTOMS

1. Refer general symptoms and signs.

2. May have fever (depends on duration of complaint). Difficulty

in swallowing.

TREATMENT

Give Artificial Ventilation if necessary otherwise get the patient to

the nearest hospital.

6. CARBON MONOXIDE POISONING;

CAUSE
IT IS A COLOURLESS GAS WITH NO SMELL.
IT IS A DANGEROUS GAS BECAUSE IT REPLACES THE
OXYGEN IN THE BLOOD
BECAUSE IT IS BETTER ABSORBED BY THE BLOOD THAN
OXYGEN .
The most common source of this gas is from the fumes of partially
burnt fuel and petrol engine exhausts.
SIGN AND SYMPTOMS
1. Refer general symptoms and signs.
2. Casualty may complain of headache.
3. Colour maybe normal but will deep to cherry pink as the level
of the carbon monoxide in the blood rises.
4. Casualty maybe confused and uncooperative.
5. Breathing will be difficult or may have stopped.
6. Unconsciousness may develop.

80
TREATMENT

1. Cut off supply of gas and drag casualty to safety.

2. If casualty is unconscious but breathing, place in Recovery

Position.

3. If breathing is difficult perform Artificial Ventilation.

4. Remove to hospital.

Therefore, the following steps can be taken to assist any person

who is asphyxiated (due to any cause).

1. Remove the cause or the victim from the cause if necessary.

2. Open and maintain a free air passage.

3. Start ARTIFICIAL RESPIRATION at once. If there is a

necessity.

4. If air passages are not open, check mouth and throat for
foreign substances and remove if possible. If not possible,
turn victim's head to one side. This is usually just to allow air
to bypass lodged object.

5. Direct bystanders to send for qualified aid.

6. Loosen victims's tight clothing if restrictive and if necessary.

7. Assist in maintaining open air passage.

8. Continue ARTIFICIAL RESPIRATION until regular breathing is

restored - or until qualified air is available.

9. Casualty must remain laying down when breathing is

restored (Recovery Position).

10. Continue to watch casualty carefully, since breathing may

cease again.

11. Move to shelter or medical care, only in laying down position.

Do not permit the casualty to stand or walk.

81
HOW TO DEAL WITH AN OBSTRUCTED AIRWAY

Any structure forming the airway can either itself block the airway or
become blocked by a foreign body. The tongue blocking the airway is the
most common cause of airway obstruction, because the tongue is
attached to the jaws.

Any condition that leads to unconsciousness or loss or tone in the

muscle of the jaw can cause the tongue to fall to - wards the back of the
pharynx and obstruct the airway.

Other causes:

1. Foreign body obstruction.

2. Trauma (injury to air passages).

3. Swelling of the tissues of the airway (infections, burns, gas, smoke

inhalation, anaphylactic reaction (allergy) .
4. Strangulation and drowning.
5. Both vocal cord paralysis.
Causes
Apart from the above causes, foreign body obstruction of the airway
usually occurs during eating. In adults, meat is the most common cause
of obstruction although a variety of other foods and foreign bodies have
been the cause of choking in children and some adults.
Common factors associated with choking on food includes:
1. Elevated blood alcohol.
2. Dentures.
3. Large, poorly chewed piece of food - this emergency has been
mistaken for a heart attack, giving rise to the name "cafe coronary"
PREVENTION
The following precautions are recommended to avoid airway obstruction:
1. Cut food into smaller pieces, chew slowly and thoroughly especially
if wearing dentures.
2. Avoid laughing and talking during chewing and swallowing.

82
3. Avoid excessive intake of alcohol before and during meals.

4. Restrict children from walking, running or playing with food or

foreign bodies in their mouths.

5. Keep foreign bodies e.g. marbles, beads, thumbtacks, away from

infants and children.

RECOGNITION

Because early recognition of foreign body airway obstruction is the key to

successful management, It is important to differentiate this emergency
from other conditions which also cause sudden respiratory failure but
which must be managed differently. Such conditions include stroke,
heart and drug overdose.

Foreign bodies may cause either partial or complete airway obstruction.

With partial airway obstruction, the victim maybe capable of either "good
air exchange" or "poor air exchange".

With good air exchange, the victim can cough forcefully, although
frequently there is wheezing (musical tone) between the coughs. As long
as good exchange continues, the victim should be allowed and
encouraged to persist with spontaneous coughing and breathing efforts.
At this point, "THE RESCUER SHOULD NOT INTERFERE WITH THE
VICTIMS'S ATTEMPTS TO EXPEL THE FOREIGN BODY".

Poor air exchange may occur initially or good air exchange may progress
to poor air exchange, as indicated by a weak, ineffective cough, high-
pitched noises while inhaling (such as crowing noises), increased
respiratory difficulty and possibly cyanosis (bluish colour of skin, finger
nails beds, and inside the mouth) .At this point the partial obstruction
should be managed as though it were a complete airway obstruction.

In the conscious victim complete foreign body airway obstrution is

recognised while a victim who is eating or just finished eating is suddenly
unable to speak or cough. The victim may use the "distress signal of
choking" by clutching his neck, He may appear dusky in colour and slow
exaggerated effort in breathing. However movement of air will be absent.
Prompt action is needed, preferable while the victim is still conscious.

Within a short time as the oxygen in the lungs is depleted (reduced) the
brain will get less oxygen (anoxic), unconsciousness will occur and death
will follow rapidly.

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MANAGEMENT

There are two manoeuvres which are recommended for, removing any
foreign body from the airway.

1. Manual thrusts

a. Abdominal thrusts

b. Chest thrusts

2. Finger sweep

1. MANUAL THRUSTS

There are two types of manual thrusts:

a. ABDOMINAL THRUSTS (HEIMILICH MANOEUVRE)
In this manoeuvre, a fist is placed on the abdomen mid-way
between the navel and eiphoid sternum. The other hand is
used to grasp this fist and a series of 5 thrusts are applied
inwards and upwards.
By doing this, the diaphragm is pushed upwards and air is
forced out of the lungs creating an artificial cough which
should force the foreign body out.
Casualty Standing or Sitting
(1) Stand behind the casualty and warp your arms around
the casualty's mid abdomen.
(2) Grasp one fist with your other hand and place the
thumb side of your fist against the casualty's abdomen,
in the mid-line between the navel and the xiphoid
sternum.
(3) Apply 5 thrusts in quick succession into the casualty's
abdomen in an inward and upward direction.

84
Casualty Lying

(1) Make sure the victim is lying on his back with your
knees close to his hip and you should be facing the
casualty.

(2) Open the airway and turn the head up (not to the sides)

(3) Place the heel of one hand against the casualty's

abdomen (same position above) and the second hand on
top.

(4) Press into the abdomen with quick inward and upward
thrusts. Never place hands on the xiphoid process.

(5) Position of the rescuer the along side the casualty

position can be used as described above or the astride
position.

85
 Casualty Alone

If the casualty is alone and no assistance is forthcoming the

above manoeuvre can also be performed.

Press a fist into the upper abdomen with a quick thrust (as
described in the standing position) or lean forward pressing
the abdomen over any firm object e.g. back of a chair, table
etc.
b. CHEST THRUSTS
It is similar to abdominal thrust except that the thrust
applied is over the mid-chest region.
It is useful when:
(1) the abdominal girth (obese) is so large the rescuer
cannot fully wrap his arms around the casualty's
abdomen;
(2) when the pressure applied to the abdomen is likely to
cause complications e.g. rupture of internal organs;
(3) or in advanced pregnancy (no pressure should be
applied over the abdomen).
Casualty Standing or Sitting
(1) Stand behind the victim, place your arms directly under
the victim's armpits and encircle the victim's chest.
(2) Place the thumb side of the fist on the middle of the
breast bone (sternum) not on xiphoid or rib cage.
(3) Grasp your fist with your other hand and exert 5 quick
backward thrusts the force applied should force the
foreign body out.

86
 Casualty Lying

The method is the same as cardiac compression.

(1) Place casualty on his back and open the airway. Kneel
by the side.

(2) Place one hand on the other the lower half of the breast
bone.
(3) Apply 5 quick downwards thrusts which will compress
the chest cavity.
2. FINGER SWEEP
1. Keeping the headup, open the casualty's mouth by
gasping the tongue and lower jaw between your thumb
and fingers and lift (tongue –jaw lift). This action draws
the tongue away from the back of the throat and away
from the foreign body that may be lodged there. This
may partially cause the obstruction. If this manoeuver
is not possible (tongue -jaw lift) use the crossed - finger
technique to open the airway (by crossing your finger
and thumb and pushing the teeth apart).
2. Insert the index finger of your other down along the
inside of the cheek deep into the throat to the back of
the tongue. Use the hooking action to dislodge the
foreign body and bring it into the mouth so that it can
be removed.
Sometime, you may have to push the foreign body
against the opposite side of the throat to dislodge and
lift. Be careful not to force the object deeper into the
airway. When the foreign body comes within reach,
grasp and remove it.

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SEQUENCE OF PROCEDURES IN RELIEVING OF FOREIGN BODY
OBSTRUCTION

A conscious victim:

ACTION REASON
1. Ask Casualty if he is able to speak. Complete airway obstruction must be
Casualty may be using "Universal established immediately. If casualty is
Distress Signal" able to speak or cough effectively. Do
not interfere with his/her attempts to
expel the foreign body.
2. Deliver 5 manual thrusts This sequence of abdominal or chest
thrusts is more effective than any other
manoeuver. This should force the
foreign body upwards .
3. Repeat these sequence until it is It is paramount importance that the
effective or the casualty becomes airway is cleared. If the airway is not
unconscious. cleared within minutes the casualty will
become unconscious.

CHOKING CASUALTY WHO BECOMES UNCONSCIOUS

ACTION REASON
1. Call for help. Position the casualty. The call for help is to alert by standers.
The casualty must be properly
positioned on his back in case CPR
becomes necessary.
2. Open airway and attempt to ventilate. Complete airway obstruction by a
foreign body is assumed but an attempt
must be made to get some air into the
lungs just in case the cough has
loosened the foreign body .
3. Activate the emergency medical service. Advanced Life Support may be required.

4. Give 5 manual thrusts Kneeling at victims side gives greater

mobility and access to the airway.
5. Check for foreign body using finger A dislodged foreign body may now be
sweep manually felt. Dentures may have to be
removed to improved finger sweep .
6. Reattempt to ventilate by repositioning Another attempt must be made to get
the head. some air to the lungs.

7. Report sequence until successful. As casualty becomes more deprived of

oxygen, the muscle will relax and the
monoeuver that was previously
ineffective may becomes effective.

88
IF CASUALTY IS UNCONSCIOUS

ACTION REASON
1. Establish unresponsiveness and Call for help to alert by standers.
call for help.
2 Open airway, establish
breathlessness Look, Listen & Feel

3. Attempt ventilation. To get some air to the lungs.

4. Reattempt ventilation Improper head-tilt is common cause

of obstruction.
5. Repeat 4,5,6,7 of the above

FOREIGN BODY OBSTRUCTION ON INFANTS AND CHILDREN

Infants - younger than 1 year

Child - from one year to eight years.

INFANT

1. The infant is straddled over the rescuer's arm with the head lower
than the trunk.

2. The head must be supported with a hand around the jaw and
chest. For additional support, it is advisable for the rescuer to rest
the forearm on his thigh.

3. Five back blows are delivered - care must be exercised since much
less force needs to be exerted than in the adult.

4. Then the rescuer's free hand is placed on the infant's back, so that
the victim is "Sandwiched" between the two hands - one supporting
the neck, jaw and chest while the other is to support the neck.

5. The infant is then turned and placed on the thigh with the head
lower than the trunk.

6. Five chest thrusts are performed over the Mid-sternum.

89
CAUTION

1. No blind sweeps are done since the foreign body can easily be
pushed back and cause further obstruction.

2. In the unconscious infant or child, a tongue - jaw lift should be

performed and if you can actually see the foreign body -remove it.

3. ABDOMINAL THRUSTS ARE NOT TO BE DONE ON THE INFANT

BECAUSE OF POSSIBLE INTRA - ABDOMINAL INJURY.

90
 RESUSCITATION
DEFINITION
Resuscitation is a process, whereby an attempt is made with or without
instruments to revice a victim whose vital functions are in jeopardy,
applying the basic principles of Artificial Respiration and Cardiac
Massage.
Artificial Respiration
This is indicated in any condition where respiration fails but heart
continues to beat.
The principles in the purpose of Artificial Respiration are:
1. By maintaining gaseous interchange, the citality of the nerve
centres as well as that of the heart maintained.
2. It helps in maintaining circulation and it is expected that
after sometimes, the respiratory centres will start functioning
spontaneously.
3. During Artificial Respiration the alternate inflation and
deflation of the lungs, reflexly stimulate the respiratory
centres, thus help them to take up their own spontaneous
rythem.
Methods of Artificial Respiration
1. Schafer's 2. Sylvester's 3. Holger-Nelson
4. Mouth-to-mouth 5. Mouth-to-Nose.
Cardiac Massage
This is indicated in any condition where the heart stops beating. It is a
process whereby external pressure is applied over the lower half of the
sternum so that the heart is compressed against the vetebral column
and by such a rhythmic process the pumping action of the heart is
main-tained to facilitate circulation.

Life Support And Cardio-Pulmonary - Resuscitation

Life entails having a healthy heart and functioning lungs among other
things. In times of emergencies when any one of this organs fails that
victim requires a LIFE SUPPORT.

91
Life support is divided into three stages.

1. Basic Life Support - First Aider.

2. Advance Life Support - Emergency Dept.

3. Prolonged Life Support - Intensive Care Unit.

Cardio-Pulmonary-Resuscitation (CPR) is a method used in resuscitating

a victim whose lungs and heart have failed him. This procedures makes
use of the principles of Artificial Respiration and Cardiac Massage put
together in a proper fashion.

CPR is basic life saving technique which all First Aiders should be
through in. It is a combination of mouth-to-mouth breathing or other
ventilation techniques and chest compressions. It keeps oxygenated
blood flowing to the brain and other vital organs. This apparent miracle
can be brought about by our hands, lungs and brains. It would be used
in any "Sudden Death Syndrome" eg. Cardiac Arrest, Electric Shock,
Drowning, Drug Reactions, Asphyxia, etc.

The most important single factor which determines whether CPR is

useful is SPEED-CPR must be initiated immediately.
Clinical death means that the heart beat and breathing have stopped.
This death is reversible.
Biological death is permanent brain death due to lack of oxygen. This
death-is-final.
INTRODUCTION
It had been proven beyond any reasonable doubt that "Sudden Death"
can be reversed. It is also heartening to know that, anyone of us can
achieve this by learning a form of resuscitation- the most useful being
Cardio-Pulmonary Resuscitation.
There are no fancy or difficult to handle instruments involved in this
procedure. All it takes is a good pair of hands, good capacity lungs and
our brains. Use them promptly and properly and you may save someone
life.
Whatever it maybe it is important to remember that CPR can help to save
life. CPR has two components -to the lungs - Artificial Respiration and to
the heart -Cardiac Massage.

92
METHODS OF ARTIFICIAL RESPIRATION
The first three methods are now considered to be obsolete because it has
been proven that mouth-to mouth or mouth-to-nose are the most
effective.
Mouth-to-mouth
Place your mouth over the victim mouth while pinching his nose with
your index finger and thumb. Take a deep breath and blow into the
mouth. Each blow must have a minimum of 800 cc of air to be effective
in an adult. In an infant a puff is sufficient.
Mouth-to-nose
The process is the same except the mouth is place over the nostril and
the mouth is closed by pulling the chin up.
A. AIRWAY
It must be remembered that whatever the injury, the victim's
airway must always be checked first. It is important to remember
that the most common cause of airway obstruction is the back of
the tongue.
1. Extend the head tilt and chin lift so that the tongue will not
fall back
2. Open the mouth and clear of any loose foreign bodies.
3. Make sure the nostrils are clear too.
4. If you are unable to extend the head, turn the victim to the
left or right side, which will also prevent the tongue from
falling back.
5. Do a quick general assessment of the victim's condition.

 Look - at the chest for movement

 Listen - for sounds of breathing

 Feel. - for breath on your cheek

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B. BREATHING

It is important to ascertain whether the victim is breathing or not

because when the breathing stops, the body has only oxygen
remaining in the lungs, and blood stream. It has no oxygen reserve.

Rescue breathing by mouth-to-mouth is the quickest, most effective

way to get oxygen into the victim's lungs. There is sufficient oxygen
in the air we exhale to supply the victim's needs.

How to check for breathing?

If you are on the right of the victim, put your left ear over his
mouth and fix your eyesight on his chest. In this way you can
LISTEN for his breath sounds, FEEL his breath hitting your ear
and LOOK if his chest is rising with every breath he is taking. If he
is breathing-you can feel and hear the air brush your ear, it may
also feel warm and you will see his chest rising and falling. If you
do not feel and see as above - breathe for him immediately.

94
C. CIRCULATION

This is when you have to ascertain, if the victim's heart is beating.

The best way is to feel for his carotid pulse (in the neck). Procedure:
Put 2- 3 fingers on the voice box just blow the chin, slide fingers
into the grove between voice box and the muscle-feel for the carotid
pulse. If it is not felt, chest compressions must be started –
CARDIAC MASSAGE. This will result in the flow of the blood from
the heart to the lungs, brain and other major organs.

Position of hands for cardiac massage

1. Put victim in the supine positon on a board or surgace.

2. Put the middle finger of the right hand over the lower margin
of the rib cage on the right side and move it along the edge till
you reach the groove above the Xiphoid sternum.

3. Place the index finger next to the middle finger.

4. Place the heel of the other hand next to the index finger on
the sternum.

5. Place the other hand on top of this hand. If the heel of the
hand is properly placed, then it should be over the lower half
of the sternum.

95
Compressions

When compressing the chest - it must be done smoothly. The shoulders

must be directly over the hands and the elbows must not be bent.

Performance Guidlines (Single Rescuer CPR}

1. Established unresponsiveness - call to victim by tapping the

shoulder. Do it three times.

2. Position the victim - effective CPR can only be done if victim is flat
on his back. The head should never be above the heart.

3. Open airway - upper hand over forehead and 1 hand over nape of
neck and extend the head.

4. Establish breathing (Look, Listen, Feel), If the chest moves but if

you do not feel the air-treat it as not breathing.

5. Blow 2 times into the victim's mouth-pinch off nos-trils-open your

mouth widely take a deep breath and blow till your lungs are
empty.

6. Establish circulation - feel the carotids.

7. If not felt - do cardiac massage.

If alone or two rescuers, the cycle is 15 compressions to 2

ventilations.

96
 Part of Hand Hand Position Depress Sternum Rate of Compression

INFANTS - tips of mid – sternum 1/2 -1 in 100/min

index and middle
finger

CHILDREN Heel of mid - sternum 1 -1 1/2 'in 8O/min

hand

For an effective CPR - a good solid carotid pulse should be present with
each compression. Check on the status of the victim's respiration and
carotid pulse every few minutes. Stop CPR when there is spontaneous
return of both functions.

Breathing

Adult - 12 times/min
1 time 5 sec. amount 800- 1500 ml.

Children - 20 times/min
1 time 4 sec. amount 100- 400 ml.

Infant - 20 times/mint
1 time 3 sec. amount 30- 100 ml.

Compression

Adult - 80- l00/mint -compression

15 : 24 times 1 cycle

Children - 80- 100

5 : 1 times 10 cycle

Infant - 100- 200

5 : 1 times 10 cycle

97
 BURNS AND SCALDS
Burns can be caused by many physical agents, eg. heat, cold thermal
injuries, acids, alkalis or by radiation.

MOIST heat normally causes SCALDS eg. steam, hot liquids.

Any heat would normally give a BURN eg. fire, hot metal, contents,
electrical, friction

CLASSIFICATION OF BURNS

Many classifications are available, but for a first aider, it is sufficient to

differentiate between SUPERFICIAL and DEEP Burns.
CLINICAL FEATURES
The changes produced by burns can be described as LOCAL or
GENERAL.
LOCAL CHANGES - Superficial burns
1. skin appears red because mild heat
produces a dilatation of arterioles and
capillaries.
2. effusion of vesicles of the tissue (fluid
collects in the tissue).
3. formation of vesicles (blisters) high
temperature increases capillary wall
permeability.
4. if pressure is applied to the burnt area
or red patch, it turns pale but returns
to red again after the pressure is
released.
5. sensation is felt.
6. pink floor colour.
- Deep burns
1. may appear like superficial burns but
on applying pressure on the burnt area
it remains pale, indicating that the
superficial blood vessels are destroyed.

98
 2. sensation over the burnt area is lost.

3. yellow, brown, charred, depressed or

cracked surface are deep.
GENERAL CHANGES

1. NEUROGENIC SHOCK (occurs from time of injury to within - two

hour) because of pain.

- this is due to the generalised response of the body resulting

from stimulation of the underlying nerves.

There is a fall in blood pressure causing pallor and cold and

clammy extremities.

2. OLIGENIC SHOCK (within 30 mins to 12 hours after injury) loss of

plasma due to oedema and a loss of plasma from the capillaries
into the tissues. Plasma is also lost from the burnt area. Poor
circulation leads to poor excretion from the kidneys.

3. Stage of TOXEMIA - (within 6- 60 hours after injury) blood

poisoning due to poor kidney excretion there is retention of
poisonous materials. May have vomiting of blood.

4. State of Healing - (two or three weeks after injury) - the slough

separates and the wound heals.

If there is superficial burn, complete regeneration of the tissue is

obtained. In cases of deep burns, the wounds will heal by the formation
scar tissue.

TREATMENT

The main objective in the treatment of burns is to save the life and
prevent infection. Treatment begins at the time of the injury and is
completed only when the wounds heal with a good cosmetic result and
the patient returns to normal work.

FIRST AID MANAGEMENT OF A BURN CASE

1. Remove the victim to safer area, away from the agent which caused
the burns.

2. Identify yourself and reassure the victim.

99
3. Remove the victim, any clothing or material which can cause
further burns, eg.

a. the victim has hot water on his shirt, remove the shirt
immediately because if the shirt is left on him, the hot water
in the shirt will worsen his burns.

b. if the victim is on fire, wrap him in any piece of cloth and roll
him on the ground.

c. if there is acid, or other corrosive agents on the face, eyes or

body, immediately wash the part of the body under a running
tap of water .

4. Make sure the victim has got basic life support

- make sure of an open airway

- treat any early shock

5. Can apply any recognised antiseptic cream eg. silver -

sulphadiazine cream, burnol or just cover with a clean sheet of
cloth and send to hospital. You can give oral fluids if the victim is
conscious.

6. Do not burst any blisters, as they can actually be useful because

they provide protection against infection.

How to express a burnt area in terms of a percentage. By the RULE OF

NINE.

Face - 9% - 9%
Upper limb - 9% each - 18%
Chest & abdomen - 18% each - 36%
Lower limb - 18% each - 36%
Genitals - 1% - 1%

Total : 100%

100
INTRODUCTION

Burns are frequent accident in every country and they are commonest at
the extremes of age.

The house is the usual location for these accident, and cooking, heating
and lighting appliances are often involved. Burns at work affect the
middle age group and certain industrial processes such as iron and steel
manufacture have a high-risk factor.

The skin is the body surface most often affected but the lining of the
respiratory and alimentary tracts can also be involved.

Brief description of skin

The skin completely covers the body, is continous with the memberanes
lining the orifices of the body and is one of the most active organs.

It contains the nerve endings of many of the sensory nerves.

It is one of the main excretory organs.

It plays an important part in the regulation of the body temperature. ,

It protects the deeper organs from injury and the invasion, of micro-
organism.
Structure of the Skin
The skin is composed of two main parts:
The epidermis
The dermis or corium
The Epidermis
The epidermis is the most superficial part of the skin and varies in
thickness in different parts of the body. It is thick on the palms of the
hands and soles or the feet. There are no blood vessels or nerve endings
in the epidermis, but its deeper layers are bathed in interstial fluid which
is drained away as lymph.
There are several layers of cells in the epidermis which extend from the
superficial statum corneum (horny layer) are flat, thin, non-nucleated,
dead cells in which the proto-plasma has been replaced by KERATIN.

101
Cells on the surface are constantly being rubbed off and they are
replaced by cells which orginated in the 'germinative layer and have
undergone gradual change as they progressed towards the surface.

The maintenance of healthy epidermis depends upon three processes

being synchoronised:

Desquantion of the keratinised cells from the surface

Effective keratinisation of the cells approaching the surgace

Continual cell division in the deeper layers with cells being pushed
to the surface

Passing through the epidermnis are the hairs, secretilon from the
sebaceoous glands and the ducts of the sweat glands.

The surface of the epidermis is ridged by projection of cells in the dermis

called the papillae. The pattern of ridged formed in this way is different
in every individual and the impression made by them is called the 'finger-
print'.

102
The dermis is tough and elastic. It is composed, of white fibrous tissue
interlaced with yellow elastic filbres. In the deeper layer forming the
subsutaneous tissue there is areolar and adipose tissue.

The structure in the dermis are :

Blood vessels Sweat glands and their ducts

Lymph vessels Hair roots, hair follicles and hairs
Sensory nerve endings Sebaceous glands
The arrectoores pilorum - involuntary
muscles attached to the hair follicles

1. Blood vessels. Arterioles from a fine network with supplying sweat

glands, sebaceous glands, hair follicles and the deep layers of the
epidermis.
2. Lymph vessels. These form a netwoork throughout the dermis and
the deeper layers of the epidermis.
3. Sensory nerve endings. Nerve endings which are sensative to
touch, change in temperature and pressure are widely distributed
in the dermis. There are no nerve endings in the epidermis.
The skin is an important sensory organ. It is one of the organs through
which the individual is aware of his environment. Nerve impulses which
originate in these nerve endings are conveyed to the spinal cord by
sensory, or cutaneous, nerves. From there are conveyed to the sensory
area of the cerebrum where the sensations of touch, tempereture and
pain are perceived.
4. Sweat glands. These are found widely distributed throughout the
skin and are most numerous in the palms of the hands, soles of the
feet, axillae, and groins.

103
The glands are composed of epithelial cells and the body of the gland has
a coiled appearance. The duct of the gland traverses both the dermis and
epidermis to open on to the surface of the skin at a minute depression
known as the pore. Each gland is supplied by a network of blood
capillaries.
The most important function of sweat is a relation to maintenance of the
normal body temperature. It has a lesser function as a route for the
excretion of waste materials. Electrolytes may be lost in abnormally large
amounts if there is excessive sweating.
The composition of sweat is as follows:
Water ) - 99.4 per cent
Potassium )
Sodium )
Chloride ) - 0.2 per cent
Sulphate )
Waste substances - 0.4 per cent

5. Hair follicles. These consist of a downward growth of epidermal-

cells into the dermis or even the subcutaneous tissue. The base of
the follicles there is a cluster of cells, called the bulb, from which
the hair grows. The hair is formed by a multiplication of cells of the
bulb and, as they are pushed upwards and away from their source
of nutrition, the cells die and are converted to keratin.
The hair consists of the shaft which protrudes from the surface of
the skin and the remainder is called the root.
The colour of the hair depends on the amount of melanin present. White
hair is the result of the replacement of melanin by tiny air bubles.
6. The sebaceous gland. These consist of secretory epithelial cells
derived from the same tissue as the hair follicles. They pour their
secretion, sebum, into the hair follicles and therefore they are
present in the skin of all parts of the body except the palms of the
hands and the soles of the feet. They are most numerous in the
skin of the scalp, the face, the axillae and the groins.
Sebum keeps the hair soft and pliable and gives it a shiny
apprearance. On the skin it provides some water rooting, acts as a
bactericidal agent preventing the successful invasion of micro-
organisms and it prevents drying especially on expoosure to heat
and sunshine.

104
7. The arrectores pilorum. These are little bundles of involuntary
muscle fibres connected with the hair follicles. When these muscles
contract they make the hair stand erect. This also causes the skin
around the hair to become elevated giving the appearance of 'goose flesh'.
The muscles are stimulated by sympathetic nerve fibre in fear and in
response to cold. Although each muscle is very small the contraction of a
large number generates an appresiable amount of heat.

Pigmentation of the Skin

When no pigment is present the skin looks pinkish white in colour due to
the blood in the capillaries of the dermis. In most individuals this colour
is modified by varying amounts and proportions of several pigments. The
three most important are:

1. Melanin - a brown pigment found in the germinative layer of

the epidermis.

2. Melanoid - a brownish pigment found distributed widely in

the cells of the epidermis.

3. Carotene - a yellow pigment found in the stratum corneumor

horny layer of the epidermis.

The Nails

The nails in human beings are equivalent to the claws, horns and hoofs
of animals. They are derived from the same cells as epidermis and hair
and consist of a hard, horny type of keratinised dead cell. They protect
the tips of the fingers and toes.

The root of the nail is embedded in the skin, is covered by the cuticle and
forms the hemispherical pale area called the lunula.

The body of the nail is the exposed part and grown out from the
germinative zone of the epidermis called the nail bed.

105
The finger nails grow more quickly then the nails. Growth is quicker
when the environmental temperature is higher and vice versa.

The nail and related structures

Function of the Skin

Protection

The skin is one of the main protective organs of the body. It protects the
deeper and more delicate organs and acts as the main barrier against the
invasion of micro-organisms and other harmful agents.

Due to the presence of the sensory nerve endings the body reacts by
reflex action to unpleasant or painful stimuli, and thus is protected from
further injury.

Formation of Vitamin D

There is a fatty substance called 7- dehydrocholesterol in the skin and

ultraviolet light from the sun converts it to vitamin D. The vitamin D
circulates in the blood and is used, with calcium and phosphorus, in the
formation and maintenance of bone. Excess of immediate requirements
is stored in the liver.

106
Regulation of Body Temperature

Human beings are warm-blooded animals and the body temperature is

maintained at an average of 36.80C (98.4°F) .In health, variations are
usually limited to between 0.50 and 0.750C, although it may be found
that the temperature in the evening is a little higher than in the morning.
This is the a optimum temperature for the many complex chemical
processes to occur. If the temperature is raise'd the metabolic rate is
increased and if it is lowered the rate of metabolism is reduced.

To ensure this constant temperature a fine balance is maintained

between heat produced in the body and heat lost to the environment.

Heat production

Some of the energy released in the cells when carbohydrates, fats and
deaminated amino acids are metabolised is in the form of heat. Because
of this the organs which are the most active, chemically and physically,
produce the most heat.

The principal organs involved are:

1. The muscles. Contraction of voluntary muscles produces a large

amount of heat. The more strenuous the muscular exercise the
greater the heat produced. Shivering involves muscle contraction
and produces heat when there is the risk of the body temperature
falling below normal.

2. The liver. It will be remembered that the liver performs many

chemical activities each involving the production of heat.

3. The digestive organs. Heat is produced by the contraction of the

muscle of the alimentary tract and by the chemical reactions
involved in digestion.

107
Heat loss

Heat is lost from the body in several ways :

97 per cent by the skin

2 per cent in expired air

1 per cent in urine and faeces

Only the heat lost by the skin can be regulated to maintain a constant
body temperature. The heat lost by the other routes is obligatory.

Heat loss from the body is affected by the difference between body and
environmental temperature, the amount of the body surface exposed to
the air and the type of clothes worn. Air is a poor conductor of heat and
when layers of air are trapped in the clothing they act as effective
insulators against excessive heat loss. For this reason several layers of
light weight clothes provide more effective insulation against a low
environmental temperature than one heavy garment.

Nervous Control

The centre controlling temperature is situated in the cerebrum and

involves a corp of nerve cells in the hypothalamus called the head
regulating centre. There is also a group of nerve cells in the medulla
oblongata known as the vasomotor centre which controls the calibre of
the blood vessels, especially the small arteries and the arterioles, and
they control the amount of blood which circulates in the capillaries in the
dermis.

The heat regulating centre and vasomotor centre are though to be

extremely sensitive to the temperature of the blood and any significant
change stimulates them to anxiety. From these centres sympathetic
nerves convey impulses to the sweat glands, arterioles and the arrector
muscles of the hairs in the skin.

Activity of the sweat glands

If the temperature of the body is increased by 0.25 to 0.9°C

the sweat glands are stimulated to secrete sweat which is

108
conveyed to the surface of the body by ducts. This moisture evaporates
into the atmospheric air cooling the body because the heat which
evaporates the water is taken from the skin. When sweat droplets can be
seen on the skin the rate of production of sweat exceeds the rate of
evaporation. This is most likely to happen when the environmental air is
humid and the temperature high.

Loss of heat from the body by evaporation is described as occuring by: .

Insensible water loss

Sweating

In insensible water loss, heat is being continuously lost by evaporation,

even although the sweat glands are not active. Water diffuses upwards
from the deeper layers of the skin to the surface of the body and
evaporates into the air.
In sweating the sweat glands are active and secrete sweat on the surface
of the body which evaporates and, in the process, cools the skin.
Effects of vasodilation
The amount of heat lost from the skin depends to a great extent on the
amount of blood in the vessels in the dermis. As the amount of heat
produced in the body increases the arterioles become dilated and more
blood pours into the capillary network in the skin. In addition to
increasing the amount of sweat produced the temperature of the skin is
raised. When this happens there is an increase in the amount of heat
lost by:
Radiation
Conduction
Convection
In radiation the exposed parts of the body radiate heat away from the
body.
In conduction the clothes in contact with the skin conduct heat away
from the body.
In convection the air passing over the exposed parts of the body is heated
and rises, cool air replaces it and convection currents are set up. Heat is
also lost from the clothes by convection.

109
If the external enviromental temperature is low or if heat production is
decreased, the blood vessels, under the influence of the sympathetic
nerves, constrict thus decreasing the blood supply to the skin and so
preventing heat loss.

In man, therefore, this fine balance of heat production and heat loss
must continously be maintained to ensure no drastic change in body
temperature.

By Extent

The area burned is expressed as a percent of the total body surface.

The skin distribution over the body varies with age.

An easily remembered 'Rule of Nine' table provides reasonable accurate

for all except the young child.

By Depth

In superficial burn, viable epithelial cells persist in the deeper layers of

the skin. Such burns can regenerate skin cover.

In deep burn, the whole thickness of the skin is destroyed, underlying

fat, muscle and bone may also suffer. Healing can only be slow.

Recognition of Depth

An accurate history will define the temperature of the burning agent and
the duration of its contact.

There are two factors along with skin thickness, determine the depth.

Most scalds (low temperature) are superficial.

Most flame burns (high temperature) are deep.

110
 SHOCK
(ACUTE CIRCULATORY FAILURE)

DEFINITION

A definition of shock is difficult but important. Shock is a state of

circulatoroy hypovolaemia (low volume) associated with a fall of blood
pressure which leads to the loss of vital functions (because of inadequate
nourishment) which eventually threatens the patients life.

Otherwise expressed as "an expression of sympthy of the whole body

with a part suddenly subjected to serious injury".

PHYSIOLOGYOF SHOCK (HOW IT OCCURS)

It must be emphasised that shock is not a disease but a syndrome

(collec-tion of symptoms).

It is a sudden process occuring in the body involving many system but

the impairment of the circulatory system is the most significant in
determining the fate of the patient.

Circulatory system being the main system involved in the development of

shock, hypovolaemia (low volume) has been studied extensively.

The main organ of the circulatory system is the heart. It is important

that the heart pumps sufficient blood (cardiac output) for all the organs
to be adequately nourished with oxygen.

If this does not happen then the volume of blood leaving the heart will
drop which will bring about a fall in the blood pressure. When the blood
pressure falls the amount of blood going back to the heart will also fall.
This vicious cycle will continue until the volume is restored.

Therefore, with low blood pressure all the organs will not be adequately
nourished causing widespread serious reduction of tissue perfusion
which if prolonged leads to cellular impairment eventually causing a loss
of vital functions.

111
 NORMAL BLOOD DILATED WEAK
SYSTEM LOSS SYSTEM PUMP

COLLAPSE OF THE CARDIOVASCULAR SYSTEM

113
The hallmark of shock is deranged micro circulation so that the critical
organs in the body are inadequately nourished (perfused) .

Depending upon the severity and rate development of hypovolaemia the

shock syndrome may develope suddenly or gradually.

CAUSES

A primary event in shock (spectic, traumatic, haemorrhagic) is believed

to be the occurence of hypovolaemia (a reduction in the effective
circulating blood volume). In traumatic and haemorrhagic shock,
hypovolaemia may occur when large amounts of blood or fluid are lost
through haemorrhage (bleeding) .

This eventually will reduce venous return and therefore diminish cardiac
output.

Since shock result from inadequate cardiac output, any factor that can
reduce cardiac output can also cause shock.

What is cardiac output ?

Cardiac output is the amount of blood pumped out of the left vertricle in
one minute.

In each beat 80 ml of blood is pumped out.

Therefore in one minute the total blood volume passes through the left
ventricle.
Factors that can bring about a reduction in cardiac output can be
grouped according to :
1. Those that decrease the inability of the heart to pump blood e.g.
Heart Attack.
2. Those that tend to decrease the venous return e.g.:
a. diminished blood volume.
b. increased resistance to blood flow.
c. the blood vessels loose their tone.
d. the capacity of vessel has increased.

113
On this basis general types of shock are described:

1. CARDIOGENIC SHOCK - When the pumping action of the heart is

inadequate.

2. HYPOVOLAEMIA SHOCK (COLD SHOCK) - as the circulating

blood volume decreases less blood is available for the various vital
organs. A decrease in venous return occurs and the cardiac output
begins ro fall unless the blood volume is inreased.

The heart rate increases in an attempt to maintain the cardiac output.

The body's protective reflexes attempt to return blood that is pooled in
capillary beds to the general circulation. These reflexes initiate
adrenaline secretion in an attempt to increase both the tone of the
vessels and the peripheral blood (elasticity) pressure thus driving the
pooled blood back into the circulation. If successful, shock is controlled.

Many times the. reflexes over conpensate and become self - defeating,
release excessive amounts of adrenaline which causes increased arterial
and venous constriction, thus blood remains pooled in the capillary beds.

3. LOW RESISTANCE SHOCK (WARM SHOCK) - in this shock, blood

volume is not decreased and cardiac output is the same - but the
vessels are dilated and therefore the capacity of the vessels is
increased as in septic shock.

In the normal individual, approximately 20% of the capillary beds

are profused at anyone time; however in septic shock many
capillary beds normally not profused overdilate and large amounts
of blood and fluid pool within them. Thus pooling creats a loss in
circulating blood volume, thus precipilating a relative
hypovolaemia.

As this cycle continues less oxygen is available to the cells and they
begin to use the anaerobic pathway to obtain energy. The end
result of this pathway is the production and accumulation of lactic
acid.

Arterioles dilate eventually while venules remain constricted, allowing

blood to enter and become trapped within the micro circulation.

114
Further it is paramount to appreciate that uncontrolled shock progresses
to acidosis which results in cell damage or death.

Septic shock, although not significantly different from the events seen in
hypovolaemia shock is more severe, the principal difference lies in the
accelerated deterioration of the micro circulation following exposure to
andotoxin (bacteria) .

COMMON PATHWAY LEADING CIRCULATORY CHANGES OBSERVED

IN SHOCK

SEPTIC (WARM) HYPOVOLAEMIA (COLD)

BACTERIA DECREASED CIRCULATORY VOLUME

ADRENALINE DECREASED VENOUS RETURN

GENERALISED VASOCONSTRICTION REDUCED CARDIAC OUTPUT

CAPILLARY DAMAGE SELECTIVE ADRENALINE RELEASE

CAPILLARY DILATATION

RELATIVE HYPOVOLAEMIA VASOCONSTRICTION

HYPOVOLAEMIA

ACIDOSIS

CELL DAMAGE

DEATH

SIGNS AND SYMPTOMS

1. PALLOR: due to the urgency of blood needed by other important

organs and to facilitate this most vessels are constricted. Therefore
the skin is pale due to this phenomeon (intense outaneous
vasoconstriction)

2. COLD & CLAMY : less blood supply to the skin therefore the
warmth is missing.

3. Sweating: this happens due to the overactivity of the body to this

catastrophy (shock).

115
4. Restlessness: the cerebral disturbances follow inadequate
perfusion of the brain.

5. Rapid & thready pulse: the heart responds to the low volume by
pumping (tachycardla) faster to, circulate the blood as usual.

6. Respiration is rapid as shallow: the respiratory rate is increased

so as to bring about a quick exchange of gases.

7. Pilo - erection: the hair stands up - as usual reaction to fear.

Treatment

Basically the aim in treating shock is to alleviale the cause and normalise
the blood pressure so that tissue perfusion can be maintained.

Therefore it requires urgent hospitalisation.

As a first aid procedure.

1. Make sure airway is open

2. Attend to any external injury.

3. Place in Trendenlenburgh position (head lowered and limbs raised).

4. Keep warm

5. No oral fluids to be given

6. Take to hospital.

116
 UNCONSCIOUSNESS AND TREATMENT
Definition : A person is said to be unconscious when the person
does not respond to any external stimuli e.g. pain, heat,
pressure.

CAUSES

The causes of unconsciousness can be atraumatic (not involving injury)

or traumatic (involving injury). Unconsciousness can be for a short
period of time or prolonged. There are many causes for this but it
paramount importance that a first aider recognises an unconscious
victim and it possible ascertain the cause and institute immediate
management.

Some common medical conditions are opiates. e.g. diabetic ; coma,

stroke, fits, poisoning etc.

Though it is important to be able to recognise the cause the traumatic

caupe - head injury is more commonly seen by first aiders.

It must be emphasized that whether traumatic or atraumatic, all cases

must be seen by a doctor eventually.

HEAD INJURY
A head injury may be localised or generalised.

Localised : caused by a small object. It expands most of its force

upon a small area of scalp; and skull and even; penetrate the skull
causing loss of consciousness of change in vital signs.

Generalised : damages the whole brain by compression or by the

'whiplash' mechanism which contures the surface of the brain against
the skull bones.

Head injuries can be further classified as open (where the brain is

exposed) and closed (when it is protected by in tacts skin and skull)
Closed head injury may also have fracture of the skull.

117
Generalised Signs and Management

After a suspected head injury it is important to observe the patient. The

purpose of observation in a head injury is centralised on the need to
detect that minority of patients who are developing features of cerebral
compression. While observing you may see that:

1. the unconsciousness maybe for a short while and they recover.

2. a small proportion remains unconscious.

3. a few get into deeper unconsciousness state.

The important signs are:

1. The conscious level: the conscious level is chartered according to

the patient's response to a stimuli - pain.

a. No response to pain
b. Inco-ordinated response (moves all 4 limbs) .
c. Co-ordinate response (patient pushes away the examiners
hand) .
d. Response to simple commands.
e. Talking but disoriented.

Any shift a higher level to a lower level in this scheme is highly

significant of deepening level of unconsciusness.

2. Pulse, respiration and blood pressure with increasing cerebral

compression, the pulse becomes slow and the breathing becomes
deep and is laboured. The blood will rise.
3. Pupils.
The pupil will dilate eventually on the effected side and as the
unconsciousness progress the other pupil will dilate and does not
respond. This is a grave sign and patients varily recover.
Treatment
- The most important aspect is the airway. Keep the airway open and
transport patient to the hospital.
- Treat any other external injury.
- Do not move him unnecessarily.

118
 SYNCOPE ( FAINTING )

DEFINITION

Atrasiant loss of consciousness due to an inadequate blood supply to the

brain tissue.

FEATURES

1. Abrupt onset.

2. Brief duration.

3. Complete recovery within a few minutes.

TREATMENT

1. Loosen all tight clothing.

2. Clear the airway -remove any obstruction to the airway e.g. loose
dentures and place the head to one side.

3. Position of the head should be lower than the body so as to

increase the cerebral blood flow.

4. Sprinkle some water on her face and cover with a blanket if cold.

5. Look out for any vomiting. Put on nil orally until patient gains
consciousness.

6. Reassure the patient and if possible give a hot drink.

119
 POISONING
Definition

A poison is any substance - solid, liquid or gas that act to produce

harmful effects on the normal body functions, when introduced into the
body.

CAUSES

Poisoning may occur in many ways, that most common being

1. Ingestion or swallowing of a harmful substance.

2. Inhalation of gases, fumes or noxious dust.

3. Injection into the body tissues or blood stream by hypodermine

needles or the bites of poisonous snakes, insects or rabid animals.

4. Absorption through the skin (poisonous liquids} or contract by the

skin (poisonous plants etc.}

TYPES OF POISONS
HOW TO RECOGNISE AND TREAT

Poisoning by Ingestion (Mouth)

- Overdose of medicine (intentional or accidental} eg. Aspirin,

Panadol, psychotrophic drugs sedatives.

- Household cleaners and chemicals, within the reach of children.

eg. bleeches, washing soda, insecticides/pesticides.

- Combining drugs and alcohol. eg. tranquilizers, sedatives.

- Poisons transferred from the original container to food container.

eg. kerosene, insecticides.

The sign and symptons of poisoning by ingestion vary according to the

type of poison, period of ingestion, amountingested and size of victim.

120
Generally:

1. Nausea, vomiting and diarrheoa.

2. Severe abdominal pain and cramps.

3. Slowed respiration and circulation.

4. Corrosive poisons (strong acids and alkalis) may corride, burn, or

destroy the tissues of the mouth, throat and stomach.

5. Contents of a drug bottle spilled out, and not all of the contents
accounted for.

6. Liquids such as kerosene or turpentine may leave characteristic

odors on the breath.

7. Certain poisons may stain the mouth.

The following is first aid care poisoning by ingestion:

The objective is first aid for this poisoning is to

* Dilute the substance by giving the victim milk or water

* Call the nearest control centre. This can be done more quickly than
transporting the victim to the hospital.

* In most cases, if medical help is not available try to remove the

substance from the stomach before it is absorbed by the system.
This gives the victim a better chance to revocery.

* Vomiting should not be included in the following cases:

- When the victim has swallowed a strong acid or alkali which

would cause further damage when coming back up. In such
cases, the victim should be given a glass of milk or water and
monitored for breathing difficulties.

- If petroleum product has been swallowed, because it can

cause a form of peneumonia if inhaled into the lungs.

- When the victim is unconscious or semi-conscious because

the victim might suck vomitus into the lung.

121
 - When the victim goes into convulsions or has convulsed.

- If the victim had a serious heart problem.

Check with the nearest control center to find out the best method to
induce vomiting. The victim would be sitting and leaning forward to
prevent vomitus from going into the lungs. Collect the vomitus and take
it to the hospital.

* The poison container should be taken to the hospital along with the
victim.

Do not neutralise. Make no attempt to neutralise swallowed position

with the vinegar or lemon juice -may cause further harms. Giving oil is of
no value.

Poisoning by Inhalation

Certain toxic or noxious gases may stop respiration by direct poisoinig

effect or by preventing the transport of oxygen by the' red blood cells.
Such gases are encountered in mining, oil drilling and similar industries.
They include sulfur dioxide, the oxides of nitrogen, ammonia, hydrogen
sulfide, hydroogen cyanide and carbon monoxide.

The signs and symptoms of inhaled poisons are as follows:

- Shortness of breath

- Coughing

- Cyanosis (bluish color)

To provide first aid care for poisoning by inhalation, proceed as follows:

* Remove the victim to fresh air as quickly as possible. The rescuer
would not risk entering a hazardous atmosphere without proper
personal protective equipment
* In appropriate cases, initiate artificial ventilation or
cardiopulmonary resuscitation.
* If the victim is breathing, administer oxygen if available.
* Treat the victim for shock.

122
Carbon Monoxide

Carbon Monoxide, a product of imcomplete combustion, is probably the

most common of the poisonous gases. Over exposure can prove fatal.
Carbon monoxide causes asphyxia because it combines with the
hemoglobin of the blood much more readily than oxygen does. The blood,
therefore, carries less and less oxygen from the lungs to the body tissues.
The first symptoms of a asphyxia when a 30 percent blood saturation
level has been sreached.

The signs and symptoms of carbon monoxide are as follows:

- Headache.
- Dizziness.
- Yawning.
- Faintness.
- Lethargy and stupor.
- Mucous membranes becoming bright cherry red in color.
- Lips and earlobes possible turning bluish in color.
- Nausea or vomiting.

To provide first aid care for carbon monoxide poisoning, proceed as

follows:
* Take the victim to fresh air.
* Maintain an open airway.
* Perform artificial ventilation, if required.
* Administer oxygen if available.

Poisons Injected Into the Skin

Poisons can enter the skin by means of injection or bites of animals,
poisonous snakes and insects. Nonpoisonous insects and drugs can be
poisonous to some people. An allergic reaction to a nonpoisonous insect
bite or drug results in anaphylactic shock.

First aid care is aimed at minimizing the travel of the poison to the heart.
The general first aid care for poisons injected into the skin is as follows:

123
* Keep the person calm, quiet and all rest.

* All jewelery, bracelets, rings, watches, etc., should be removed from

the bitten extremity, in case of swelling.

* Apply a constricting bandage above and below the bite at the edge
of the swelling, loosely enough to slide a finger under the bandage.

* The pulse should be checked periodically below the bite: bandages

are only to be used as constriction, not as a tourniquet.

* Transport the victim to a medical facility as quickly as possible

while monitoring for changes in respiration and circulation.

FURTHER: READ UNDER BITES (WOUNDS)

Many insects bite or sting, but few can cause serious symptoms by
themselves, unless of course, the person is allergic to them. However,
some insects transmit deseases. For example, certain types of
mosquitoes transmit malaria, yellow fever and other diseases: certain
types of ticks transmit spotted or Rocky Mountain fever; and certain
types of biting flies transmit tularemia or rabbit fever.

Occasionally, stinging or biting insects that have been feeding on or have

been in contact with poisonous substances, can transmit this position at
the time of sting or bite.

Persons who have experienced serious reactions from previous insect

bites should be urged to secure any possible immunization or have an
antidote readily available to prevent more serious results from future
insect bites and stings.

The signs and symptoms of insect bites and stings are as follows:

- The stings of bees, wasps, yellow jackets and hornets and the bites
of mosquitoes, ticks, fleas and bedbugs usually cause only local
irritation and pain in the region stung or bitten.

- Moderate swelling and redness can occur and some itching,

burning and pain may be present.

124
The first aid care for insect bites and stings is as follows: ,

* The sting area should be inspected to determine whether the

stinger is still left in the body. If it is, remove it in order to prevent
further injection of toxin. The stinger should be carefully scraped
off the skin rather than grasped with tweezers because this might
squeeze toxin into the body.

* Application of ice or ice water to the bite helps to slow absorption of

toxin into the blood stream. A paste of baking soda and water can
also be applied to the bite.

* The victim should be observed for signs of an allergic reaction. For

people who are allergic, use a constricting bandage. If the sting is
on an extremity, use ice, maintain an open airway, treat for shock,
and get the allergic victim to medical helps as, quickly as possible.

Poisoning by Contact With Skin

Dermatoses

Many substances in the form of gases, fumes, mists, liquids ' and dust,
cause poisoning or dermatoses when they come in contact with the skin.
Dermatoses are diseases of the skin and its underlying tissue (hair
follicles, oil glands, and sweat glands) .These disease change the normal
structure of the skin and produce irritation and inflamation. Usually,
dermatoses do not progress rapidly, but show themselves gradually after
continued exposure to the cause. Persons who note changes in the
normal texure of their skin or continued irritation of the skin should seek
medical advice before a chronic dermatoses develops. Needles discomfort
and loss of time prevented by early medical care. .

The first aid care for victim of contact poisoning is as follows:

* Remove contaminated clothing and flood the area with plenty of

water.

* If the poison has contacted the eyes, wash with plenty of water.

* Watch the person for signs of shock and changes in respiration.

125
The first aid care for the victim of such poisoning is as follows:

- Contaminated clothing and jewellery should be removed.

- Wash the area with soap and water.

- A calamine preparation or a soothing skin lotion can be used if the

rash is mild.

- If severe reaction appears, seek medical help .

/hrs.
WS:A:AFID3-20/4/95

126
ADVANCE
FIRST
AID

PERSATUAN BULAN SABIT MERAH MALAYSIA

( Malaysian Red Crescent Society )
Ibu Pejabat Kebangsaan, 32 Jalan Nipah Off Jalan Ampang 55000 KUALA LUMPUR
Tel : 03-42578122 Fax : 03-42579867 E-mail:mrcs@po.jarring.my