Chapter 1

BEFORE GIVING CARE AND CHECKING AN INJURED OR ILL PERSON

LESSON OBJECTIVES:
1. Describe how to recognize an emergency.
2. Describe how to prioritize care for injuries and sudden illnesses.
3. Describe the purpose of Good Samaritan laws.
4. Identify the difference between (expressed) consent and implied consent.
5. Identify how to reduce the risk of disease transmission when giving care.
6. Explain how to activate and work with the EMS system.
7. Explain when to move an injured or ill person from a dangerous scene.
8. Explain how to check a conscious person for life-threatening and non-life-threatening
conditions.
9. Identify the signals of shock.
10. Describe how to minimize the effects of shock.
11. Demonstrate how to check an unconscious person for life-threatening conditions.

INTRODUCTION

Medical emergencies can happen every day, in any setting. People are injured in situations like
falls or motor-vehicle accidents, or they develop sudden illnesses, such as heart attack or stroke.
The statistics are sobering. For example, about 900,000 people in the United States die e ach year
from some form of heart disease. More than 300,000 of these deaths are caused by sudden
cardiac arrest. Heart disease is the number one cause of death in this country.
Given the large number of injuries and sudden illnesses that occur in the United States each year,
it is possible that you might have to deal with an emergency situation someday. If you do, you
should know who and when to call, what care to give and how to give that care until emergency
medical help takes over.
This chapter discusses your role in the emergency medical services (EMS) system, the purpose
of Good Samaritan laws, how to gain consent from an injured or ill person and how to reduce your
risk of disease transmission while giving care.
In addition, you will read about the emergency action steps, CHECK—CALL—CARE, which guide
you on how to check and give emergency care for an injured or suddenly ill person. You also will
read about the effects of incident stress and how to identify the signals of shock and minimize its
effects.
YOUR ROLE IN THE EMS SYSTEM
You play a major role in making the EMS system work effectively. The EMS system is a network
of community resources, including police, fi re and medical personnel—and you.
The system begins when someone like you recognizes that an emergency exists and decides to
take action, such as calling 9-1-1 or the local emergency number for help. The EMS dispatcher
or call taker answers the call and uses the information that you give to determine what help is
needed. Emergency personnel are dispatched to the scene based on the information given.
These personnel then give care at the scene and transport the injured or ill person to the hospital
where emergency department staff and other professionals take over.
Early arrival of emergency personnel increases a person’s chance of surviving a life-threatening
emergency. Calling 9-1-1 or the local emergency number is the most important action that you
can take.
Your role in the EMS system includes four basic steps:
Step 1: Recognize that an emergency exists.
Step 2: Decide to act.
Step 3: Activate the EMS system.
Step 4: Give care until help takes over.

STEP 1: RECOGNIZE THAT AN EMERGENCY EXISTS

Emergencies can happen to anyone, anywhere. Before you can give help, however, you must be
able to recognize an emergency. You may realize that an emergency has occurred only if you
become aware of unusual noises, sights, odors and appearances or behaviors . Examples include
the following:
 Unusual noises
o Screaming, moaning, yelling or calls for help
o Breaking glass, crashing metal or screeching tires
o A change in the sound made by machinery or equipment Sudden, loud noises,
such as the sound of collapsing buildings or falling ladders
o Unusual silence

 Unusual sights
o A stopped vehicle on the roadside or a car that has run off of the road
o Downed electrical wires
o A person lying motionless
o Spilled medication or empty container
o An overturned pot in the kitchen
o Sparks, smoke or fire

 Unusual odors
o Odors that are stronger than usual
o Unrecognizable odors
o Inappropriate odors

 Unusual appearances or behaviors

o Unconsciousness
o Confusion, drowsiness or unusual behavior
o Trouble breathing
o Sudden collapse, slip or fall
o Clutching the chest or throat A person doubled over in pain
o Slurred, confused or hesitant speech
o Sweating for no apparent reason
o Uncharacteristic skin color
o Inability to move a body part
STEP 2: DECIDE TO ACT

Once you recognize that an emergency has occurred, you must decide how to help and what to
do. There are many ways you can help in an emergency, but in order to help, you must act.
Overcoming Barriers to Act

Being faced with an emergency may bring out mixed feelings. While wanting to help, you also
may feel hesitant or may want to back away from the situation. These feelings are personal and
real.

Sometimes, even though people recognize that an emergency has occurred, they fail to act.
The most common factors that keep people from responding are:
 Panic or fear of doing something wrong
 Being unsure of the person’s condition and what to do
 Assuming someone else will take action
 Type of injury or illness
 Fear of catching a disease
 Fear of being sued
 Being unsure of when to call 9-1-1 or the local emergency number

PANIC OR FEAR OF DOING SOMETHING WRONG

People react differently in emergencies. Some people are afraid of doing the wrong thing and
making matters worse. Sometimes people simply panic. Knowing what to do in an emergency
can instill confidence that can help you to avoid panic and be able to provide the right care. If you
are not sure what to do, call 9-1-1 or the local emergency number and follow the instructions of
the EMS dispatcher or call taker. The worst thing to do is nothing.

BEING UNSURE OF THE PERSON’S CONDITION AND WHAT TO DO

Because most emergencies happen in or near the home, you are more likely to find yourself giving
care to a family member or a friend than to someone you do not know. However, you may be
faced with an emergency situation involving a stranger, and you might f eel uneasy about helping
someone whom you do not know. For example, the person may be much older or much younger
than you, be of a different gender or race, have a disabling condition, be of a different status at
work or be the victim of a crime.

Sometimes, people who have been injured or become suddenly ill may act strangely or be
uncooperative. The injury or illness; stress; or other factors, such as the effects of drugs, alcohol
or medications, may make people unpleasant or angry. Do not take this behavior personally. If
you feel at all threatened by the person’s behavior, leave the immediate area and call 9 -1-1 or the
local emergency number for help.

ASSUMING SOMEONE ELSE WILL TAKE ACTION

If several people are standing around, it might not be easy to tell if anyone is giving care. Always
ask if you can help. Just because there is a crowd does not mean someone is caring for the
injured or ill person. In fact, you may be the only one on the scene who knows first aid.
Although you may feel embarrassed about coming forward in front of other people, this should
not stop you from offering help. Someone has to take action in an emergency, and it may have to
be you.

If others already are giving care, ask if you can help. If bystanders do not appear to be helping,
tell them how to help. You can ask them to call 9-1-1 or the local emergency number, meet the
ambulance and direct it to your location, keep the area free of onlookers and traffic, send them
for blankets or other supplies such as a first aid kit or an automated external defibrillator (AED),
or help to give care.

THE TYPE OF INJURY OR ILLNESS

An injury or illness sometimes may be very unpleasant. Blood, vomit, bad odors, deformed body
parts, or torn or burned skin can be very upsetting. You may have to turn away for a moment and
take a few deep breaths to get control of your feelings before you can give care. If you still are
unable to give care, you can help in other ways, such as volunteering to call 9 -1-1 or the local
emergency number.

FEAR OF CATCHING A DISEASE

Many people worry about the possibility of being infected with a disease while giving care.
Although it is possible for diseases to be transmitted in a first aid situation, it is extremely unlikely
that you will catch a disease this way. (For more information on disease transmission, see the
Disease Transmission section in this chapter.)

FEAR OF BEING SUED

Sometimes people worry that they might be sued for giving care. In fact, lawsuits against people
who give emergency care at a scene of an accident are highly unusual and rarely successful.

Good Samaritan Laws The vast majority of states and the District of Columbia have Good
Samaritan laws that protect people against claims of negligence when they give emergency care
in good faith without accepting anything in return. Good Samaritan laws usually protect citizens
who act the same way that a “reasonable and prudent person” would if that person were in the
same situation.

For example, a reasonable and prudent person would:

 Move a person only if the person’s life were in danger.
 Ask a conscious person for permission, also called consent, before giving care.
 Check the person for life-threatening conditions before giving further care.
 Call 9-1-1 or the local emergency number.
 Continue to give care until more highly trained personnel take over.

Good Samaritan laws were developed to encourage people to help others in emergency
situations. They require the “Good Samaritan” to use common sense and a reasonable level of
skill and to give only the type of emergency care for which he or she is trained. They assume
each person would do his or her best to save a life or prevent further injury.

Non-professionals who respond to emergencies, also called “lay responders,” rarely are sued
for helping in an emergency. Good Samaritan laws protect the responder from financial
responsibility. In cases in which a lay responder’s actions were deliberately negligent or reckless
or when the responder abandoned the person after starting care, the courts have ruled Good
Samaritan laws do not protect the responder.

For more information about your state’s Good Samaritan laws, contact a legal professional or
check with your local library.

BEING UNSURE WHEN TO CALL 9-1-1

People sometimes are afraid to call 9-1-1 or the local emergency number because they are not
sure that the situation is a real emergency and do not want to waste the time of the EMS
personnel.

Your decision to act in an emergency should be guided by your own val ues and by your
knowledge of the risks that may be present. However, even if you decide not to give care, you
should at least call 9-1-1 or the local emergency number to get emergency medical help to the
scene.

STEP 3: ACTIVATE THE EMS SYSTEM

Activating the EMS system by calling 9-1-1 or the local emergency number is the most important
step you can take in an emergency. Remember, some facilities, such as hotels, office and
university buildings, and some stores, require you to dial a 9 or some other number to get an
outside line before you dial 9-1-1.

Also, a few areas still are without access to a 9-1-1 system and use a local emergency number
instead. Becoming familiar with your local system is important because the rapid arrival of
emergency medical help greatly increases a person’s chance of surviving a life-threatening
emergency.

When your call is answered, an emergency call taker (or dispatcher) will ask for your phone
number, address, location of the emergency and questions to determine whether you need police,
fire or medical assistance.

You should not hang up before the call taker does so. Once EMS personnel are on the way, the
call taker may stay on the line and continue to talk with you. Many call takers also are trained to
give first aid instructions so they can assist you with life-saving techniques until EMS personnel
take over.

STEP 4: GIVE CARE UNTIL HELP TAKES OVER

This manual and the American Red Cross First Aid/ CPR/AED courses provide you with the
confidence, knowledge and skills you need to give care to a person in an emergency medical
situation.

In general, you should give the appropriate care to an ill or injured person until: You see an
obvious sign of life, such as
 breathing.
 Another trained responder or EMS personnel take over.
 You are too exhausted to continue.
 The scene becomes unsafe.
If you are prepared for unforeseen emergencies, you can help to ensure that care begins as soon
as possible for yourself, your family and your fellow citizens. If you are trained in first aid, you can
give help that can save a life in the first few minutes of an emergency. First aid can be the
difference between life and death. Often, it makes the difference between complete recovery and
permanent disability. By knowing what to do and acting on that knowledge, you can make a
difference.

GETTING PERMISSION TO GIVE CARE

People have a basic right to decide what can and cannot be done to their bodies. They have the
legal right to accept or refuse emergency care. Therefore, before giving care to an injured or ill
person, you must obtain the person’s permission.

To get permission from a conscious person, you must first tell the person who you are, how much
training you have (such as training in first aid, CPR and/or AED), what you think is wrong and
what you plan to do. You also must ask if you may give care. When a conscious person who
understands your questions and what you plan to do gives you permission to give care, this is
called expressed consent. Do not touch or give care to a conscious person who refuses it. If the
person refuses care or withdraws consent at any time, step back and call for more advanced
medical personnel.

Sometimes, adults may not be able to give expressed consent. This includes people who are
unconscious or unable to respond, confused, mentally impaired, seriously injured or seriously ill.
In these cases, the law assumes that if the person could respond, he or she would agree to care.
This is called implied consent.

If the conscious person is a child or an infant, permission to give care must be obtained from a
parent or guardian when one is available. If the condition is life threatening, permission—or
consent—is implied if a parent or guardian is not present. If the parent or guardian is present but
does not give consent, do not give care. Instead, call 9-1-1 or the local emergency number.

DISEASE TRANSMISSION AND PREVENTION

Infectious diseases—those that can spread from one person to another—develop when germs
invade the body and cause illness.

How Disease Spreads

The most common germs are bacteria and viruses. Bacteria can live outside of the body and do
not depend on other organisms for life. The number of bacteria that infect humans is small, but
some cause serious infections. These can be treated with medications called antibiotics.

Viruses depend on other organisms to live. Once in the body, it is hard to stop their progression.
Few medications can fight viruses. The body’s immune system is its number one protection
against infection.

Bacteria and viruses spread from one person to another through direct or indirect contact. Direct
contact occurs when germs from the person’s blood or other body fluids pass directly into your
body through breaks or cuts in your skin or through the lining of your mouth, nose or eyes.
Some diseases, such as the common cold, are transmitted by droplets in the air we breathe. They
can be passed on through indirect contact with shared objects like spoons, doorknobs and
pencils that have been exposed to the droplets. Fortunately, exposure to these germs usually is
not adequate for diseases to be transmitted.

Animals, including humans and insects, also can spread some diseases through bites.
Contracting a disease from a bite is rare in any situation and uncommon when giving first aid care.

Some diseases are spread more easily than others. Some of these, like the fl u, can create
discomfort but often are temporary and usually not serious for healthy adults.

Other germs can be more serious, such as the Hepatitis B virus (HBV), Hepatitis C virus (HCV)
and Human Immunodeficiency Virus (HIV), which causes Acquired Immune Deficiency Syndrome
(AIDS) (see HIV and AIDS box in this chapter). Although serious, they are not easily transmitted
and are not spread by casual contact, such as shaking hands. The primary way to transmit HBV,
HCV or HIV during first aid care is through blood-to-blood contact.

Preventing Disease Transmission

By following some basic guidelines, you can greatly decrease your risk of getting or transmitting
an infectious disease while giving care or cleaning up a blood spill.

While Giving Care

To prevent disease transmission when giving care, follow what are known as
standard precautions:

 Avoid contact with blood and other body fluids or objects that may be soiled with blood
and other body fluids. Use protective CPR breathing barriers.
 Use barriers, such as disposable gloves, between the person’s blood or body fluids and
yourself.
 Before putting on personal protective equipment (PPE), such as disposable gloves,
cover any of your own cuts, scrapes or sores with a bandage.
 Do not eat, drink or touch your mouth, nose or eyes when giving care or before you wash
your hands after care has been given.
 Avoid handling any of your personal items, such as pens or combs, while giving care or
before you wash your hands.
 Do not touch objects that may be soiled with blood or other body fluids.
 Be prepared by having a first aid kit handy and stocked with PPE, such as disposable
gloves, CPR breathing barriers, eye protection and other supplies.
 Wash your hands thoroughly with soap and warm running water when you have finished
giving care, even if you wore disposable gloves. Alcohol-based hand sanitizers allow
you to clean your hands when soap and water are not readily available and your hands
are not visibly soiled. (Keep alcohol-based hand sanitizers out of reach of children.)
 Tell EMS personnel at the scene or your health care provider if you have come into
contact with an injured or ill person’s body fluids.
 If an exposure occurs in a workplace setting, follow your company’s exposure control
plan for reporting incidents and follow-up (post-exposure) evaluation.
While Cleaning Up Blood Spills

To prevent disease transmission while cleaning up a blood spill:

 Clean up the spill immediately or as soon as possible after the spill occurs (Fig. 1 -3).
 Use disposable gloves and other PPE when cleaning spills.
 Wipe up the spill with paper towels or other absorbent material.
 If the spill is mixed with sharp objects, such as broken glass or needles, do not pick
these up with your hands. Use tongs, a broom and dustpan or two pieces of cardboard
to scoop up the sharp objects.
 After the area has been wiped up, flood the area with an appropriate disinfectant, such
as a solution of approximately 11⁄2 cups of liquid chlorine bleach to 1 gallon of fresh
water (1part bleach per 9 parts water), and allow it to stand for at least 10 minutes.
 Dispose of the contaminated material used to clean up the spill in a labeled biohazard
container.
 Contact your worksite safety representative or your local health department regarding
the proper disposal of potentially infectious material. For more information on
preventing disease transmission, visit the federal Occupational Safety and Health
administration: http://www.osha.gov/SLTC/bloodbornepathogens/ index.html.

TAKING ACTION: EMERGENCY ACTION STEPS

In any emergency situation, follow the emergency action steps:

1. CHECK the scene and the person.
2. CALL 9-1-1 or the local emergency number.
3. CARE for the person.

CHECK

Before you can help an injured or ill person, make sure that the scene is safe for you and any
bystanders (Fig. 1-4).

Look the scene over and try to answer these questions:

 Is immediate danger involved?
 What happened?
 How many people are involved?
 Is anyone else available to help?
 What is wrong?

Is It Safe?

Check for anything unsafe, such as spilled chemicals, traffic, fire, escaping steam, downed
electrical lines, smoke or extreme weather. Avoid going into confined areas with no ventilation or
fresh air, places where there might be poisonous gas, collapsed structures, or places where
natural gas, propane or other substances could explode. Such areas should be entered by
responders who have special training and equipment, such as respirators and self -contained
breathing apparatus.

If these or other dangers threaten, stay at a safe distance and call 9-1-1 or the local emergency
number immediately. If the scene still is unsafe after you call, do not enter. Dead or injured heroes
are no help to anyone! Leave dangerous situations to professionals like firefighters and police.
Once they make the scene safe, you can offer to help.
Is Immediate Danger Involved?

Do not move a seriously injured person unless there is an immediate danger, such as fire, flood
or poisonous gas; you have to reach another person who may have a more serious injury or
illness; or you need to move the injured person to give proper care and you are able to do so
without putting yourself in danger from the fire, flood or poisonous gas. If you must move the
person, do it as quickly and carefully as possible. If there is no danger, tell the person not to move.
Tell any bystanders not to move the person.
What Happened?

Look for clues to what caused the emergency and how the person might be injured. Nearby
objects, such as a fallen ladder, broken glass or a spilled bottle of medicine, may give you
information. Your check of the scene may be the only way to tell what happened.

If the injured or ill person is a child, keep in mind that he or she may have been moved by well-
meaning adults. Be sure to ask about this when you are checking out what happened. If you find
that a child has been moved, ask the adult where the child was and how he or she was found.

How Many People Are Involved?

Look carefully for more than one person. You might not spot everyone at first. If one person is
bleeding or screaming, you might not notice an unconscious person. It also is easy to overlook a
small child or an infant. In an emergency with more than one injured or ill person, you may need
to prioritize care (in other words, decide who needs help first).

Is Anyone Else Available to Help?

You already have learned that the presence of bystanders does not mean that a person is
receiving help. You may have to ask them to help. Bystanders may be able to tell you what
happened or make the call for help while you provide care. If a family member, friend or co -worker
is present, he or she may know if the person is ill or has a medical condition.

The injured or ill person may be too upset to answer your questions. Anyone who awakens after
having been unconscious also may be frightened. Bystanders can help to comfort the person and
others at the scene. A child may be especially frightened. Parents or guardians who are present
may be able to calm a frightened child. They also can tell you if a child has a medical condition.

What Is Wrong?

When you reach the person, try to find out what is wrong. Look for signals that may indicate a life-
threatening emergency. First, check to see if the injured or ill person is conscious (Fig. 1-5).
Sometimes this is obvious. The person may be able to speak to you. He or she may be moaning,
crying, making some other noise or moving around. If the person is conscious, reassure him or
her and try to find out what happened.

If the person is lying on the ground, silent and not moving, he or she may be unconscious. If you
are not sure whether someone is unconscious, tap him or her on the shoulder and ask if he or
she is OK. Use the person’s name if you know it. Speak loudly. If you are not sure whether an
infant is unconscious, check by tapping the infant’s shoulders and shouting or flicking the bottom
of the infant’s foot to see if the infant responds.
Unconsciousness is a life-threatening emergency. If the person does not respond to you in any
way, assume that he or she is unconscious. Make sure that someone calls 9 -1-1 or the local
emergency number right away.

For purposes of first aid, an adult is defined as someone about age 12 (adolescent) or older;
someone between the ages of 1 and 12 is considered to be a child; and an infant is someone
younger than 1 year. When using an AED, a child is considered to be someone between the ages
of 1 and 8 years or weighing less than 55 pounds.

Look for other signals of life-threatening injuries including trouble breathing, the absence of
breathing or breathing that is not normal, and/or severe bleeding.

While you are checking the person, use your senses of sight, smell and hearing. They will help
you to notice anything abnormal. For example, you may notice an unusual smell that could be
caused by a poison. You may see a bruise or a twisted arm or leg. You may hear the person say
something that explains how he or she was injured.

Checking Children and the Elderly

Keep in mind that it is often helpful to take a slightly different approach when you check and care
for children, infants and elderly people in an emergency situation. For more information on
checking and caring for children, infants, the elderly and others with special needs, see
Chapter 9.

Identifying Life-Threatening Conditions

At times you may be unsure if advanced medical personnel are needed. Your first aid training will
help you to make this decision. The most important step you can take when giving care to a
person who is unconscious or has some other life-threatening condition is to call for emergency
medical help. With a life-threatening condition, the survival of a person often depends on both
emergency medical help and the care you can give. You will have to use your best judgment—
based on the situation, your assessment of the injured or ill person, information gained from this
course and other training you may have received—to make the decision to call. When in doubt,
and you think a lif e-threatening condition is present, make the call.

CALL

Calling 9-1-1 or the local emergency number for help often is the most important action you can
take to help an injured or ill person (Fig. 1-6). It will send emergency medical help on its way as
fast as possible. Make the call quickly and return to the person. If possible, ask someone else to
make the call.

As a general rule, call 9-1-1 or the local emergency number if the person has any of the following
conditions:
 Unconsciousness or an altered level of consciousness (LOC), such as drowsiness or
confusion
 Breathing problems (trouble breathing or no breathing)
 Chest pain, discomfort or pressure lasting more than a few minutes that goes away and
comes back or that radiates to the shoulder, arm, neck, jaw, stomach or back
 Persistent abdominal pain or pressure Severe external bleeding (bleeding that spurts
or gushes steadily from a wound)
  Vomiting blood or passing blood
 Severe (critical) burns
 Suspected poisoning
 Seizures
 Stroke (sudden weakness on one side of the face/ facial droop, sudden weakness on
one side of the body, sudden slurred speech or trouble getting words out or a sudden,
severe headache)
 Suspected or obvious injuries to the head, neck or spine
 Painful, swollen, deformed areas (suspected broken bone) or an open fracture

Also call 9-1-1 or the local emergency number immediately for any of these situations:
 Fire or explosion
 Downed electrical wires
 Swiftly moving or rapidly rising water
 Presence of poisonous gas
 Serious motor-vehicle collisions
 Injured or ill persons who cannot be moved easily

Deciding to Call First or Care First

If you are ALONE:
 Call First (call 9-1-1 or the local emergency number before giving care) for:
o Any adult or child about 12 years of age or older who is unconscious.
o A child or an infant who you witnessed suddenly collapse.
o An unconscious child or infant known to have heart problems.

 Care First (give 2 minutes of care, then call 9-1-1 or the local emergency number) for:
o An unconscious child (younger than about 12 years of age) who you did not see
collapse.
o Any drowning victim.

Call First situations are likely to be cardiac emergencies, where time is a critical factor. In Care
First situations, the conditions often are related to breathing emergencies.

CARE

Once you have checked the scene and the person and have made a decision about calling 9 -1-
1 or the local emergency number, you may need to give care until EMS personnel take over. After
making the 9-1-1 call, immediately go back to the injured or ill person. Check the person for life-
threatening conditions and give the necessary care.

To do so, follow these general guidelines:

 Do no further harm.
 Monitor the person’s breathing and consciousness.
 Help the person rest in the most comfortable position.
 Keep the person from getting chilled or overheated.
 Reassure the person.
 Give any specific care as needed.

Transporting the Person, Yourself

In some cases, you may decide to take the injured or ill person to a medical facility yourself instead
of waiting for EMS personnel. NEVER transport a person:
 When the trip may aggravate the injury or illness or cause additional injury.
 When the person has or may develop a life-threatening condition.
 If you are unsure of the nature of the injury or illness.

If you decide it is safe to transport the person, ask someone to come with you to keep the person
comfortable. Also, be sure you know the quickest route to the nearest medical facility capable of
handling emergency care. Pay close attention to the injured or ill person and watch for any
changes in his or her condition.

Discourage an injured or ill person from driving him- or herself to the hospital. An injury may
restrict movement, or the person may become groggy or faint. A sudden onset of pain may be
distracting. Any of these conditions can make driving dangerous for the person, passengers, other
drivers and pedestrians.

Moving an Injured or Ill Person

One of the most dangerous threats to a seriously injured or ill person is unnecessary movement.
Moving an injured person can cause additional injury and pain and may complicate his or her
recovery. Generally, you should not move an injured or ill person while giving care. However, it
would be appropriate in the following three situations:

1. When you are faced with immediate danger, such as fire, lack of oxygen, risk of explosion or a
collapsing structure.

2. When you have to get to another person who may have a more serious problem. In this case,
you may have to move a person with minor injuries to reach someone needing immediate care.

3. When it is necessary to give proper care. For example, if someone needed CPR, he or she
might have to be moved from a bed because CPR needs to be performed on a firm, flat surface.
If the surface or space is not adequate to give care, the person should be moved.

Techniques for Moving an Injured or Ill Person

Once you decide to move an injured or ill person, you must quickly decide how to do so. Carefully
consider your safety and the safety of the person. Move an injured or ill person only when it is
safe for you to do so and there is an immediate life threat. Base your decision on the dangers you
are facing, the size and condition of the person, your abilities and physical condition, and whether
you have any help.

To improve your chances of successfully moving an injured or ill person without injuring yourself
or the person:
 Use your legs, not your back, when you bend.
 Bend at the knees and hips and avoid twisting your body.
 Walk forward when possible, taking small steps and looking where you are going.
 Avoid twisting or bending anyone with a possible head, neck or spinal injury.
 Do not move a person who is too large to move comfortably.

You can move a person to safety in many different ways, but no single way is best for every
situation. The objective is to move the person without injuring yourself or causing further injury to
the person. The following common types of emergency moves can all be done by one or two
people and with minimal to no equipment.

Types of Non-Emergency Moves

Walking Assist

The most basic emergency move is the walking assist. Either one or two responders can use this
method with a conscious person. To perform a walking assist, place the injured or ill person’s arm
across your shoulders and hold it in place with one hand. Support the person with your other hand
around the person’s waist. In this way, your body acts as a crutch, supporting the person’s weight
while you both walks. A second responder, if present, can support the person in the same way on
the other side. Do not use this assist if you suspect that the person has a head, neck or spinal
injury.

1. This is for someone who has suffered a minor injury and merely feels weak. He can still
walk, but needs help.

2. Bring one arm over your shoulder.

3. Grasp his wrist with the hand now below the arm.
4. Place your free arm around his waist.

5. In this manner, walk slowly to your destination. Allow the victim to set the pace.

Two-Person Seat Carry

The two-person seat carry requires a second responder. This carry can be used for any person
who is conscious and not seriously injured. Put one arm behind the person’s thighs and the other
across the person’s back. Interlock your arms with those of a second responder behind the
person’s legs and across his or her back. Lift the person in the “seat” formed by the responders’
arms. Responders should coordinate their movement so they walk together. Do not use this assist
if you suspect that the person has a head, neck or spinal injury.

1. This is another carry for two rescuers. It will work for an unconscious victim as well as a
conscious one.

2. The two rescuers kneel down on either side of the victim.

3. Each rescuer slides one arm under the victim's back, and one under his thighs.

4. The bearers grasp each others wrists and shoulders.

5. They then rise from the ground slowly with the patient supported between them.

6. The two walk slowly to their destination. In all rescues, call emergency care as soon as
possible.

Types of Emergency Moves

Pack-Strap Carry

The pack-strap carry can be used with conscious and unconscious persons. Using it with an
unconscious person requires a second responder to help position the injured or ill person on your
back. To perform the pack-strap carry, have the person stand or have a second responder support
the person. Position yourself with your back to the person, back straight, knees bent, so that your
shoulders fi t into the person’s armpits.
Cross the person’s arms in front of you and grasp the person’s wrists. Lean forward slightly and
pull the person up and onto your back. Stand up and walk to safety. Depending on the size of the
person, you may be able to hold both of his or her wrists with one hand, leaving your other hand
free to help maintain balance, open doors and remove obstructions. Do not use this assist if you
suspect that the person has a head, neck or spinal injury.

1. This is for a victim who is too tired to walk, and you have no one else to assist you with the
carrying.

2. Kneel in front of the victim with your back to his chest.

3. Grasp his hands over your chest.

4. Slowly stand up, lifting with your legs to avoid straining your back.
5. Carry the victim piggyback to your destination. If the victim is small enough to carry in front of
you, this may work easier than heaving them over your back. Place one arm around their back and the
other hand under their legs. This carry is used mainly for women and children.

Clothes Drag

The clothes drag can be used to move a conscious or unconscious person with a suspected head,
neck or spinal injury. This move helps keep the person’s head,
neck and back stabilized. Grasp the person’s clothing behind the neck, gathering enough to
secure a firm grip. Using the clothing, pull the person (headfirst) to safety.

During this move, the person’s head is cradled by clothing and the responder’s arms. Be aware
that this move is exhausting and may cause back strain for the responder, even when done
properly.

Blanket Drag

The blanket drag can be used to move a person in an emergency situation when equipment is
limited. Keep the person between you and the blanket. Gather half of the blanket and place it
against the person’s side. Roll the person as a unit toward you. Reach over and place the blanket
so that it is positioned under the person, then roll the person onto the blanket. Gather the blanket
at the head and move the person.

Ankle Drag
Use the ankle drag (also known as the foot drag) to move a person who is too large to carry or
move in any other way. Firmly grasp the person’s ankles and move backward. The person’s arms
should be crossed on his or her chest. Pull the person in a straight line, being careful not to bump
the person’s head.

Reaching a Person in the Water

Do not enter the water unless you are specifically trained to perform in-water rescues. Get help
from a trained responder, such as a lifeguard, to get the person out of the water as quickly and
safely as possible. You can help a person in trouble in the water from a safe position by using
reaching assists, throwing assists or wading assists.

When possible, start by talking to the person. Let the person know that help is coming. If noise is
a problem or if the person is too far away to hear you, use nonverb al communication. Direct the
person what to do, such as grasping a line, ring buoy or other object that fl oats. Ask the person
to move toward you, which may be done by using the back fl oat with slight leg movements or
small strokes. Some people can reach safety by themselves with the calm and encouraging
assistance of someone calling to them.

Reaching Assists.

Firmly brace yourself on a pool deck, pier or shoreline and reach out to the person with any object
that will extend your reach, such as a pole, oar or paddle, tree branch, shirt, belt or towel. If no
equipment is available, you can still perform a reaching assist by lying down and extending your
arm or leg for the person to grab.

Throwing Assists.

An effective way to rescue someone beyond your reach is to throw a floating object out to the
person with a line attached. Once the person grasps the object, pull the individual to safety.
Throwing equipment includes heaving lines, ring buoys, throw bags or any floating object
available, such as a picnic jug, small cooler, buoyant cushion, kickboard or extra life jacket.
CHECKING A CONSCIOUS PERSON

If you determine that an injured or ill person is conscious and has no immediate life -threatening
conditions, you can begin to check for other conditions that may need care. Checking a conscious
person with no immediate life-threatening conditions involves two basic steps:
 Interview the person and bystanders.
 Check the person from head to toe.

Conducting Interviews

Ask the person and bystanders simple questions to learn more about what happened. Keep these
interviews brief. Remember to first identify yourself and to get the person’s consent to give care.
Begin by asking the person’s name. This will make him or her feel more comfortable. Gather
additional information by asking the person the following questions:

 What happened?
 Do you feel pain or discomfort anywhere?
 Do you have any allergies?
 Do you have any medical conditions or are you taking any medication?

If the person feels pain, ask him or her to describe it and to tell you where it is located. Descriptions
often include terms such as burning, crushing, throbbing, aching or sharp pain. Ask when the pain
started and what the person was doing when it began. Ask the person to rate his or her pain on
a scale of 1 to 10 (1 being mild and 10 being severe).

Sometimes an injured or ill person will not be able to give you the information that you need. The
person may not speak your language. In some cases, the person may not be able to speak
because of a medical condition. Known as a laryngectomee, a person whose larynx (voice box)
was surgically removed breathes through a permanent opening, or stoma, in the neck and may
not be able to speak. Remember to question family members, friends or bystanders as well. They
may be able to give you helpful information or help you to communicate with the person.

Children or infants may be frightened. They may be fully aware of you but still unable to answer
your questions. In some cases, they may be crying too hard and be unable to stop. Approach
slowly and gently, and give the child or infant some time to get used to you. Use the child’s name,
if you know it. Get down to or below the child’s eye level.

Write down the information you learn during the interviews or, preferably, have so meone else
write it down for you. Be sure to give the information to EMS personnel when they arrive. It may
help them to determine the type of medical care that the person should receive.

Checking from Head to Toe

Next you will need to thoroughly check the injured or ill person so that you do not overlook any
problems. Visually check from head to toe. When checking a conscious person:

 Do not move any areas where there is pain or discomfort, or if you suspect a head,
neck or spinal injury.
 Check the person’s head by examining the scalp, face, ears, mouth and nose.
 Look for cuts, bruises, bumps or depressions. Think of how the body usually looks. If
you are unsure if a body part or limb looks injured, check it against the opposite limb or
the other side of the body.
 Watch for changes in consciousness. Notice if the person is drowsy, confused or is not
alert.
 Look for changes in the person’s breathing. A healthy person breathes easily, quietly,
regularly and without discomfort or pain. Young children and infants generally breathe
faster than adults. Breathing that is not normal includes noisy breathing, such as
gasping for air; rasping, gurgling or whistling sounds; breathing that is unusually fast or
slow; and breathing that is painful.
 Notice how the skin looks and feels. Skin can provide clues that a person is injured or
ill. Feel the person’s forehead with the back of your hand to determine if the skin feels
unusually damp, dry, cool or hot. Note if it is red, pale or ashen.
 Look over the body. Ask again about any areas that hurt. Ask the person to move each
part of the body that does not hurt. Ask the person to gently move his or her head from
side to side. Check the shoulders by asking the person to shrug them. Check the chest
and abdomen by asking the person to take a deep breath. Ask the person to move his
or her fingers, hands and arms; and then the toes, legs and hips in the same way.
Watch the person’s face and listen for signals of discomfort or pain as you check for
injuries.
 Look for a medical identification (ID) tag, bracelet or necklace on the person’s wrist,
neck or ankle. A tag will provide medical information about the person, explain how to
care for certain conditions and list whom to call for help. For example, a person with
diabetes may have some form of medical ID tag, bracelet or necklace identifying this
condition.

If a child or an infant becomes extremely upset, conduct a toe-to-head check of the child or infant.
This will be less emotionally threatening. Parents or guardians who are present may be able to
calm a frightened child. In fact, it often is helpful to check a young child while he or she is seated
in his or her parent’s or guardian’s lap. Parents also can tell you if a child has a medical condition.

When you have finished checking, determine if the person can move his or her body without any
pain. If the person can move without pain and there are no other signals of injury, have him or her
attempt to rest in a sitting position or other comfortable position (Fig. 1-16). When the person feels
ready, help him or her to stand up. Determine what additional care is needed and whether to call
9-1-1 or the local emergency number.

SHOCK

When the body is healthy, three conditions are needed to keep the right amount of blood fl owing:

 The heart must be working well.

 An adequate amount of oxygen-rich blood must be circulating in the body.
 The blood vessels must be intact and able to adjust blood flow.
Shock is a condition in which the circulatory system f ails to deliver enough oxygen-rich blood to
the body’s tissues and vital organs. The body’s organs, such as the brain, heart and lungs, do not
function properly without this blood supply. This triggers a series of responses that produce
specific signals known as shock. These responses are the body’s attempt to maintain adequate
blood flow.

When someone is injured or becomes suddenly ill, these normal body functions may be
interrupted. In cases of minor injury or illness, this interruption is brief because the body is able to
compensate quickly. With more severe injuries or illnesses, however, the body may be unable to
adjust. When the body is unable to meet its demand for oxygen because blood fails to circulate
adequately, shock occurs.

WHAT TO LOOK FOR?

The signals that indicate a person may be going into shock include:
 Restlessness or irritability.
 Altered level of consciousness.
 Nausea or vomiting.
 Pale, ashen or grayish, cool, moist skin.
 Rapid breathing and pulse.
 Excessive thirst.

Be aware that the early signals of shock may not be present in young children and infants.
However, because children are smaller than adults, they have less blood volume and are more
susceptible to shock.

WHEN TO CALL 9-1-1

In cases where the person is going into shock, call 9-1-1 or the local emergency number
immediately. Shock cannot be managed effectively by first aid alone. A person suffering from
shock requires emergency medical care as soon as possible.

WHAT TO DO UNTIL HELP ARRIVES?

Caring for shock involves the following simple steps:

 Have the person lie down. This often is the most comfortable position. Helping the
person rest in a more comfortable position may lessen any pain. Helping the person to
rest comfortably is important because pain can intensify the body’s stress and speed
up the progression of shock.
 Control any external bleeding.
 Since you may not be sure of the person’s condition, leave him or her lying fl at.
 Help the person maintain normal body temperature. If the person is cool, try to cover
him or her to avoid chilling.
 Do not give the person anything to eat or drink, even though he or she is likely to be
thirsty. The person’s condition may be severe enough to require surgery, in which case
it is better if the stomach is empty.
 Reassure the person.
 Continue to monitor the person’s breathing and for any changes in the person’s
condition. Do not wait for signals of shock to develop before caring for the underlying
injury or illness.

CHECKING AN UNCONSCIOUS PERSON

If you think someone is unconscious, tap him or her on the shoulder and ask if he or she is OK.
Use the person’s name if you know it. Speak loudly. If you are not sure whether an infant is
unconscious, check by tapping the infant’s shoulder and shouting or by flicking the bottom of the
infant’s foot to see if the infant responds.

If the person does not respond, call 9-1-1 or the local emergency number and check for other life-
threatening conditions.
Always check to see if an unconscious person:
 Has an open airway and is breathing normally?
 Is bleeding severely.

Consciousness, effective (normal) breathing and circulation and skin characteristics sometimes
are referred to as signs of life.

Airway

Once you or someone else has called 9-1-1 or the local emergency number, check to see if the
person has an open airway and is breathing. An open airway allows air to enter the lungs for the
person to breathe. If the airway is blocked, the person cannot breathe. A blocked airway is a life-
threatening condition.
 When someone is unconscious and lying on his or her back, the tongue may fall to the
back of the throat and block the airway. To open an unconscious person’s airway, push
down on his or her forehead while pulling up on the bony part of the chin with two or
three fingers of your other hand. This procedure, known as the head-tilt/chin-lift
technique, moves the tongue away from the back of the throat, allowing air to enter
the lungs.

o For a child: Place one hand on the forehead and tilt the head slightly past a
neutral position (the head and chin are neither flexed downward toward the
chest nor extended backward).

o For an infant: Place one hand on the forehead and tilt the head to a neutral
position while pulling up on the bony part of the chin with two or three fingers of
your other hand.

 If you suspect that a person has a head, neck or spinal injury, carefully tilt the head and
lift the chin just enough to open the airway.

Check the person’s neck to see if he or she breathes through an opening. A person whose larynx
was removed may breathe partially or entirely through a stoma instead of through the mouth.
person may breathe partially or entirely through this opening instead of through the mouth and
nose. It is important to recognize this difference in the way a person breathes. This will help you
give proper care.

Breathing

After opening the airway, quickly check an unconscious person for breathing. Position yourself so
that you can look to see if the person’s chest clearly rises and falls, listen for escaping air and
feel for it against the side of your face. Do this for no more than 10 seconds . If the person needs
CPR, chest compressions must not be delayed.

Normal breathing is regular, quiet and effortless. A person does not appear to be working hard or
struggling when breathing normally. This means that the person is not making noise when
breathing, breaths are not fast (although it should be noted that normal breathing rates in children
and infants are faster than normal breathing rates in adults) and breathing does not cause
discomfort or pain. In an unconscious adult you may detect an irregular, gasping or shal low
breath. This is known as an agonal breath. Do not confuse this with normal breathing. Care for
the person as if there is no breathing at all. Agonal breaths do not occur frequently in children.

If the person is breathing normally, his or her heart is beating and is circulating blood containing
oxygen. In this case, maintain an open airway by using the head-tilt/chin-lift technique as you
continue to look for other life-threatening conditions.

If an adult is not breathing normally, this person most likely needs immediate CPR.

If a child or an infant is not breathing, give 2 rescue breaths. Tilt the head back and lift chin up.
Pinch the nose shut then make a complete seal over the child’s mouth and blow in for about 1
second to make the chest clearly rise. For an infant, seal your mouth over the infant’s mouth and
nose. Give rescue breaths one after the other.
If you witness the sudden collapse of a child, assume a cardiac emergency. Do not give 2 rescue
breaths. CPR needs to be started immediately, just as with an adult.

Sometimes you may need to remove food, liquid or other objects that are blocking the person’s
airway. This may prevent the chest from rising when you attempt rescue breaths. You will learn
how to recognize an obstructed airway and give care to the person in Chapter 4.

Circulation

It is important to recognize breathing emergencies in children and infants and to act before the
heart stops beating. Adults’ hearts frequently stop beating because of disease. Children’s and
infants’ hearts, however, are usually healthy. When a child’s or an infant’s heart stops, it usually
is the result of a breathing emergency.

If an adult is not breathing or is not breathing normally and if the emergency is not the result of
non-fatal drowning or other respiratory cause such as a drug overdose, assume that the problem
is a cardiac emergency.

Quickly look for severe bleeding by looking over the person’s body from head to toe for signals
such as blood-soaked clothing or blood spurting out of awound (Fig. 1-23). Bleeding usually looks
worse than it is. A small amount of blood on a slick surface or mixed with water usually looks like
a large volume of blood. It is not always easy to recognize severe bleeding.
 CHAPTER 2
CARDIAC EMERGENCIES AND CPR

LESSON OBJECTIVES
- Recognize the signals of a cardiac emergency.
- Identify the links in the Cardiac Chain of Survival.
- Describe how to care for a heart attack.
- List the causes of cardiac arrest.
- Explain the role of CPR in cardiac arrest.
- Demonstrate how to perform CPR
INTRODUCTION
Cardiac emergencies are life threatening. Heart attack and cardiac arrest are major causes of
illness and death in the United States. Every day in U.S. homes, parks and workplaces someone
will have a heart attack or go into cardiac arrest. Recognizing the signals of a heart attack and
cardiac arrest, calling 9-1-1 or the local emergency number and giving immediate care in a cardiac
emergency saves lives. Performing CPR and using an automated external defibrillator (AED)
immediately after a person goes into cardiac arrest can greatly increase his or her chance of
survival.
In this chapter you will find out what signals to look for if you suspect a person is having a heart
attack or has gone into cardiac arrest. This chapter also discusses how to care for a person having
a heart attack and how to perform CPR for a person in cardiac arrest. In addition, this chapter
covers the important links in the Cardiac Chain of Survival.
Although cardiac emergencies occur more commonly in adults, they also occur in infants and
children. This chapter discusses the causes of cardiac arrest and how to provide care for all age
groups.
BACKGROUND
The heart is a fascinating organ. It beats more than 3 billion times in an average lifetime.
The heart is about the size of a fist and lies between the lungs in the middle of the chest. It pumps
blood throughout the body. The ribs, breastbone and spine protect it from injury. The heart is
separated into right and left halves.
Blood that contains little or no oxygen enters the right side of the heart and is pumped to the
lungs. The blood picks up oxygen in the lungs when you breathe. The oxygen-rich blood then goes
to the left side of the heart and is pumped from the heart’s blood vessels, called the arteries, to all
other parts of the body. The heart and your body’s vital organs need this constant supply of
oxygen-rich blood.
Cardiovascular disease is an abnormal condition that affects the heart and blood vessels.
An estimated 80 million Americans suffer from some form of the disease. It remains the number
one killer in the United States and is a major cause of disability. The most common conditions
caused by cardiovascular disease include coronary heart disease, also known as coronary artery
disease, and stroke, also called a brain attack.

Coronary heart disease occurs when the arteries that supply blood to the heart muscle harden and
narrow. This process is called atherosclerosis. The damage occurs gradually, as cholesterol and
fatty deposits called plaque build-up on the inner artery walls. As this build-up worsens, the
arteries become narrower. This reduces the amount of blood that can flow through them and
prevents the heart from getting the blood and oxygen it needs. If the heart does not get blood
containing oxygen, it will not work properly. Coronary heart disease accounts for about half of the
greater than 800,000 adults who die each year from cardiovascular disease.
When the heart is working normally, it beats evenly and easily, with a steady rhythm. When
damage to the heart causes it to stop working effectively, a person can experience a heart attack
or other damage to the heart muscle. A heart attack can cause the heart to beat in an irregular
way. This may prevent blood from circulating effectively.
When the heart does not work properly, normal breathing can be disrupted or stopped. A heart
attack also can cause the heart to stop beating entirely. This condition is called cardiac arrest.
The number one cause of heart attack and cardiac arrest in adults is coronary heart disease. Other
significant causes of cardiac arrest are non-heart related (e.g., poisoning or drowning).
HEART ATTACK
When blood flow to the heart muscle is reduced, people experience chest pain. This reduced blood
flow usually is caused by coronary heart disease. When the blood and oxygen supply to the heart
is reduced, a heart attack may result.
What to Look For?
A heart attack can be indicated by common signals. Even people who have had a heart attack
may not recognize the signals, because each heart attack may not show the same signals. You
should be able to recognize the following signals of a heart attack so that you can give prompt and
proper care:
 Chest pain, discomfort or pressure. The most common signal is persistent pain, discomfort
or pressure in the chest that lasts longer than 3 to 5 minutes or goes away and comes back.
Unfortunately, it is not always easy to distinguish heart attack pain from the pain of
indigestion, muscle spasms or other conditions. This often causes people to delay getting
medical care. Brief, stabbing pain or pain that gets worse when you bend or breathe deeply
usually is not caused by a heart problem.
o The pain associated with a heart attack can range from discomfort to an unbearable
crushing sensation in the chest.
o The person may describe it as pressure, squeezing, tightness, aching or heaviness in
the chest.
o Many heart attacks start slowly as mild pain or discomfort.
o Often the person feels pain or discomfort in the center of the chest (Fig. 2-3).
o The pain or discomfort becomes constant. It usually is not relieved by resting,
changing position or taking medicine.
o Some individuals may show no signals at all.

 Discomfort in other areas of the upper body in addition to the chest. Discomfort, pain or
pressure may also be felt in or spread to the shoulder, arm, neck, jaw, stomach or back.

 Trouble breathing. Another signal of a heart attack is trouble breathing. The person may be
breathing faster than normal because the body tries to get the much-needed oxygen to the
heart. The person may have noisy breathing or shortness of breath.
 Other signals. The person’s skin may be pale or ashen (gray), especially around the face.
Some people suffering from a heart attack may be damp with sweat or may sweat heavily, feel
dizzy, become nauseous or vomit. They may become fatigued, lightheaded or lose
consciousness. These signals are caused by the stress put on the body when the heart does
not work as it should. Some individuals may show no signals at all.

 Differences in signals between men and women. Both men and women experience the
most common signal for a heart attack: chest pain or discomfort. However, it is important to
note that women are somewhat more likely to experience some of the other warning signals,
particularly shortness of breath, nausea or vomiting, back or jaw pain and unexplained fatigue
or malaise. When they do experience chest pain, women may have a greater tendency to
have atypical chest pain: sudden, sharp but short-lived pain outside of the breastbone.
When to Call 9-1-1?
Remember, the key signal of a heart attack is persistent chest pain or discomfort that lasts
more than 3 to 5 minutes or goes away and comes back. If you suspect the person is having a
heart attack based on his or her signals, call 9-1-1 or the local emergency number immediately. A
person having a heart attack probably will deny that any signal is serious. Do not let this influence
you. If you think the person might be having a heart attack, act quickly.
What to Do Until Help Arrives?
It is important to recognize the signals of a heart attack and to act on those signals. Any
heart attack might lead to cardiac arrest, but prompt action may prevent further damage to the
heart. A person suffering from a heart attack, and whose heart is still beating, has a far better
chance of living than does a person whose heart has stopped. Most people who die of a heart
attack die within 2 hours of the first signal. Many could have been saved if people on the scene or
the person having the heart attack had been aware of the signals and acted promptly.
Many people who have heart attacks delay seeking care. Nearly half of all heart attack victims
wait for 2 hours or more before going to the hospital. Often, they do not realize they are having a
heart attack. They may say the signals are just muscle soreness, indigestion or heartburn.
Early treatment with certain medications—including aspirin—can help minimize damage to the
heart after a heart attack. To be most effective, these medications need to be given within 1 hour
of the start of heart attack signals.
If you suspect that someone might be having a heart attack, you should:
 Call 9-1-1 or the local emergency number immediately.
 Have the person stop what he or she is doing and rest comfortably (Fig. 2-4).
 This will ease the heart’s need for oxygen. Many people experiencing a heart attack
find it easier to breathe while sitting.
 Loosen any tight or uncomfortable clothing.
 Closely watch the person until advanced medical personnel take over. Notice any
changes in the person’s appearance or behavior. Monitor the person’s condition.
 Be prepared to perform CPR and use an AED, if available, if the person loses
consciousness and stops breathing. Ask the person if he or she has a history of
heart disease. Some people with heart disease take prescribed medication for chest
pain. You can help by getting the medication for the person and assisting him or her
 with taking the prescribed medication.
 Offer aspirin, if medically appropriate and local protocols allow, and if the patient
can swallow and has no known contraindications (see the following section). Be
sure that the person has not been told by his or her health care provider to avoid
taking aspirin.
 Be calm and reassuring. Comforting the person helps to reduce anxiety and eases
some of the discomfort.
 Talk to bystanders and if possible, the person to get more information.
 Do not try to drive the person to the hospital yourself. He or she could quickly get
worse on the way.
Giving Aspirin to Lessen Heart Attack Damage
You may be able to help a conscious person who is showing early signals of a heart attack
by offering him or her an appropriate dose of aspirin when the signals first begin. However, you
should never delay calling 9-1-1 or the local emergency number to do this. Always call for help as
soon as you recognize the signals of a heart attack. Then help the person to be comfortable
before you give the aspirin.
If the person is able to take medicine by mouth, ask:
 Are you allergic to aspirin?
 Do you have a stomach ulcer or stomach disease?
 Are you taking any blood thinners, such as warfarin (Coumadin™)?
 Have you ever been told by a doctor to avoid taking aspirin?
If the person answers no to all of these questions, you may offer him or her two chewable
(81 mg each) baby aspirins, or one 5-grain (325 mg) adult aspirin tablet with a small amount of
water. Do not use coated aspirin products or products meant for multiple uses such as for cold,
fever and headache. You also may offer these doses of aspirin if the person regains
consciousness while you are giving care and is able to take the aspirin by mouth.
Be sure that you offer only aspirin and not Tylenol®, acetaminophen or nonsteroidal anti-
inflamatory drugs (NSAIDs), such as ibuprofen, Motrin®, Advil®, naproxen and Aleve®.
CARDIAC ARREST
Cardiac arrest occurs when the heart stops beating or beats too ineffectively to circulate
blood to the brain and other vital organs. The beats, or contractions, of the heart become
ineffective if they are weak, irregular or uncoordinated, because at that point the blood no longer
flows through the arteries to the rest of the body.
When the heart stops beating properly, the body cannot survive. Breathing will soon stop,
and the body’s organs will no longer receive the oxygen they need to function. Without oxygen,
brain damage can begin in about 4 to 6 minutes, and the damage can become irreversible after
about 10 minutes.
A person in cardiac arrest is unconscious, not breathing and has no heartbeat. The heart
has either stopped beating or is beating weakly and irregularly so that a pulse cannot be
detected.
Cardiovascular disease is the primary cause of cardiac arrest in adults. Cardiac arrest also
results from drowning, choking, drug abuse, severe injury, brain damage and electrocution.
 Causes of cardiac arrest in children and infants include airway and breathing problems, traumatic
injury, a hard blow to the chest, congenital heart disease and sudden infant death syndrome
(SIDS).
Cardiac arrest can happen suddenly, without any of the warning signs usually seen in a
heart attack. This is known as sudden cardiac arrest or sudden cardiac death and accounts
for more than 300,000 deaths annually in the United States. Sudden cardiac arrest is caused by
abnormal, chaotic electrical activity of the heart (known as arrhythmias). The most common life-
threatening abnormal arrhythmia is ventricular fibrillation (V-fi b).
What to Look For?
The main signals of cardiac arrest in an adult, a child and an infant are unconsciousness
and no breathing.
The presence of these signals means that no blood and oxygen are reaching the person’s
brain and other vital organs.
When to Call 9-1-1
Call 9-1-1 or the local emergency number immediately if you suspect that a person is in
cardiac arrest or you witness someone suddenly collapse.
What to Do Until Help Arrives
Perform CPR until an AED is available and ready to use or advanced medical personnel
take over.
Early CPR and Defibrillation A person in cardiac arrest needs immediate CPR and
defibrillation. The cells of the brain and other important organs continue to live for a short time—
until all of the oxygen in the blood is used.
Cardio Pulmonary Resuscitation (CPR)
A combination of chest compressions and rescue breaths. When the heart is not beating,
chest compressions are needed to circulate blood containing oxygen. Given together, rescue
breaths and chest compressions help to take over for the heart and lungs. CPR increases the
chances of survival for a person in cardiac arrest.
In many cases, however, CPR alone cannot correct the underlying heart problem:
defibrillation delivered by an AED is needed. This shock disrupts the heart’s electrical activity
long enough to allow the heart to spontaneously develop an effective rhythm on its own. Without
early CPR and early defibrillation, the chances of survival are greatly reduced. (Using an AED is
discussed in detail in Chapter 3.)
CPR FOR ADULTS
To determine if an unconscious adult needs CPR, follow the emergency action steps (CHECK—CALL—
CARE) that you learned in Chapter 1.
CHECK ■ the scene and the injured or ill person. CALL
■ 9-1-1 or the local emergency number.
CHECK ■ for breathing for no more than 10 seconds. Quickly
■ CHECK for severe bleeding. (If the person is not breathing)
■ CARE by beginning CPR. For chest compressions to be the most effective, the person should be
on his or her back on a firm, flat surface. If the person is on a soft surface like a sofa or bed, quickly
move him or her to a firm, flat surface before you begin.
To perform CPR on an adult:

 Position your body correctly by kneeling beside the person’s upper chest, placing your
hands in the correct position, and keeping your arms and elbows as straight as possible so
that your shoulders are directly over your hands. Your body position is important when
giving chest compressions. Compressing the person’s chest straight down will help you
reach the necessary depth. Using the correct body position also will be less tiring for you.

 Locate the correct hand position by placing the heel of one hand on the person’s sternum
(breastbone) at the center of his or her chest. Place your other hand directly on top of the
first hand and try to keep your fingers off of the chest by interlacing them or holding them
upward. If you feel the notch at the end of the sternum, move your hands slightly toward the
person’s head. If you have arthritis in your hands, you can give compressions by grasping
the wrist of the hand positioned on the chest with your other hand. The person’s clothing
should not interfere with finding the proper hand position or your ability to give effective
compressions. If it does, loosen or remove enough clothing to allow deep compressions in
the center of the person’s chest.

 Give 30 chest compressions. Push hard, push fast at a rate of at least 100 compressions
per minute. Note that the term “100 compressions per minute” refers to the speed of
compressions, not the number of compressions given in a minute. As you give
compressions, count out loud, “One and two and three and four and five and six and…” up
to 30. Push down as you say the number and come up as you say “and.”, This will help you
to keep a steady, even rhythm.

 Give compressions by pushing the sternum down at least 2 inches. The downward and
upward movement should be smooth, not jerky. Push straight down with the weight of your
upper body, not with your arm muscles. This way, the weight of your upper body will create
the force needed to compress the chest. Do not rock back and forth. Rocking results in less-
effective compressions and wastes much needed energy. If your arms and shoulders tire
quickly, you are not using the correct body position. After each compression, release the
pressure on the chest without removing your hands or changing hand position. Allow the
chest to return to its normal position before starting the next compression. Maintain a steady
down-and-up rhythm and do not pause between compressions. Spend half of the time
pushing down and half of the time coming up. When you press down, the walls of the heart
squeeze together, forcing the blood to empty out of the heart. When you come up, you
should release all pressure on the chest, but do not take hands off the chest. This allows the
heart’s chambers to fill with blood between compressions.

 Once you have given 30 compressions, open the airway using the head-tilt/chin-lift
technique and give 2 rescue breaths. Each rescue breath should last about 1 second and
make the chest clearly rise.
 o Open the airway and give rescue breaths, one after the other.
o Tilt the head back and lift the chin up.
o Pinch the nose shut then make a complete seal over the person’s mouth.
o Blow in for about 1 second to make the chest clearly rise.
o Continue cycles of chest compressions and rescue breaths.
o Each cycle of chest compressions and rescue breaths should take about 24
seconds. Minimize the interruption of chest compressions.

If Two Responders Are Available

If two responders trained in CPR are at the scene, both should identify themselves as being
trained. One should call 9-1-1 or the local emergency number for help while the other performs CPR.
If the first responder is tired and needs help:
 The first responder should tell the second responder to take over.
 The second responder should immediately take over CPR, beginning with chest
compressions.
When to Stop CPR
Once you begin CPR, do not stop except in one of these situations:
 You notice an obvious sign of life, such as breathing.
 An AED is available and ready to use.
 Another trained responder or EMS personnel take over.
 You are too exhausted to continue.
 The scene becomes unsafe.
If at any time you notice that the person is breathing, stop CPR. Keep his or her airway open
and continue to monitor the person’s breathing and for any changes in the person’s condition until
EMS personnel take over.
CARDIAC EMERGENCIES IN CHILDREN AND INFANTS
It is rare for a child or an infant to initially suffer a cardiac emergency. Usually, a child or an
infant has a respiratory emergency first and then a cardiac emergency develops.
Causes of cardiac arrest in children and infants include:
 Airway and breathing problems.
 Traumatic injury or an accident (e.g., motor-vehicle collision, drowning, electrocution
or poisoning).
 A hard blow to the chest.
 Congenital heart disease.
 Sudden infant death syndrome (SIDS).
 If you recognize that a child or an infant is not breathing, begin CPR.
CPR FOR CHILDREN AND INFANTS
Follow the emergency action steps (CHECK— CALL—CARE) to determine if you will need to
perform CPR for a child or an infant. The principles of CPR (compressing the chest and giving
rescue breaths) are the same for children and infants as for adults. However, the CPR techniques
are slightly different since children’s and infants’ bodies are smaller.
CPR FOR A CHILD
 If during the unconscious check you find that the child is not breathing, place the child face-up
on a firm, flat surface. Begin CPR by following these steps:
 Locate the proper hand position on the middle of the breastbone as you would for
an adult. If you feel the notch at the end of the sternum, move your hands slightly
toward the child’s head.
 Position your body as you would for an adult, kneeling next to the child’s upper
chest, positioning your shoulders over your hands and keeping your arms and
elbows as straight as possible.
 Give 30 chest compressions. Push hard, push fast to a depth of about 2 inches and
at a rate of at least 100 compressions per minute. Lift up, allowing the chest to fully
return to its normal position, but keep contact with the chest.
 After giving 30 chest compressions, open the airway and give 2 rescue breaths.
Each rescue breath should last about 1 second and make the chest clearly rise.
Use the head-tilt/chin-lift technique to ensure that the child’s airway is open.
Continue cycles of 30 chest compressions and 2 rescue breaths. Do not stop CPR except in one of
these situations:
 You find an obvious sign of life, such as breathing.
 An AED is ready to use.
 Another trained responder or EMS personnel take over.
 You are too exhausted to continue.
 The scene becomes unsafe.
If at any time you notice the child begin to breathe, stop CPR, keep the airway open
and monitor breathing and for any changes in the child’s condition until EMS personnel take over.
CPR FOR AN INFANT
If during your check you find that the infant is not breathing, begin CPR by following these steps:
 Find the correct location for compressions. Keep one hand on the infant’s forehead
to maintain an open airway. Use the pads of two or three fingers of your other hand
to give chest compressions on the center of the chest, just below the nipple line
(toward the infant’s feet). If you feel the notch at the end of the infant’s sternum,
move your fingers slightly toward the infant’s head.
 Give 30 chest compressions using the pads of these fingers to compress the chest.
Compress the chest about 1½ inches. Push hard, push fast. Your compressions
should be smooth, not jerky. Keep a steady rhythm. Do not pause between each
compression. When your fingers are coming up, release pressure on the infant’s
chest completely but do not let your fingers lose contact with the chest. Compress
at a rate of at least 100 compressions per minute.
 After giving 30 chest compressions, give 2 rescue breaths, covering the infant’s
mouth and nose with your mouth. Each rescue breath should last about 1 second
and make the chest clearly rise. Continue cycles of 30 chest compressions and 2
rescue breaths. Do not stop CPR except in one of these situations:
 You find an obvious sign of life, such as breathing.
 An AED is ready to use.
 Another trained responder or EMS personnel take over.
 You are too exhausted to continue.
 The scene becomes unsafe.
 If at any time you notice the infant begin to breathe, stop CPR, keep the airway open and
monitor breathing and for any changes in the infant’s condition until EMS personnel take over.

IF CHEST DOES NOT RISE WITH RESCUE BREATHS

If the chest does not rise with the initial rescue breath, retilt the head before giving the
second breath. If the second breath does not make the chest rise, the person may be choking.
After each subsequent set of chest compressions and before attempting breaths, look for an
object and, if seen, remove it. Continue CPR.
Continuous Chest Compressions (Hands-Only CPR)
If you are unable or unwilling for any reason to perform full CPR (with rescue breaths), give
continuous chest compressions after checking the scene and the person and calling 9-1-1 or the
local emergency number. Continue giving chest compressions until EMS personnel take over or
you notice an obvious sign of life, such as breathing.

Skill Components Adult Child Infant

HAND POSITION Two hands in center Two hands in center Two or three fingers
of chest of chest in center of chest
(on lower half of sternum) (on lower (on lower half
half of sternum) of sternum, just
below nipple line)
CHEST At least 2 inches Until the About 2 inches Until About 1 1/2 inches Until
COMPRESSIONS chest clearly rises the chest clearly rises the chest clearly rises
RESCUE BREATHS (about 1 second per (about 1 second per (about 1 second per
breath) breath) breath)

CYCLE 30 chest compressions 30 chest compressions 30 chest compressions

and 2 rescue breaths and 2 rescue breaths and 2 rescue breaths

RATE 30 chest compressions in 30 chest compressions 30 chest compressions

about 18 seconds in about 18 seconds in about 18 seconds
(at least 100 (at least 100 (at least 100
compressions per compressions per compressions per
minute) minute) minute)

PUTTING IT ALL TOGETHER

Cardiac emergencies are life threatening. Every day someone will have a heart attack or go into
cardiac arrest. These cardiac emergencies usually happen in the home. If you know the signals of a
heart attack and cardiac arrest, you will be able to respond
immediately. Call 9-1-1 or the local emergency number and give care until help takes over. If the
person is in cardiac arrest, perform CPR. Use an AED if one is available. These steps will increase
the chances of survival for the person having a cardiac emergency.
 CHAPTER 3
BREATHING EMERGENCIES

LESSON OBJECTIVES
- Recognize the signals of a breathing emergency.
- Demonstrate how to care for a person who is choking.
INTRODUCTION
A breathing emergency is any respiratory problem that can threaten a person’s life. Breathing
emergencies happen when air cannot travel freely and easily into the lungs. Respiratory distress,
respiratory arrest and choking are examples of breathing emergencies. In a breathing
emergency, seconds count so you must react at once. This chapter discusses how to recognize
and care for breathing emergencies.
BACKGROUND
The human body needs a constant supply of oxygen to survive. When you breathe through your
mouth and nose, air travels down your throat, through your windpipe and into your lungs. This
pathway from the mouth and nose to the lungs is called the airway.

As you might imagine, the airway, mouth and nose are smaller in children and infants than they
are in adults. As a result, they can be blocked more easily by small objects, blood, fluids or
swelling.

In a breathing emergency, air must reach the lungs. For any person, regardless of age, it is
important to keep the airway open when giving care.

Once air reaches the lungs, oxygen in the air is transferred to the blood. The heart pumps the
blood throughout the body. The blood flows through the blood vessels, delivering oxygen to the
brain, heart and all other parts of the body.

In some breathing emergencies the oxygen supply to the body is greatly reduced, whereas in
others the oxygen supply is cut off entirely. As a result, the heart soon stops beating and blood
no longer moves through the body. Without oxygen, brain cells can begin to die within 4 to 6
minutes. Unless the brain receives oxygen within minutes, permanent brain damage or death
will result.

It is important to recognize breathing emergencies in children and infants and act before the
heart stops beating. Frequently, an adult’s heart stops working (known as cardiac arrest)
because of heart disease. However, children and infants usually have healthy hearts. When the
heart stops in a child or infant, it usually is the result of a breathing emergency.

No matter what the age of the person, trouble breathing can be the first signal of a more serious
emergency, such as a heart problem. Recognizing the signals of breathing problems and giving
care often are the keys to preventing these problems from becoming more serious emergencies.
If the injured or ill person is conscious, he or she may be able to indicate what is wrong by
speaking or gesturing to you and may be able to answer questions. However, if you are unable
to communicate with a person, it can be difficult to determine what is wrong.
Therefore, it is important to recognize the signals of breathing emergencies, know when to call
9-1-1 or the local emergency number and know what to do until help arrives and takes over.

RESPIRATORY DISTRESS AND RESPIRATORY ARREST

Respiratory distress and respiratory arrest are types of breathing emergencies.

Respiratory distress is a condition in which breathing becomes difficult. It is the most common
breathing emergency. Respiratory distress can lead to respiratory arrest, which occurs when
breathing has stopped.

Normal breathing is regular, quiet and effortless. A person does not appear to be working hard
or struggling when breathing normally. This means that the person is not making noise when
breathing, breaths are not fast and breathing does not cause discomfort or pain. However, it
should be noted that normal breathing rates in children and infants are faster than normal
breathing rates in adults. Infants have periodic breathing, so changes in breathing patterns are
normal for infants.

You usually can identify a breathing problem by watching and listening to the person’s breathing
and by asking the person how he or she feels.

CAUSES OF RESPIRATORY DISTRESS AND RESPIRATORY ARREST

Respiratory distress and respiratory arrest can be caused by:

■ Choking (a partially or completely obstructed airway).
■ Illness.
■ Chronic conditions (long-lasting or frequently recurring), such as asthma.
■ Electrocution.
■ Irregular heartbeat.
■ Heart attack.
■ Injury to the head or brain stem, chest, lungs or abdomen.
■ Allergic reactions.
■ Drug overdose (especially alcohol, narcotic painkillers, barbiturates, anesthetics and
other depressants).
■ Poisoning.
■ Emotional distress.
■ Drowning.

ASTHMA

Asthma is the inflammation of the air passages that results in a temporary narrowing of the
airways that carry oxygen to the lungs. An asthma attack happens when a trigger, such as
exercise, cold air, allergens or other irritants, causes the airway to swell and narrow. This makes
breathing difficult.

The Centers for Disease Control and Prevention (CDC) estimate that in 2005, nearly 22.2 million
Americans were affected by asthma. Asthma is more common in children and young adults than
in older adults, but its frequency and severity is increasing in all age groups in the United States.
Asthma is the third-ranking cause of hospitalization among those younger than 15 years.

You often can tell when a person is having an asthma attack by the hoarse whistling sound that
he or she makes while exhaling. This sound, known as wheezing, occurs because air becomes
trapped in the lungs. Trouble breathing, shortness of breath, tightness in the chest and coughing
after exercise are other signals of an asthma attack. Usually, people diagnosed with asthma
prevent and control their attacks with medication. These medications reduce swelling and mucus
production in the airways. They also relax the muscle bands that tighten around the airways,
making breathing easier.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a long-term lung disease encompassing

both chronic bronchitis and emphysema. COPD causes a person to have trouble breathing
because of damage to the lungs. In a person with COPD, the airways become partly blocked
and the air sacs in the lungs lose their ability to fill with air. This makes it hard to breathe in and
out. There is no cure for COPD, and it worsens over time.

The most common cause of COPD is cigarette smoking, but breathing in other types of lung
irritants, pollution, dust or chemicals over a long period also can cause COPD. It usually is
diagnosed when a person is middle aged or older. It is the fourth-ranking cause of death in the
United States and a major cause of illness.

Common signals of COPD include:

■ Coughing up a large volume of mucus.
■ Tendency to tire easily.
■ Loss of appetite.
■ Bent posture with shoulders raised and lips pursed to make breathing easier.
■ A fast pulse.
■ Round, barrel-shaped chest.
■ Confusion (caused by lack of oxygen to the brain).

EMPHYSEMA

Emphysema is a type of COPD. Emphysema is a disease that involves damage to the air sacs
in the lungs. It is a chronic (long-lasting or frequently recurring) disease that worsens over time.
The most common signal of emphysema is shortness of breath. Exhaling is extremely difficult.
In advanced cases, the affected person may feel restless, confused and weak, and even may
go into respiratory or cardiac arrest.

BRONCHITIS

Bronchitis is an inflammation of the main air passages to the lungs. It can be acute (short-
lasting) or chronic. Chronic bronchitis is a type of COPD. To be diagnosed with chronic
bronchitis, a person must have a cough with mucus on most days of the month for at least 3
months.

Acute bronchitis is not a type of COPD; it develops after a person has had a viral respiratory
infection. It first affects the nose, sinuses and throat and then spreads to the lungs. Those most
at risk for acute bronchitis include children, infants, the elderly, people with heart or lung disease
and smokers.

Signals of both types of bronchitis include:

■ Chest discomfort.
■ Cough that produces mucus.
■ Fatigue.
■ Fever (usually low).
■ Shortness of breath that worsens with activity.
 ■ Wheezing. Additional signals of chronic bronchitis include:
■ Ankle, feet and leg swelling.
■ Blue lips.
■ Frequent respiratory infections, such as colds or the flu.

HYPERVENTILATION

Hyperventilation occurs when a person’s breathing is faster and more shallow than normal.
When this happens, the body does not take in enough oxygen to meet its demands. People who
are hyperventilating feel as if they cannot get enough air. Often, they are afraid and anxious or
seem confused. They may say that they feel dizzy or that their fingers and toes feel numb and
tingly.

Hyperventilation often results from fear or anxiety and usually occurs in people who are tense
and nervous. However, it also can be caused by head injuries, severe bleeding or illnesses,
such as high fever, heart failure, lung disease and diabetic emergencies. Asthma and exercise
also can trigger hyperventilation.

Hyperventilation is the body’s way of compensating when there is a lack of enough oxygen.
The result is a decrease in carbon dioxide, which alters the acidity of the blood.

ALLERGIC REACTIONS

An allergic reaction is the response of the immune system to a foreign substance that enters
the body. Common allergens include bee or insect venom, antibiotics, pollen, animal dander,
sulfa and some foods such as nuts, peanuts, shellfish, strawberries and coconut oils.

Allergic reactions can cause breathing problems. At first the reaction may appear to be just a
rash and a feeling of tightness in the chest and throat, but this condition can become life
threatening. The person’s face, neck and tongue may swell, closing the airway.

A severe allergic reaction can cause a condition called anaphylaxis, also known as anaphylactic
shock. During anaphylaxis, air passages swell and restrict a person’s breathing. Anaphylaxis
can be brought on when a person with an allergy comes into contact with allergens via insect
stings, food, certain medications or other substances. Signals of anaphylaxis include a rash,
tightness in the chest and throat, and swelling of the face, neck and tongue. The person also
may feel dizzy or confused. Anaphylaxis is a life-threatening emergency.

Some people know that they are allergic to certain substances or to insect stings. They may
have learned to avoid these things and may carry medication to reverse the allergic reaction.
People who have severe allergic reactions may wear a medical identification (ID) tag, bracelet
or necklace.

CROUP

Croup is a harsh, repetitive cough that most commonly affects children younger than 5 years.
The airway constricts, limiting the passage of air, which causes the child to produce an unusual-
sounding cough that can range from a high-pitched wheeze to a barking cough. Croup mostly
occurs during the evening and nighttime.

Most children with croup can be cared for at home using mist treatment or cool air. However, in
some cases, a child with croup can progress quickly from respiratory distress to respiratory
arrest.

EPIGLOTTITIS

Epiglottitis is a far less common infection than croup that causes severe swelling of the
epiglottis. The epiglottis is a piece of cartilage at the back of the tongue. When it swells, it can
block the windpipe and lead to severe breathing problems. Epiglottitis usually is caused by
infection with Hemophilus influenzae bacteria.

The signals of epiglottitis may be similar to croup, but it is a more serious illness and can result
in death if the airway is blocked completely.

In the past, epiglottitis was a common illness in children between 2 and 6 years of age. However,
epiglottitis in children has dropped dramatically in the United States since the 1980s when
children began routinely receiving the H. influenzae type B (Hib) vaccine.

For children and adults, epiglottitis begins with a high fever and sore throat. A person with
epiglottitis may need to sit up and lean forward, perhaps with the chin thrust out in order to
breathe. Other signals include drooling, difficulty swallowing, voice changes, chills, shaking and
fever.

Seek medical care immediately for a person who may have epiglottitis. This condition is a
medical emergency.

WHAT TO LOOK FOR?

Although breathing problems have many causes, you do not need to know the exact cause of a
breathing emergency to care for it. You do need to be able to recognize when a person is having
trouble breathing or is not breathing at all.

Signals of breathing emergencies include:

■ Trouble breathing or no breathing.
■ Slow or rapid breathing.
■ Unusually deep or shallow breathing.
■ Gasping for breath.
■ Wheezing, gurgling or making high-pitched noises.
■ Unusually moist or cool skin.
■ Flushed, pale, ashen or bluish skin.
■ Shortness of breath.
■ Dizziness or light-headedness.
■ Pain in the chest or tingling in the hands, feet or lips.
■ Apprehensive or fearful feelings.

WHEN TO CALL 9-1-1?

If a person is not breathing or if breathing is too fast, too slow, noisy or painful, call 9-1-1 or the
local emergency number immediately.

WHAT TO DO UNTIL HELP ARRIVES?

If an adult, child or infant is having trouble breathing:

■ Help the person rest in a comfortable position. Usually, sitting is more comfortable than
 lying down because breathing is easier in that position
■ If the person is conscious, check for other conditions.
■ Remember that a person having breathing problems may find it hard to talk. If the
person cannot talk, ask him or her to nod or to shake his or her head to answer yes-or-no
questions. Try to reassure the person to reduce anxiety. This may make breathing easier.
■ If bystanders are present and the person with trouble breathing is having difficulty
answering your questions, ask them what they know about the person’s condition.
■ If the person is hyperventilating and you are sure whether it is caused by emotion, such
as excitement or fear, tell the person to relax and breathe slowly. A person who is
hyperventilating from emotion may resume normal breathing if he or she is reassured and
calmed down. If the person’s breathing still does not slow down, the person could have a
serious problem. If an adult is unconscious and not breathing, the cause is most likely a
cardiac emergency. Immediately begin CPR starting with chest compressions.

If an adult is not breathing because of a respiratory cause, such as drowning, or drug overdose,
give 2 rescue breaths after checking for breathing and before quickly scanning for severe
bleeding and beginning CPR.

Remember, a nonbreathing person’s greatest need is for oxygen. If breathing stops or is

restricted long enough, a person will become unconscious, the heart will stop beating and body
systems will quickly fail.

If a child or an infant is unconscious and not breathing, give 2 rescue breaths after checking for
breathing and before quickly scanning for severe bleeding and beginning CPR.

CHOKING

Choking is a common breathing emergency. It occurs when the person’s airway is partially or
completely blocked. If a conscious person is choking, his or her airway has been blocked by a
foreign object, such as a piece of food or a small toy; by swelling in the mouth or throat; or by
fluids, such as vomit or blood. With a partially blocked airway, the person usually can breathe
with some trouble. A person with a partially blocked airway may be able to get enough air in and
out of the lungs to cough or to make wheezing sounds. The person also may get enough air to
speak. A person whose airway is completely blocked cannot cough, speak, cry or breathe at all.

Causes of Choking in Adults Causes of choking in an adult include:

■ Trying to swallow large pieces of poorly chewed food.
■ Drinking alcohol before or during meals. (Alcohol dulls the nerves that aid swallowing.)
■ Wearing dentures. (Dentures make it difficult to sense whether food is fully chewed
before it is swallowed.)
■ Eating while talking excitedly or laughing, or eating too fast.
■ Walking, playing or running with food or objects in the mouth.

CAUSES OF CHOKING IN CHILDREN AND INFANTS

Choking is a common cause of injury and death in children younger than 5 years. Because
young children put nearly everything in their mouths, small, nonfood items, such as safety pins,
small parts from toys and coins, often cause choking. However, food is responsible for most of
the choking incidents in children.

The American Academy of Pediatrics (AAP) recommends that young children not be given hard,
smooth foods such as raw vegetables. These foods must be chewed with a grinding motion,
which is a skill that children do not master until 4 years of age; therefore, children may attempt
to swallow these foods whole. For this same reason, the AAP recommends not giving children
peanuts until they are 7 years of age or older.

The AAP also recommends that young children not be given round, firm foods such as hot dogs
and carrot sticks unless they are chopped into small pieces no larger than ½ inch. Since choking
remains a significant danger to children younger than 5 years, the AAP further recommends
keeping the following foods, and other items meant to be chewed or swallowed, away from
young children:

■ Hard, gooey or sticky candy

■ Grapes
■ Popcorn
■ Chewing gum
■ Vitamins

Although food items cause most of the choking injuries in children, toys and household items
also can be hazardous. Balloons, when broken or un-inflated, can choke or suffocate young
children who try to swallow them. According to the Consumer Product Safety Commission
(CPSC), more children have suffocated on non-inflated balloons and pieces of broken balloons
than any other type of toy.

Other nonfood items that can cause choking include:

■ Baby powder.
■ Objects from the trash, such as eggshells and pop-tops from beverage cans.
■ Safety pins.
■ Coins.
■ Marbles.
■ Pen and marker caps.
■ Small button-type batteries. What to Look for Signals of choking include:
■ Coughing, either forcefully or weakly.
■ Clutching the throat with one or both hands (Fig. 4-4).
■ Inability to cough, speak, cry or breathe.
■ Making high-pitched noises while inhaling or noisy breathing.
■ Panic.
■ Bluish skin color.
■ Losing consciousness if blockage is not removed.

WHEN TO CALL 9-1-1?

If the person continues to cough without coughing up the object, have someone call 9-1-1 or the
local emergency number. A partially blocked airway can quickly become completely blocked.

A person whose airway is completely blocked cannot cough, speak, cry or breathe. Sometimes
the person may cough weakly or make high-pitched noises. This tells you that the person is not
getting enough air to stay alive. Act at once! If a bystander is available, have him or her call 9-
1-1 or the local emergency number while you begin to give care.

WHAT TO DO UNTIL HELP ARRIVES?

Caring for a Conscious Choking Adult or Child

If the choking person is coughing forcefully, let him or her try to cough up the object. A person
who is getting enough air to cough or speak is getting enough air to breathe. Stay with the person
and encourage him or her to continue coughing.

A conscious adult or child who has a completely blocked airway needs immediate care. Using
more than one technique often is necessary to dislodge an object and clear a person’s airway.
A combination of 5 back blows followed by 5 abdominal thrusts provides an effective way to
clear the airway obstruction.

To give back blows, position yourself slightly behind the person. Provide support by placing one
arm diagonally across the chest and bend the person forward at the waist until the upper airway
is at least parallel to the ground. Firmly strike the person between the shoulder blades with the
heel of your other hand.

To give abdominal thrusts to a conscious choking adult or child:

■ Stand or kneel behind the person and wrap your arms around his or her waist.
■Locate the navel with one or two fingers of one hand. Make a fist with the other hand
and place the thumb side against the middle of the person’s abdomen, just above the
navel and well below the lower tip of the breastbone.
■ Grab your fist with your other hand and give quick, upward thrusts into the abdomen.

Each back blow and abdominal thrust should be a separate and distinct attempt to dislodge the
obstruction. Continue sets of 5 back blows and 5 abdominal thrusts until the object is dislodged;
the person can cough forcefully, speak or breathe; or the person becomes unconscious. For a
conscious child, use less force when giving back blows and abdominal thrusts. Using too much
force may cause internal injuries.

A person who has choked and has been given back blows, abdominal thrusts and/or chest
thrusts to clear the airway requires a medical evaluation. Internal injuries and damage to the
airway may not be evident immediately.

SPECIAL SITUATIONS IN CARING FOR THE CONSCIOUS CHOKING ADULT OR CHILD

Special situations include:

■ A large or pregnant person. If a conscious choking person is too large for you to reach
around, is obviously pregnant or is known to be pregnant, give chest thrusts instead.
Chest thrusts for a conscious adult are like abdominal thrusts, except for the placement
of your hands. For chest thrusts, place your fist against the center of the person’s
breastbone. Then grab your fist with your other hand and give quick thrusts into the chest.

■ Being alone and choking. If you are alone and choking, bend over and press your
abdomen against any fi rm object, such as the back of a chair, a railing or the kitchen
sink. Do not bend over anything with a sharp edge or corner that might hurt you, and be
careful when leaning on a rail that is elevated. Alternatively, give yourself abdominal
thrusts, using your hands, just as if you were administering the abdominal thrusts to
another person.

■ A person in a wheelchair. For a choking person in a wheelchair, give abdominal thrusts

CARING FOR A CONSCIOUS CHOKING INFANT

If you determine that a conscious infant cannot cough, cry or breathe, you will need to give a
combination of 5 back blows followed by 5 chest thrusts.
To give back blows:

■ Position the infant face-up on your forearm. Place one hand and forearm on the child’s
back, cradling the back of the head, and one hand and forearm on the front of the infant.
Use your thumb and fingers to hold the infant’s jaw while sandwiching the infant between
your forearms. Turn the infant over so that he or she is face-down along your forearm.

■ Lower your arm onto your thigh so that the infant’s head is lower than his or her chest.
Then give 5 firm back blows with the heel of your hand between the shoulder blades.
Each back blow should be a separate and distinct attempt to dislodge the object.

■ Maintain support of the infant’s head and neck by firmly holding the jaw between your
thumb and forefinger.

To give chest thrusts:

■ Place the infant in a face-up position.

Place one hand and forearm on the child’s back, cradling the back of the head, while
keeping your other hand and forearm on the front of the infant. Use your thumb and fingers
to hold the infant’s jaw while sandwiching the infant between your forearms.
Turn the infant onto his or her back.
■ Lower your arm that is supporting the infant’s back onto your opposite thigh. The infant’s
head should be lower than his or her chest, which will assist in dislodging the object.
■ Place the pads of two or three fingers in the center of the infant’s chest just below the
nipple line (toward the infant’s feet).
■ Use the pads of these fingers to compress the breastbone. Compress the breastbone 5
times about 11⁄2 inches and then let the breastbone return to its normal position. Keep
your fingers in contact with the infant’s breastbone.

Continue giving sets of 5 back blows and 5 chest thrusts until the object is forced out; the infant
begins to cough forcefully, cry or breathe on his or her own; or the infant becomes
unconscious.

You can give back blows and chest thrusts effectively whether you stand, kneel or sit, as long
as the infant is supported on your thigh and the infant’s head is lower than the chest. If the
infant is large or your hands are too small to adequately support it, you may prefer to sit.

Use less force when giving back blows and chest thrusts to an infant than for a child or an
adult. Using too much force may cause internal injuries.
 CHAPTER 4
SOFT TISSUE INJURIES

LESSON OBJECTIVES

1. Identify signals of various soft tissue and musculoskeletal injuries.

2. Describe how to care for various soft tissue and musculoskeletal injuries.
3. Demonstrate how to control external bleeding.

INTRODUCTION

Soft tissue injuries happen to children and adults of all ages. They can be minor, serious or life
threatening. Examples of minor soft tissue injuries include scrapes, bruises and mild sunburns.
Examples of serious soft tissue injuries include large cuts that require stitches and partial-thickness
burns. Life-threatening soft tissue injuries include stab wounds to the abdomen, lacerations that
cause serious bleeding and full-thickness burns. This chapter discusses the signals of soft tissue
injuries, including closed wounds, open wounds and burns. You will read about the differences
between major wounds and minor wounds and between different types of burns. In addition, you
will learn when to call 9-1-1 or the local emergency number and how to give care.
WOUNDS
Soft tissues are the layers of skin and the fat and muscle beneath the skin’s outer layer. An injury
to the soft tissue commonly is called a wound. Any time the soft tissue is damaged or torn, the body
is threatened. Injuries may damage the soft tissue at or near the skin’s surface or deep in the body.
Severe bleeding can occur at the skin’s surface or beneath, where it is harder to detect. Germs can
enter the body through the wound and cause infection.
Wounds usually are classified as either closed or open. In a closed wound, the skin’s surface is
not broken; therefore, tissue damage and any bleeding occur below the surface. In an open
wound, the skin’s surface is broken, and blood may come through the tear in the skin.
Fortunately, most of the bleeding you will encounter will not be serious. In most cases it usually
stops by itself within a few minutes with minimal intervention. The trauma may cause a blood vessel
to tear causing bleeding, but the blood at the wound site usually clots quickly and stops flowing.
Sometimes, however, the damaged blood vessel is too large or the pressure in the blood vessel is
too great for the blood to clot, then bleeding can be life threatening. This can happen with both
closed and open wounds.
Closed Wounds
The simplest closed wound is a bruise. A bruise develops when the body is bumped or hit, such as
when you bump your leg on a table or chair. The force of the blow to the body damages the soft
tissue layers beneath the skin. This causes internal bleeding. Blood and other fluids seep into the
surrounding tissues, causing the area to swell and change color.
A more serious closed wound can be caused by a violent force hitting the body. This type of force
can injure larger blood vessels and deeper layers of muscle tissue, which may result in heavy
bleeding beneath the skin and damage to internal organs.
WHAT TO LOOK FOR?

Signals of internal bleeding include:

■ Tender, swollen, bruised or hard areas of the body, such as the abdomen.
■ Rapid, weak pulse.
■ Skin that feels cool or moist or looks pale or bluish.
■ Vomiting blood or coughing up blood.
■ Excessive thirst.
■ An injured extremity that is blue or extremely pale.
■ Altered mental state, such as the person becoming confused, faint, drowsy or unconscious.

WHEN TO CALL 9-1-1

Call 9-1-1 or the local emergency number if:

■ A person complains of severe pain or cannot move a body part without pain.
■ You think the force that caused the injury was great enough to cause serious damage.
■ An injured extremity is blue or extremely pale.
■ The person’s abdomen is tender and distended.
■ The person is vomiting blood or coughing up blood.
■ The person shows signals of shock or becomes confused, drowsy or unconscious.

WHAT TO DO UNTIL HELP ARRIVES?

Many closed wounds, like bruises, do not require special medical care. To care for a closed wound,
you can apply an ice pack to the area to decrease bleeding beneath the skin.

Applying cold also can be effective in helping to control both pain and swelling (Fig. 7-3). Fill a
plastic bag with ice and water or wrap ice in a wet cloth and apply it to the injured area for periods
of about 20 minutes. Place a thin barrier between the ice and bare skin. Remove the ice and wait
for 20 minutes before reapplying. If the person is not able to tolerate a 20–minute application, apply
the ice pack for periods of 10 minutes on and off. Elevating the injured part may help to reduce
swelling; however, do not elevate the injured part if it causes more pain.

Do not assume that all closed wounds are minor injuries. Take the time to find out whether more
serious injuries could be present. With all closed wounds, help the person to rest in the most
comfortable position possible. In addition, keep the person from getting chilled or overheated. It
also is helpful to comfort and reassure the person. Be sure that a person with an injured lower
extremity does not bear weight on it until advised to do so by a medical professional.
OPEN WOUNDS

In an open wound, the break in the skin can be as minor as a scrape of the surface layers or as
severe as a deep penetration. The amount of bleeding depends on the location and severity of the
injury.

The four main types of open soft tissue wounds are abrasions, lacerations, avulsions and
punctures.

ABRASIONS

Abrasions are the most common type of open wound. They usually are caused by something
rubbing roughly against the skin. Abrasions do not bleed much. Any bleeding that occurs comes
from capillaries (tiny blood vessels). Dirt and germs frequently have been rubbed into this type of
wound, which is why it is important to clean and irrigate an abrasion thoroughly with soap and water
to prevent infection.

Other terms for an abrasion include a scrape, a rug burn, a road rash or a strawberry. Abrasions
usually are painful because scraping of the outer skin layers exposes sensitive nerve endings.

LACERATIONS

Laceration is a cut in the skin, which commonly is caused by a sharp object, such as a knife,
scissors or broken glass. A laceration also can occur when a blunt force splits the skin. Deep
lacerations may cut layers of fat and muscle, damaging both nerves and blood vessels. Bleeding
may be heavy or there may be none at all. Lacerations are not always painful because damaged
nerves cannot send pain signals to the brain. Infection can easily occur with lacerations if proper
care is not given.

AVULSIONS

Avulsion is a serious soft tissue injury. It happens when a portion of the skin, and sometimes other
soft tissue, is partially or completely torn away. This type of injury often damages deeper tissues,
causing significant bleeding. Sometimes a violent force may completely tear away a body part,
including bone, such as a finger. This is known as an amputation. With amputations, sometimes
bleeding is easier to control because the tissues close around the vessels at the injury site. If there
is a violent tearing, twisting or crushing of the extremity, the bleeding may be hard to control.

PUNCTURES

Punctures usually occur when a pointed object, such as a nail, pierces the skin. A gunshot wound
is a puncture wound. Puncture wounds do not bleed much unless a blood vessel has been injured.
However, an object that goes into the soft tissues beneath the skin can carry germs deep into the
body. These germs can cause infections—sometimes serious ones. If the object remains in the
wound, it is called an embedded object.

WHEN TO CALL 9-1-1?

Call 9-1-1 or the local emergency number immediately for any major open or closed wound.

What to Do Until Help Arrives?

Give general care for all open wounds. Specific care depends on whether the person has a minor
or a major open wound.

GENERAL CARE FOR OPEN WOUNDS

General care for open wounds includes controlling bleeding, preventing infection and using
dressings and bandages.

Preventing Infection

When the skin is broken, the best initial defense against infection is to clean the area. For minor
wounds, after controlling any bleeding, wash the area with soap and water and, if possible, irrigate
with large amounts of fresh running water to remove debris and germs. You should not wash more
serious wounds that require medical attention because they involve more extensive tissue damage
or bleeding and it is more important to control the bleeding.

Sometimes even the best care for a soft tissue injury is not enough to prevent infection. You usually
will be able to recognize the early signals of infection. .
If this happens, the infected person should seek immediate professional medical attention.

If you see any signals of infection, keep the area clean, soak it in clean, warm water and apply an
antibiotic ointment if the person has no known allergies or sensitivities to the medication. Change
coverings over the wound daily.

DETERMINING IF THE PERSON NEEDS STITCHES

It can be difficult to judge when a wound requires stitches. One rule of thumb is that a health care
provider will need to stitch a wound if the edges of skin do not fall together, the laceration involves
the face or when any wound is over 1⁄2-inch-long.

Stitches speed the healing process, lessen the chances of infection and minimize scarring. They
should be placed within the first few hours after the injury. The following major injuries often require
stitches:
■ Bleeding from an artery or uncontrolled bleeding.
■ Wounds that show muscle or bone, involve joints, gape widely, or involve hands or feet.
 ■ Wounds from large or deeply embedded objects.
■ Wounds from human or animal bites.
■ Wounds that, if left unstitched, could leave conspicuous scars, such as those on the face.

USING DRESSINGS AND BANDAGES

All open wounds need some type of covering to help control bleeding and prevent infection. These
coverings commonly are referred to as dressings and bandages, and there are many types.

Dressings are pads placed directly on the wound to absorb blood and other fluids and to prevent
infection. To minimize the chance of infection, dressings should be sterile. Most dressings are
porous, allowing air to circulate to the wound to promote healing. Standard dressings include
varying sizes of cotton gauze, commonly ranging from 2 to 4 inches square. Larger dressings are
used to cover very large wounds and multiple wounds in one body area. Some dressings have
nonstick surfaces to prevent them from sticking to the wound.

An occlusive dressing is a bandage or dressing that closes a wound or damaged area of the body
and prevents it from being exposed to the air or water. By preventing exposure to the air, occlusive
dressings help to prevent infection. Occlusive dressings help to keep in place medications that
have been applied to the affected area. They also help to keep in heat, body fluids and moisture.
Occlusive dressings are manufactured but can be improvised. An example of an improvised
occlusive dressing is plastic wrap secured with medical tape. This type of dressing can be used for
certain chest and abdominal injuries. A bandage is any material that is used to wrap or cover any
part of the body.

Bandages are used to hold dressings in place, to apply pressure to control bleeding, to protect a
wound from dirt and infection, and to provide support to an injured limb or body part. Any bandage
applied snugly to create pressure on a wound or an injury is called a pressure bandage.

You can purchase many different types of bandages, including:

 Adhesive compresses, which are available in assorted sizes and consist of a small pad of
nonstick gauze on a strip of adhesive tape that is applied directly to minor wounds.

 Bandage compresses, which are thick gauze dressings attached to a bandage that is tied in place.
 Roller bandages, which are usually made of gauze or gauze-like material. Roller bandages are
available in assorted widths from 1⁄2 to 12 inches (1.3–30.5 cm) and in lengths from 5 to 10 yards.
A narrow bandage would be used to wrap a hand or wrist. A medium-width bandage would be used
for an arm or ankle. A wide bandage would be used to wrap a leg. A roller bandage generally is
wrapped around the body part. It can be tied or taped in place. A roller bandage also may be used
to hold a dressing in place, secure a splint or control external bleeding.

Follow these general guidelines when applying a roller bandage:

■ Check for feeling, warmth and color of the area below the injury site, especially fingers and
toes, before and after applying the bandage.
■ Elevate the injured body part only if you do not suspect that a bone has been broken and if
doing so does not cause more pain.
■ Secure the end of the bandage in place with a turn of the bandage. Wrap the bandage around
the body part until the dressing is completely covered and the bandage extends several inches
beyond the dressing. Tie or tape the bandage in place.
■ Do not cover fingers or toes. By keeping these parts uncovered, you will be able to see if the
bandage is too tight. If fingers or toes become cold or begin to turn pale, blue or ashen, the
bandage is too tight and should be loosened slightly.
■ Apply additional dressings and another bandage if blood soaks through the first bandage. Do not
remove the blood-soaked bandages and dressings. Disturbing them may disrupt the formation of
a clot and restart the bleeding.

Elastic roller bandages, sometimes called elastic wraps, are designed to keep continuous
pressure on a body part. Elastic bandages are available in 2-, 3-, 4- and 6-inch widths. As with
roller bandages, the first step in using an elastic bandage is to select the correct size of the
bandage: a narrow bandage is used to wrap a hand or wrist; a medium-width bandage is used for
an arm or ankle and a wide bandage is used to wrap a leg.

When properly applied, an elastic bandage may control swelling or support an injured limb, as in
the care for a venomous snakebite. However, an improperly applied elastic bandage can restrict
blood fl ow, which is not only painful but also can cause tissue damage if not corrected.

To apply an elastic roller bandage:

■ Check the circulation of the limb beyond where you will be placing the bandage by checking for
feeling, warmth and color.
■ Place the end of the bandage against the skin and use overlapping turns.
■ Gently stretch the bandage as you continue wrapping. The wrap should cover a long body
section, like an arm or a calf, beginning at the point farthest from the heart. For a joint like a knee
or an ankle, use figure-eight turns to support the joint.
■ Check the snugness of the bandaging—a finger should easily, but not loosely, pass under the
bandage.
■ Always check the area above and below the injury site for feeling, warmth and color, especially
fingers and toes, after you have applied an elastic roller bandage. By checking both before and
after bandaging, you will be able to tell if any tingling or numbness is from the bandaging or the
injury.

SPECIFIC CARE GUIDELINES FOR MINOR OPEN WOUNDS

In minor open wounds, such as abrasions, there is only a small amount of damage and minimal
bleeding. To care for a minor open wound, follow these general guidelines:
■ Use a barrier between your hand and the wound. If readily available, put on disposable
gloves and place a sterile dressing on the wound.
■ Apply direct pressure for a few minutes to control any bleeding.
■ Wash the wound thoroughly with soap and water. If possible, irrigate an abrasion for about
5 minutes with clean, warm, running tap water.
■ Apply an antibiotic ointment to a minor wound if the person has no known allergies or
sensitivities to the medication.
■ Cover the wound with a sterile dressing and a bandage or with an adhesive bandage to
keep the wound moist and prevent drying.

SPECIFIC CARE GUIDELINES FOR MAJOR OPEN WOUNDS

A major open wound has serious tissue damage and severe bleeding. To care for a major open
wound, you must act at once. Follow these steps:
■ Put on disposable gloves. If you suspect that blood might splatter, you may need to wear eye
and face protection.
■ Control bleeding by:
 Covering the wound with a dressing and firmly pressing against the wound with a
gloved hand until the bleeding stops.
 Applying a pressure bandage over the dressing to maintain pressure on the wound
and to hold the dressing in place.
 If blood soaks through the bandage, do not remove the blood-soaked bandages.
Instead, add more dressings and bandages and apply additional direct pressure.
■ Continue to monitor the person’s condition. Observe the person closely for signals that may
indicate that the person’s condition is worsening, such as faster or slower breathing, changes in
skin color and restlessness.
■ Care for shock. Keep the person from getting chilled or overheated.
■ Have the person rest comfortably and provide reassurance.
■ Wash your hands immediately after giving care, even if you wore gloves.

USING TOURNIQUETS WHEN HELP IS DELAYED

A tourniquet is a tight band placed around an arm or leg to constrict blood vessels in order to stop
blood flow to a wound. Because of the potential for adverse effects, a tourniquet should be used
only as a last resort in cases of delayed care or situations where response from emergency
medical services (EMS) is delayed, when direct pressure does not stop the bleeding or you are not
able to apply direct pressure.

For example, a tourniquet may be appropriate if you cannot reach the wound because of
entrapment, there are multiple injuries or the size of the wound prohibits application of direct
pressure. In most areas, application of a tourniquet is considered to be a skill at the emergency
medical technician (EMT) level or higher and requires proper training. There are several types of
manufactured tourniquets available and are preferred over makeshift (improvised) devices. For a
manufactured tourniquet, always follow the manufacturer’s instructions.

In general, the tourniquet is applied around the wounded extremity, just above the wound. The tag
end of the strap is routed through the buckle, and the strap is pulled tightly, which secures the
tourniquet in place. The rod (windlass) then is twisted to tighten the tourniquet until the bright-red
bleeding stops. The rod then is secured in place. The tourniquet should not be removed in the
prehospital setting once it is applied. The time that the tourniquet was applied should be noted and
recorded and then given to EMS personnel.

Blood pressure cuffs sometimes are used as a tourniquet to slow the fl ow of blood in an upper
extremity. Another technique is to use a bandage that is 4 inches wide and six to eight layers deep.
Always follow local protocols when the use of a tourniquet is considered.

HEMOSTATIC AGENTS

Hemostatic agents generally are substances that speed clot formation by absorbing the excess
moisture caused by the bleeding. Hemostatic agents are found in a variety of forms, including
treated sponge or gauze pads and powder or granular forms. The powder or granular forms are
poured directly on the bleeding vessel, then other hemostatic agents, such as gauze pads, are
used in conjunction with direct pressure.

Over-the-counter versions of hemostatic bandages are available in addition to hemostatic agents

intended for use by professional rescuers. Some are more effective than others. However, because
some types present a risk of further injury or tissue damage, the routine use of hemostatic agents
in first aid settings is not recommended.

BURNS

Burns are a special kind of soft tissue injury. Like other types of soft tissue injury, burns can
damage the top layer of skin or the skin and the layers of fat, muscle and bone beneath. Burns are
classified by their depth. The deeper the burn, the more severe it is. The three classifications of
burns are as follows: superficial (sometimes referred to as first degree), partial thickness
(sometimes referred to as second degree) and full thickness (sometimes referred to as third
degree). Burns also are classified by their source: heat (thermal), chemical, electrical and radiation
(such as from the sun).

A critical burn requires immediate medical attention. These burns are potentially life threatening,
disfiguring and disabling. Unfortunately, it often is difficult to tell if a burn is critical. Even superficial
burns can be critical if they affect a large area or certain body parts. You cannot judge a burn’s
severity by the person’s level of pain because nerve endings may be destroyed.

Be aware that burns to a child or an infant could be caused by child abuse. Burns that are done
intentionally to a child often leave an injury that cannot be hidden. One example is a sharp line
dividing the burned and unburned skin such as from scalding water in a tub. If you think you have
reasonable cause to believe that abuse has occurred, report your suspicions to the appropriate
community or state agency.

WHAT TO LOOK FOR?

Signals of burns depend on whether the burn is superficial, partial thickness or full thickness.

■ Superficial burns:
 Involve only the top layer of skin.
 Cause skin to become red and dry, usually painful and the area may swell.
 Usually heal within a week without permanent scarring.

■ Partial-thickness burns:
 Involve the top layers of skin.
 Cause skin to become red; usually painful; have blisters that may open and weep
clear fluid, making the skin appear wet; may appear mottled; and often swells.
 Usually heal in 3 to 4 weeks and may scar.

■ Full-thickness burns:
 May destroy all layers of skin and some or all of the underlying structures—fat,
muscles, bones and nerves.
 The skin may be brown or black (charred), with the tissue underneath sometimes
appearing white, and can either be extremely painful or relatively painless (if the
burn destroys nerve endings).
 Healing may require medical assistance; scarring is likely.

WHEN TO CALL 9-1-1

You should always call 9-1-1 or the local emergency number if the burned person has:
■ Trouble breathing.
■ Burns covering more than one body part or a large surface area.
 ■ Suspected burns to the airway. Burns to the mouth and nose may be a sign of this.
■ Burns to the head, neck, hands, feet or genitals.
■ A full-thickness burn and is younger than 5 years or older than 60 years.
■ A burn caused by chemicals, explosions or electricity.

WHAT TO DO UNTIL HELP ARRIVES?

Care given for burns depends on the type of burn.

Heat (Thermal) Burns

Follow these basic steps when caring for a heat burn:

■ Check the scene for safety.
■ Stop the burning by removing the person from the source of the burn.
■ Check for life-threatening conditions.
■ As soon as possible, cool the burn with large amounts of cold running water, at least until
pain is relieved.
■ Cover the burn loosely with a sterile dressing
■ Take steps to minimize shock. Keep the person from getting chilled or overheated.
■ Comfort and reassure the person.
■ Do not apply ice or ice water to any burn. Ice and ice water can cause the body to lose
heat rapidly and further damages body tissues.
■ Do not touch a burn with anything except a clean covering.
■ Do not remove pieces of clothing that stick to the burned area.
■ Do not try to clean a severe burn.
■ Do not break blisters.
■ Do not use any kind of ointment on a severe burn.

When a person suffers a burn, he or she is less able to regulate body temperature. As a
result, a person who has been burned tends to become chilled. To help maintain body temperature
and prevent hypothermia, keep the person warm and away from drafts. Remember that cooling a
burn over a large area of the body can bring on hypothermia. Be aware of this risk and look for
signals of hypothermia. If possible, monitor the person’s core body temperature when cooling a
burn that covers a large area.

CHEMICAL BURNS

When caring for chemical burns it is important to remember that the chemical will continue to burn
as long as it is on the skin. You must remove the chemical from the skin as quickly as possible.
To do so, follow these steps:
■ If the burn was caused by dry chemicals, brush off the chemicals using gloved hands or a
towel and remove any contaminated clothing before flushing with tap water (under pressure).
Be careful not to get the chemical on yourself or on a different area of the person’s skin.
■ Flush the burn with large amounts of cool running water. Continue flushing the burn for at
least 20 minutes or until EMS personnel take over.
■ If an eye is burned by a chemical, flush the affected eye with water until EMS personnel
take over. Tilt the head so that the affected eye is lower than the unaffected eye as you flush.
■ If possible, have the person remove contaminated clothes to prevent further contamination
while you continue to flush the area.

Be aware that chemicals can be inhaled, potentially damaging the airway or lungs.
ELECTRICAL BURNS

If you encounter a person with an electrical burn, you should:

■ Never go near the person until you are sure he or she is not still in contact with the power
source.
■ Turn off the power at its source and care for any life-threatening conditions.
■ Call 9-1-1 or the local emergency number. Any person who has suffered an electrical shock
needs to be evaluated by a medical professional to determine the extent of injury.
■ Be aware that electrocution can cause cardiac and respiratory emergencies. Therefore,
be prepared to perform CPR or use an automated external defibrillator (AED).
■ Care for shock and thermal burns.
■ Look for entry and exit wounds and give the appropriate care.
■ Remember that anyone suffering from electric shock requires advanced medical care.

RADIATION BURNS

Care for a radiation (sun) burn as you would for any thermal burn. Always cool the burn and protect
the area from further damage by keeping the person away from the source of the burn.

PREVENTING BURNS

■ Heat burns can be prevented by following safety practices that prevent fire and by being
careful around sources of heat.
■ Chemical burns can be prevented by following safety practices around all chemicals and
by following manufacturers’ guidelines when handling chemicals.
■ Electrical burns can be prevented by following safety practices around electrical lines and
equipment and by leaving outdoor areas when lightning could strike.
■ Sunburn can be prevented by wearing appropriate clothing and using sunscreen.
Sunscreen should have a sun protection factor (SPF) of at least 15.

WHAT TO LOOK FOR?

Signals of a serious chest injury include:

■ Trouble breathing.
■ Severe pain at the site of the injury.
■ Flushed, pale, ashen or bluish skin.
■ Obvious deformity, such as that caused by a fracture.
■ Coughing up blood (may be bright red or dark, like coffee grounds).
■ Bruising at the site of a blunt injury, such as that caused by a seat belt.
■ A “sucking” noise or distinct sound when the person breathes.

WHEN TO CALL 9-1-1?

Call 9-1-1 or the local emergency number for any open or closed chest wound, especially
if the person has a puncture wound to the chest. Also call if the person has trouble breathing or a
sucking chest wound, or if you suspect rib fractures.

WHAT TO DO UNTIL HELP ARRIVES?

Care for a chest injury depends on the type of injury.

WHAT TO LOOK FOR?

Signals of serious abdominal injury include:

■ Severe pain.
■ Bruising.
■ External bleeding.
■ Nausea.
■ Vomiting (sometimes blood).
■ Weakness.
■ Thirst.
■ Pain, tenderness or a tight feeling in the abdomen.
■ Organs protruding from the abdomen.
■ Rigid abdominal muscles.
■ Other signals of shock.

WHEN TO CALL 9-1-1?

Call 9-1-1 or the local emergency number for any serious abdominal injury.

WHAT TO DO UNTIL HELP ARRIVES?

With a severe open injury, abdominal organs sometimes protrude through the wound.
To care for an open wound to the abdomen, follow these steps:
 Put on disposable gloves or use another barrier.
 Carefully position the person on his or her back with the knees bent, if that position does
not cause pain.
 Do not apply direct pressure.
 Do not push any protruding organs back into the open wound.
 Remove clothing from around the wound.
 Apply moist, sterile dressings loosely over the wound (clean, warm tap water can be used).
 Cover dressings loosely with plastic wrap, if available.

To care for a closed wound to the abdomen:

While keeping the injured area still, apply cold to the affected area to control pain and swelling.
Carefully position the person on his or her back with the knees bent, if that position does not
cause pain.
Keep the person from getting chilled or overheated.

PUTTING IT ALL TOGETHER

For minor soft tissue injuries like scrapes, bruises and sunburns, it is important to give
quick care and take steps to prevent infection. If you do this, these types of wounds and burns
usually heal quickly and completely.

Serious and life-threatening soft tissue injuries are emergencies. Call 9-1-1 or the local
emergency number and give immediate care. These are crucial steps for any serious wound or
burn.