TRAUMA III

Effects of heat, cold, electric shock, drowing, wounds and bleeding,

dressing and bandages

EFFECTS OF HEAT

Regulation of body temperature

• Normal body temperature• Heat production• Heat loss

Body Heat Production

• Basal energy metabolism (adults) – 65 to 85 Kcal/hr or 50 to 60 Kcal/hr/m2

body surface area• 1/2 of body heat generated by the liver,

heart and brain• At rest, muscle contributes 25 %• Exposure to cold leads to increase in muscle

tone which increases body heat production by 50 to 100 %

• Shivering increases body heat production 400 %

Mechanisms of Heat Loss

• Conduction (2 %)– Transfer of heat by direct physical contact

• Convection (1 to 40 %, depends on wind velocity)– Transfer of heat to air / water vapor circulating around

body• Radiation (30 to 65 %)

– Heat transfer by infrared waves• Evaporation (10 to 80 %)

– Conversion of liquid sweat to vapor (0.58 Kcal / cc of H2O evaporated)

• Breathing

Predisposing Factors to Heat-Related Illness

• Exogenous heat gain• Endogenous heat gain• Impaired heat dissipation

Sources of Exogenous Heat Gain

• Closed spaces (locked cars, etc.)• Bright sunshine (150 Kcal / hr)• Lack of air conditioning• Hot soil (can transmit heat through shoes)

Sources of Endogenous Heat Gain

• Exercise (300 to 900 Kcal / hr)• Agitation• Fever / infection• Hypermetabolism / hyperthyroidism

Causes of Impaired Heat Dissipation

• High environmental temperature• High environmental humidity• Lack of acclimatization• Excessive clothing• Obesity• Diabetes / autonomic neuropathy• Sweat gland dysfunction (dehydration, cystic

fibrosis, ectodermal dysplasia, scleroderma, extensive scars)

• Previous heatstroke

FORMS OF HEAT ILLNESS

• Mild forms of heat illness :– Heat edema– Heat cramps– Heat syncope– Prickly heat

• Heat Exhaustion :– Sodium depletion type– Water depletion type

• Heatstroke :– Classic – Exertional

Treatment of Mild Forms of Heat Illness

• Heat edema (usually only hands, feet, ankles)– Elevation, support hose (do not use diuretics)

• Heat cramps (due to Na depletion)– Cooling, PO fluids containing some salt

• Heat syncope (usually due to mild fluid depletion)– Rest, PO fluids

• Prickly heat– Skin cleansing, loose clothing, antibiotics if pustular

Heat Exhaustion: Sodium Depletion Type

• Etiology– Usually in unacclimatized– Usually young age– Exercise in hot environment– Mildly inadequate fluid intake & moderate

inadequate Na intake• Signs: febrile, headache, weakness, fatigue,

nausea, diarrhea, cramps, hypotension / tachycardia

• treatment: Rest, cooling, fluids (PO or IV) with sodium

Heat Exhaustion : Water Depletion Type

• Etiology: Usually elderly with inadequate free water intake ; can lead to heatstroke

• Signs: Febrile, thirst, weakness, confusion

• Treatment: Cooling, rest, hypotonic fluids ; if elderly, may need hospital admission

Heatstroke : Items Required for Diagnosis

• Exposure to heat stress : internal or external• Elevated body temperature (usually > 40 C)• Major CNS dysfunction (bizarre behavior,

seizures, coma, etc.)• Usually tachypneic, tachycardic, hypotensive• Usually anhydratic

Heatstroke

• A true emergency• Two types :

– Classic (Usually elderly,occurs after exposure to heat for > 1

week, mortality 70 % untreated, 10 to 20 % treated)– Exertional(Usually younger age, usually after heavy exertion, may

still have sweating, may have rhabdomyolysis / renal failure, mortality 30 % untreated, < 10 % treated

Heatstroke : Emergency Treatment Protocol

• Airway management : intubate if comatose ; High flow O2 for all

• Large bore IV and rapid bolus 500 to 1000 cc NS• Draw blood (CBC, lytes, BUN, glucose,

creatinine, PT, PTT, platelets, lactate, calcium, LFT's, CPK, ABG)

• Rapid external cooling : fully undress patient, ice bath or cool skin soaks and fans

• Foley and NG tube insertion : iced NG lavage

Heatstroke : Emergency Treatment Protocol(cont.)

• Monitor core temp. (high rectal probe or esophageal) ; stop external cooling when core temp. < 39O C

• Monitor for hypotension, hypocalcemia, arrhythmias, seizures, acidosis, ARF

• Admit to ICU• Acetaminophen (do not use aspirin)• Consider low dose phenothiazine

(chlorpromazine 25 mg IV) or diazepam IV to promote heat loss and lessen shivering

Heat Illness : Prevention

• Time exertion to avoid sunlight exposure and the hottest daytime hours (10:00 am to 3:00 pm)

• Light loose clothing permitting airflow over body surface• Consume 400 to 500 cc fluid before exertion and 200 to

300 cc at 20 min. intervals during exertion• Check body weight before practice : if wt. down 3 % ,

increase PO fluids ; if wt. down 5 %, cancel participation that day ; if wt. down 7 %, immediate fluids & consider medical attention

• Use only low osmolal fluids (< 2.5 g glucose and < 0.2 g NaCl per 100 cc)

• Extra NaCl and potassium intake during acclimatization

EFFECTS OF COLD

Hypothermia – general effect of cold

• Definition :– Body temperature < 35 degrees C (95 F)

• Severe hypothermia :– Body temperature < 28 C

Signs and symptoms

• Shiverings• Amnesia• Poor muscular coordination• Stupor• Irregular heart rythms• Loss of consciousness• Pupils dilate• Unresponsivness• Hypoternsion• Hypoventilation

Hypothermia : Neurologic Effects

• Cerebral blood flow decreased by 6 to 7 % for each 1° C decrease in core temperature

• May cause fatigue / confusion : "paradoxical undressing"

• EEG flat line below 20 0 C (68 0F)

Hypothermia : Typical Cardiac Rhythms

Temp. (˚C)

33 to 36

32 to 35

28 to 32

< 28

< 26

Rhythms

Sinus tachycardia

Sinus bradycardia

Atrial fibrillation

Ventricular fibrillation

Asystole

Conditions Predisposing to Hypothermia

1. Extremes of age

2. Metabolic diseases– Hypothyroidism– Diabetes– Renal failure– Hypoadrenalism

3. CNS diseases– Cerebrovascular disease– Any degenerative CNS

disease– Head trauma– Parkinson's

4. Shock− AMI / CHF− Hemorrhage

5. Malnutrition

6. Drugs− Any CNS depressant − ETOH

7. Dermal diseases

8. Paget's disease

9. Infections

10. Pancreatitis

Factors That Predispose to Cold Injuries

Factor MechanismWind Increase heat lossMoistureInadequate clothingAlcohol consumption Increased heat loss,Fatigue impaired judgment Injury Increased heat lossLoss of consciousnessTobacco use Diminished peripheral Constricting garments blood supplyHigh altitude Hypoxia

Causes of Vulnerability to Hypothermia by the Elderly

• Lack of ability to shiver• Thinner epidermis; less effective insulator• Lack of cardiovascular reserve for compensation• Tendency toward baseline dehydration• Movement impairment• Effects of concurrent medications

Hypothermia in Trauma Patients

• If occurs, shown to increase mortality compared to that expected from their Injury Severity Score (ISS)

• Can occur in just a few minutes after E.D. arrival• Exacerbated by soak dressings for burns or wounds• Often first manifested by sudden coagulopathy &

capillary bleeding• Always should not just measure temp. early, but also

continue to monitor core temp.• Can cause "masking" of pain from injuries

GOALS OF PREHOSPITAL TREATMNET

• Reduce further heat loss• Avoid ventricular arrhythmias-gentle handling of

patient • Modification of CPR• Restricted passive rewarming techniques

Hypothermia : Field Care

• Core Temperature < 28 0 C• Hold CPR if :

– No monitor available– Any patient movement observed– Respiratory rate 4 to 6 breaths / min.– Sinus bradycardia or atrial fib on monitor– Pulse present (even if slow)

• CPR if :– VF or asystole on monitor– Arrested and only mild hypothermia (320to 350C)

• IV Glucose or checking dextrostick should be routine (+/- naloxone)

Hypothermia : Rewarming

• Objective of rewarming :– Core temperature rise > 1 C per hour– If this cannot be achieved, then either more

aggressive rewarming measures need to be done, or the patient is dead & unresuscitatible

• Core Rewarming Techniques– Warmed O2 (420C) by FM or ETT– Warmed IV fluid (420C ) – Nasogastric tube lavage– Rectal tube lavage– Peritoneal dialysis catheter lavage– Chest tube lavage– Thoracotomy / mediastinal lavage– Cardiopulmonary bypass (fem-fem)

Hypothermia : External Rewarming Techniques

• Warm blankets ; cover scalp• Warm environment (heat the room or

ambulance)• Warm water bath• Axillary / groin hot packs

Disadvantages of Active External Rewarming as Sole Rewarming Technique

• May cause :– Core temp. "afterdrop"– May result in V-fib– Hypotension / cardiovascular collapse from peripheral

vasodilatation– Increased hypoxia & acidosis if peripheral metabolism

increases but the "cold" heart not yet able to compensate

Prevention of Hypothermia in Trauma Patients

• Warm the trauma resuscitation room– Should have separate thermostat from rest of E.D.– Limit personnel traffic in & out of room

• Heating lamps• Heating blanket

– Have in place before patient placed on stretcher

• Warm all IV fluids & blood• Cover patient's scalp once it is examined• Maintain coverage of patient's body with

blankets once exam is complete

General Prevention Measures for Exposure Hypothermia

• Adequate clothing in layers• Cover scalp• Avoid alcohol / sedatives• Limit wind exposure• Maintain fluid intake• Change wet clothes promptly• If getting wet is unavoidable, use wool garments (wool

maintains insulation effect even when wet, unlike cotton)• Trip planning• If immersed in cold water, extend survival time by

remaining still, huddling in group

Local cold injuries

• Frostbite –freezing cold injury• Nonfreezing cold injury

– Trenchfoot (immersion foot) : due to exposure to wet cold for 1 to 2 days; causes skin damage like partial thickness burns ; deep damage rare

– Chilblain (pernio) : due to prolonged exposure of limb to dry cold : small painful ulcers over exposed areas

– Frostnip

Frostbite : Pathophysiology

• Extracellular ice formation• Intracellular ice formation• Cell dehydration and shrinkage• Abnormal intracellular electrolytes• Thermal shock• Lipid-protein denaturation

Frostbite : Two Types

• Superficial : – skin is cold, pale, gray, bloodless, but pliable and soft

beneath the surface– 24 hours : large clear blisters– 2 to 7 days : skin blackens, demarcates (dry gangrene)– Several months : peels off, revealing sensitive new skin

• Deep : – tissue feels woody or stony– May include muscle, bone or tendon necrosis– Distal portions remain cold and cyanotic after rewarming– Risk of rhabdomyolysis

• Can diagnose these only prior to thawing

Frostbite : Clinical Presentation

• First degree– Erythema, yellowish plaque

• Second degree– Skin vesicles filled with clear or milky fluid

• Third degree– Skin vesicles filled with bloody fluid

• Fourth degree– Injury across dermis ; dysfunction and damage of deep

structures

Frostbite : Treatment

• Rapid rewarming in 420 C water (do not thaw in field if refreezing might occur)

• Narcotics• Tetanus prophylaxis• Topical antibiotics as for 2nd degree burns• No debridement surgery for at least several

months unless wet gangrene / infection occur• If large amounts of tissue involved, watch for

rhabdomyolysis / renal failure

EFFECTS OF ELECTRIC SHOCK

Electrical Current Flow Effect on Humans

• Alternating current has a tetanizing effect on muscles– "Let-go current" (the current level at which the person

is unable to release his grasp on the conductor) is 15 milliamps for men & 10 milliamps for women

• Strong sustained muscle contraction can cause fractures

• Can induce ventricular fibrrilation• Direct current (DC) felt as heat only & can cause

a single violent muscle contraction that can throw the victim from the power source

High Voltage Electrical Injuries: Pathology

• Causes coagulation necrosis of tissue along current path

• Points of maximum destruction are at skin entrance and exit sites

• May cause extensive muscle necrosis in limb or trunk beneath unburned skin

• May cause myocardial necrosis, peripheral nerve injuries, bowel wall necrosis

• Retrograde amnesia / confusion for several days common

High Voltage Electrical Injury: Complications

• Acute MI / arrhythmias• Respiratory arrest• Renal failure

– This is really an iatrogenic problem & should be preventable if sufficient resuscitation fluid is given

• Infections / sepsis• Peripheral neuropathy• Amputations• Cataracts

Lightning Injury : Types

• Direct strike – High morbidity (since head is hit)

• Splash current – On outside of body – Causes flame-like burns

• Ground current– May cause mass casualities from one strike– Arrhythmias or asystole predominate

Lightning Injury : Skin Injuries

• "Feathering" – Very common– Is superficial fern-like marks– Not a true skin burn– Disappear after a few days

• 2nd or 3rd degree burns– Usually due to clothing fire or contact with heated

metal

Lightning Injury : Cardiac Effects

• Depolarizes entire myocardium at once• Single systolic contraction ; leads to asystole • Then return of cardiac function (bradycardia)• If apnea however, leads to hypoxia, then

ventricular fibrillation• May show EKG changes -acute MI without

coronary artery occlusion• May have vasomotor spasm & prolonged arterial

vasoconstriction

• Loss of consciousness : 72 % of cases• Paralysis of respiratory center ; leads to apnea• Rarely : rapid cerebral edema and even

brainstem herniation• Transient motor paralysis : 70 %• Mechanical trauma : skull fracture, intracranial

hematomas

Lightning Injury : Neurologic Effects

Assessment and treatment

• Ensure your safety (confirm that the electric power is off)

• Perform ABC control - CPR if necessary.• Be carefull of any fractures (cervical spine!) • Assess and dress wounds, burns.

DROWING

Drowning : Definitions

• Drowning : death by suffocation after submersion in a liquid (pt. dies within 24 hours of submersion)

• Near drowning : survival (short or long term) following asphyxia secondary to submersion

• Secondary drowning (or delayed drowning or postimmersion syndrome) : death more than 24 hours post submersion from complications related to submersion (pulmonary injury, sepsis, renal failure, etc.)

Drowning : Salt Water Vs. Fresh Water : Features Common to Both

• Surfactant loss (washout vs. denatured)• Persistent hypoxemia due to intrapulmonary

shunt• Pulmonary edema• Focal lung hemorrhages• No major change in blood volume• No major change in serum electrolytes• No dysrhythmias (unless Vfib due to hypoxia or

hypothermia

Human Near-drowning Sequence

• Violent struggle to reach the surface• Period of calmness and apnea• Swallowing large amounts of fluid, followed by

vomiting• Gasping respirations and aspiration• Convulsions, coma, and death

Drowning : First Aid

• Start mouth to mouth ventilation while patient in water, with Sellick maneuver if possible

• Immobilize neck early if diving• Clear airway of debris• ? Heimlich maneuver (may cause emesis

& aspiration)• Do not rely on estimated submersion

time• O2 always, if available

Hypothermia and Drowning

• Rapid core cooling from aspiration and swallowing cold water

• BMR decreases to 50 % at 28 C• Children (large surface to weight

ratio) cool rapidly• Enhanced cooling from exercise or

alcohol (such as struggling or swimming)

WOUNDS

Classification Scheme for Wounds

• Abrasion : tangential, superficial injury to epidermis only• Simple laceration : linear, short length break in

epidermis• Deep laceration : penetrates to dermis +/- deeper

structures• Complex laceration : irregular edges (nonlinear), +/-

deep• Skin avulsion : complete removal of epidermal +/- dermal

tissue• Crush injury : vertical compression injury to epidermis &

dermis• Burns : thermal or chemical coagulation of epidermis /

dermis• Frostbite : freezing injury to epidermis / dermis• Infected : established microbial invasion of tissue• Wounds associated with other injuries : open fractures,

etc.

Types of wounds

Types of wounds

Surgical Wound Types Classification

• Type I : "Clean" ; usual infection risk 1 to 5 %• Type II : "Clean-contaminated" ; infection risk 5

to 10 %• Type III : "Contaminated" ; infection risk 10 to

15 %• Type IV : "Dirty" ; infection risk 30 to 50 %

Objectives of Wound Care

• Lessen pain• Stop bleeding• Prevent infection• Control if underlying structures are damaged• Enhance healing• Achieve best cosmetics

Sequence of Steps for Routine Wound Care

1. Adequately expose the wound area.

2. Remove superficial contaminants (gravel, etc.).− leave deeply imbedded objects in place for removal in O.R.

3. Cleanse around the wound.− most cleansing agents damage exposed deep tissues.

4. Consider local hair removal.− usually do not need to remove hair (can just slick it down with

betadine or K-Y jelly).

5. Irrigate the wound : the most important step for reducing bacterial counts in the wound.

6. Dress and bandage the wound.7.Use cold packs to reduce swelling and bleeding.

Amputation

• Amputated part should be carefuly rinsed with sterile saline or water, wrapped in sterile gauze and placed in a plastic bag and transported on ice

Further Wound Care

• Don't forget to consider tetanus immunization for all wounds

• Consider antibiotics for :– Bite wounds– Contaminated wounds– Hand or foot wounds– If delayed presentation– Wound already infected– Risk factors for infection ( diabetes, chronic steroids,

immunosuppressed, malnutrition, PVD, age > 70)

Burns

can be caused by:• thermal (heat) injury

– burns – dry heat (flames)– scalds – wet heat: hot liquids and vapour

• chemical injury (corrosive substances)• electrical injury• radiation injury (X-rays, sun)

Classification and assessment of burns

• Depth of the burn• Extent of the burn• Location of the burn• Complicating factors (age, respiratory

involvement, associated medical or traumatic conditions)

Depth of burns

• Superficial burns (1st degree)– involve only the outer layer of the skin– redness, swelling, tendreness, pain– examples: mild sunburn, scald produced by a splash of

hot liquid– heal well if prompt first aid is given– do not require medical attention unless exstensive

• Partial – thickness burns – 2nd degree– the skin looks raw with blisters formation– heal well but > 50% of the body surface can be fatal

• Full thickness burns – 3rd degree– all layers of the skin are burned– affected nerves, muscles and fat– the skin may appear pale, waxy, charred– any size of that type need medical attention as quickly

as possible

EXTENT OF BURNS

The area of burn gives an approximate indication of the degree of shock that will develop.

• any II0 burn of 1% bs (area of patient hand) must be seen by doctor

• II0 burn of 9% bs or more can cause shock

• every III0 burn of any size requires hospital treatment

Location of burns

Burns to the special areas are more critical:• the face – often accompanied by respiratory

tract involvement, possibility of oedema• the perineum and genitalia – prone to infection

as a result of contamination from fecal bacteria• the feet and hands – special handling to avoid

contractures and scarring that will restrict future function

Complicating factors

• inhalation injuries – damage to the airways and lung themselves

• age of the patient – adults > 55 y. and children < 5 y. are considered at increased risk

• associated conditions – preexisting disorders (lungs, heart, diabetes)

• Effect of toxic gases (carbon monoxide)

Treatment of burns

• stop the burning process + cooling (cold water for at least 10 minutes)

• remove the patient from the smoky environment

• provide supplemental oxygen (reversing the effects of carbon monoxide)

• treat the patient for shock• the blisters should be left intact (barrier to

infection)• prevent infection – use non-fluffy material for

dressing – kitchen film, clean plastic bag• transport the patient to the appropriate facility

Burns

CHEMICAL• the signs of chemical burns develop slowly.• DO NOT delay starting treatment by searching

for an antidote.• flood the affected area with water to disperse

the chemical and stop the burning process (> 20 min.)

SUNBURN• place the casualty in the shade, cool by cold

water, give cold water to drink, administer aspirin

Electrical burns

• electricity transvering the body is converted to heat that burns the tissues in its path

• death can result from passage of currnet through vital organs

• electrical current passing through the body follows an internal path of least resistance (skin, bones > muscles > vessels and nerves)

• current can enter and exit at relatively small surface areas

BLEEDING

Types of bleeding Internal

External

• arterial - pulsing, strong, haemorrhagic shock can occur

• venous - depends on the size of vein, serious from varicose veins

• capillary - not very intensive, from the surface of the skin, depends on what the surface is

Effects of bleeding

• Hypovolemia → hypovolemic shock • Loss of blood cells (anemia)• Loss of platelets and clotting factors

Methods of bleeding control

• Direct pressure• Elevation• Presure points• tourniquet

Severe external bleeding

• raise and support the injured limb over the level of the casualty’s heart

• apply direct pressure over the wound with your fingers or palm over a sterile dressing or clean pad (min. 10 minutes)

• living a pad apply sterile dressing and bandage firmly but not so tightly to impede the circulation

INDIRECT PRESSURE

PESSURE POINTS

• the place where the main artery runs close to the bone.

• Pressure at these points will cut the blood supply to the limb.

• It must be applied for longer than 10 minutes.

• tourniquet as a last resort

• It can make the bleeding worse and can result in tissue damage and gangrene.

Internal bleeding

• pallor, cold and clammy skin, rapid and weak pulse, thirst, pain

• Your aims are: to arrange urgent removal to hospital, to minimise shock

1. Help the casualty to lie down, and raise and support his legs.

2. Dial 999 or 112(mobile phone) for an ambulance. Insulate the casualty from cold. Check and record breathing, pulse, and level of response every 10 minutes.

3. Note the type, amount and source of any blood loss from body orifices. If possible, send a sample with casualty to hospital.

DRESSING & BANDAGING

Dressing & Bandage

• Dressing : – the covering immediately next to the wound

surface

• Bandage : – the material holding the dressing in place

Choices for Wound Dressings

• Dry gauze : suitable for most wounds or if steri-strips used

• Nonadherent dressings : preferred for abrasions, nailbed injuries, skin flaps, or thin skinned elderly

• Can use clear dressings like Op-site for some wounds

• Duoderm commercial dressing also useful for covering some types of chronic open wounds

GENERAL RULES FOR BANDAGING

Before applying bandages:

• Explain to the casualty what are you going to do, and keep reassuring him.

• Make the casualty comfortable, in sitting or lying position, if possible.

• Keep the injured part supported. The casualty may be able to do this for you.

• Always work in front of the casualty, and from the injured site where possible

When applying bandages:

• Apply bandages firmly enough to control any bleeding and hold a dressing in place, but not so tightly as to impede the circulation.

• Leave fingers and toes on a bandaged limb exposed, if possible, so that you can check the circulation afterwards.

• Ensure knots do not hurt the casualty, do not knot over bony areas.

Recognition of impaired circulation

• Pale, cold skin on the hand or foot• Later, a dusky gray/blue appearance to the skin• Tingling or numbness• Inability to move the affected part

Checking for impaired circulation

• Press one of the nails, or the skin of the hand or foot, until its pale. On releasing the pressure, the color should quickly return. If the nail-bed or skin remains pale, the bandage is too tight.

When bandaging to immobilize a limb

• Make sure there is padding between the limb and body, or between the legs, especially around the joints. Use towels, cotton wool, or folded clothing, and insert the padding before tying the bandages.

• Tie knots at the front of the body on the uninjured side, avoiding bony areas. If both sides of the body are injured, tie knots in the middle of the body.

Scalp bandage

• apply gentle pressure to the wound with a flat hand

• begin the head bandage by anchoring the bandage below the occipital protuberance

• circle the head completely once or twice

• begin to traverse the bandage back and forth across the top of the head until the area with dressing is completely covered

• secure the bandage in place by circling the head once or twice and taping the bandage in place

Slings

Slings can be made from triangular bandages, or any square metre of strong cloth, cut or folded diagonally. There are two different types of slings:

• arm slings are used to support injured arms or wrists, or to take the weight of the arm off a dislocated shoulder.

• elevation slings are used to support the arm in cases of collar bone or shoulder injuries. They can also be used in cases of hand injuries, as they help to control bleeding and reduce swelling because the hand is raised then.

Elbow and knee bandage

1. Support the injured arm in a semi-flexed position. If this is not possible, support the arm in the position most comfortable for the casualty.

2. Place the tail of the bandage on the inside of the elbow, and pass the bandage around the elbow 11/2 times, so that the elbow joint is covered.

3. Take the head of the bandage above the elbow to the upper arm, and make one turn, covering half of the bandage from the first turn. Take the head of the bandage under the elbow to just below the joint, and make one turn around the lower arm, covering half of the first straight turn.

4. Continue to alternate these turns, steadily extending the bandaging by covering only between half and two-thirds of the previous layer each time. Make two straight turns to finish off, and secure the end.

Hand and foot bandage1. Support the casualty’s arm. Place the tail of the bandage on

the inside of the wrist, at the base of the thumb, and make two straight turns.

2. Take the bandage diagonally across the back of the casualty’s hand, so that the edge meets the base of the nail of the little finger.

3. Take the bandage under and around the fingers, and up at the forefinger (so that the edge is at the base of the nail of the forefinger).

4. Take the bandage diagonally across the back of the hand to the wrist, and then around the wrist and up. Repeat the sequence of turns, covering three-quarters of the bandage from the previous turn each time. Work towards the wrist, leaving the thumb free.

5. When the whole hand is covered, make two straight turns at the wrist and secure the bandage.

Improvised slings

• If the casualty is wearing a jacket, undo it, and turn the hem of the jacket up and over the injured arm, and pin it to the jacket breast

• If the casualty is wearing a button-up coat, jacket or waistcoat, you can undo a button and place the hand of the injured arm inside the fastening.

• Pin the casualty’s sleeve to the opposite breast of her shirt or jacket. For an improvised elevation sling, pin the sleeve further up at the shoulder.

• You can use a belt, a tie, or a pair of braces or tights to make a „collar-and-cuff” support. Do not use this method if you suspect that the forearm is broken.

Bites and stings

General rules

• All bites are very vulnerable to infection – disinfect and cover the wound with the sterile pad

• Control bleeding• Rabies – potentially fatal viral infection of the

CNS – catch or identify the animal for further observation; if the animal cannot be found, a patient requires a course of anti-rabies injections

Insects stings

• Bee, wasp, hornet stings

• Not dangerous unless a patient is allergic (anaphylactic shock), or a sting is in region of upper airways (mouth or throat)

Bites

• Tick bites -Lyme disease or other CNS infections (acute meningitis)

• Spiders or marine creatures – anaphylactic shock and/or toxic reaction

Snake bites

• Pit viper can be distinguished from the non-poisonous snakes by their elliptical pupils, the pit (heat sensor) between the eyes and nostril, fangs and the single row of plates on the tail, and the triangular head

Snake bites

• Venomous snakes in the US: pit viper (rattle snake, cottonmouth, copperhead) and coral snake

• The venom of the pit viper causes local necrosis – symptoms: swelling, pain, redness at the site, in severe cases systemic effects occur and death may result

Snake bites

Treating a snake bite:• Have the victim rest; remove jewellery and

immobilize the extremity with a splint as you would for a fracture

• If swelling is present, make a small mark at its edge so that any changes are evident on later evaluation

• Transport the victim to the closest hospital that is able to care for the snake bites – antivenom administration

Snake bites

• If possible, bring the dead snake (or have it brought) to the hospital for identification, but do not handle it directly, not even decapitated head, since reflex actions of the snake can cause envenomation

• If coral snake bite suspected – application of an elastic bandage above and around the bite side to slow systemic absorption until antivenom can be given

Anaphylactic shockallergic emergency

• Severe allergic reaction to a drug, vaccine,food,toxin,plant venom or other antigen

• Acute multisystem allergic response mediated by immunoglobuline IgE

• Occurs immedietly-in seconds to minutes-after contact with an antigen

Pathophysiology of anaphylactic shock

• Exposure to an allergen(antigen)

• Performed IgE antibody activated in response to same allergen

• Its intreaction with mast cells and basofils

• Release of inflamatory,anaphylactic mediators and vasoactive substances

Characteristic of anaphylactic shock

• Venodilatation

• Systemic vasodilatation

• Increased capillary permeability-capillary leak,intravascular volume depletion,relative hypovolemia

• Pulmonary vasoconstriction

• Increased right ventricular afterload

• Fall in cardiac output

Signs and symptoms of anapfylactic shock

• Anxiety or agitation • Skin rash or hives• Burning or itching of the skin• Nausea and vomiting • Angioedema-svelling of the

face,neck,lips,tongue or respiratory passages• Respiratory difficulties(distress) with stridor or

wheezing• Weak pulse-hypotension,tachycardia• Loss of consciousness

Clinical signs of allergic airway obstruction

• Tachypnea

• Increased inspiratory/respiratory effort-upper airway angioedema,bronchoconstriction

• Change in voice –eg.hoarseness

• Stridor (usually inspiratory but may be biphasic)

• Poor chest rise

• Poor air entry on auscultation

Management of anaphylactic shock

• Treatment of livethreatening cardiorespiratory problems• Reverse or blokade of the mediators released as part of

the uncontrolled allergic respone• Remove source of reaction if possible• Control victims upper respiratory ways,provide oxygen • If hypowolemia,hypotension is present place in

Trendelenburg position as tolerated• Rapidly administer pharmacologic support• Epinephrine-drug of choice- 0,01mg/kg -0,5-0,7 mg in

adult use autoinjector or draw up appropiate dose and give im,iv depending on severity of symptoms-can stop release of histamin and other allergic mediators

Management of anaphylactic shock

• Epinephrine:• alpha agonist effects-vasoconstiction,decreased vascular

permeability stop of angioedema• beta agonist effects-bronchodilatation,cardiac inotropy,stabilisation

mast cell membrane.• Epinephrine-an infusion-0,3ug/kg/min titrate as needed-with severe

anaphylaxis and refractory hypotension• Start fluid resuscitation to restore blood volume and blood presurre-

give iv 20ml/kg bolus NS or LR• Administer diphenhydramine (H1 blokers) and H2 blokers• If stridor or wheezing is present albuterol(beta 2 agonists aerosol)

by metered dose inhaler or nebuliser• Administer methyloprednisolon or equivalent corticosteroid• Start CPA if cardiac arrest,call forEMS

Treatment of Allergic Reactions from Insects Stings

ƒ If local reaction only :–Ice pack, pain med, diphenhydramine PO–Watch at least 30 minutes to be sure systemic reaction does not occur

ƒ If systemic reaction :–O2, epi, IV fluid bolus, IV diphenhydramine, IV steroids, observe at least 4 hours

ƒ For both types :–Check sting site & remove stinger if imbedded (scrape, don't squeeze), update tetanus, consider antibiotic if ? cellulitis