Comprehensive Study Notes: ACEP First Aid Manual (American College of Emergency Physicians) First Aid Manual

BECOMING A FIRST AIDER

  • Definition of First Aid: The initial assistance or treatment given to a person who is injured or suddenly becomes ill. This can be provided by a first aider, first responder, law enforcement, firefighter, or EMT/paramedic.
  • Aims and Objectives:
    • Understand personal abilities and limitations.
    • Stay safe and calm at all times.
    • Assess situations quickly to summon appropriate help.
    • Provide treatment, utilizing bystanders when possible.
    • Pass relevant information to emergency services.
    • Be aware of personal physical and emotional needs.
  • First Aid Priorities:
    • Assess the scene: Stay calm and check for safety before approaching.
    • Protect yourself and casualties: Never enter hazardous circumstances; call 911 if the area is unsafe.
    • Prevent cross-contamination: Use barriers like gloves and masks.
    • Comfort and reassure: Build trust to facilitate better assessments.
    • Assess the casualty: Identify the nature of the illness or injury.
    • Early treatment: Address life-threatening conditions first.
    • Arrange help: Stay with the casualty until higher-level care arrives.
  • Psychological Preparation and Control:
    • Emotional Responses: Understand the "fight, flight, or freeze" response caused by hormones, manifesting as faster heartbeat, quickened breathing, and sweating.
    • Staying in Control: Take slow breaths. Cognitive behavioral link: thoughts influence feelings and actions; maintaining calm allows for clearer planning.
  • Protection from Infection:
    • Cross-contamination Risk: Germs can be transmitted both ways, even in minor injuries. Blood-borne viruses of concern include Hepatitis B, Hepatitis C, and HIV. The risk during resuscitation is proven to be extremely low.
    • Protection Methods: Wash hands thoroughly with soap and water or alcohol gel. Wear latex-free disposable gloves (nitrile is recommended, often blue or purple). Use pocket masks or face shields for rescue breaths.
    • Hand-Washing Procedure: (1) Wet hands and apply soap. (2) Rub palms. (3) Rub back of fingers against opposing palms. (4) Interlock fingers and work soap between them. (5) Rub thumbs in rotating motion. (6) Rub fingertips in palms and pat dry with disposable towels.
    • Waste Disposal: Soiled materials go in plastic biohazard bags labeled "clinical waste." Sharp objects/needles go in red sharps containers. If unavailable, use a secure jar with a screw top.
  • Dealing with a Casualty:
    • Building Trust: Introduce yourself, find out what the casualty likes to be called, kneel to their eye level, explain actions before performing them, and gain consent.
    • Diversity and Communication: Use simple language or signs for those with hearing impairments or language barriers.
    • Treating Children: Use simpler words and shorter sentences. Establish trust with the parent/caregiver first to reassure the child.
    • Listening Skills: Use eye contact (without staring), affirming nods ("mmms"), simple hand gestures, and summarize their statements to show understanding.
    • When a Casualty Resists Help: A person has the right to refuse care even if it causes harm. Monitor from a distance and tell the 911 dispatcher help was refused. This refusal may be due to head injury or hypothermia.
  • Enlisting Help from Others: Bystanders can control traffic, call 911, retrieve AEDs, hold blankets for privacy, or help move the casualty if they are in immediate danger.
  • Record Keeping: Keep notes on the history of the incident, injuries, vital signs (response level, breath rate, pulse), medications taken, and next-of-kin details. Information is confidential.
  • Requesting Help via 911:
    • Details to Provide: Phone number, exact location (road name, intersection, or landmarks), type/gravity of emergency, and number/age/gender of casualties.
    • The Call: Always let the dispatcher hang up first. Tracy the call if the location is unknown.
  • Use of Medication: First aid is largely confined to helping a casualty take their own prescribed medicines. Do not buy or borrow medication for a casualty. Never give aspirin to anyone under 16 due to the risk of Reye’s syndrome.
  • Self-Care Post-Incident: First aiders may feel satisfaction, confusion, worry, anger, or fear. Discuss the event with trusted individuals. Persistent symptoms like flashbacks or nightmares require medical consultation.

MANAGING AN INCIDENT

  • Plan of Action: (1) Assess the situation for safety. (2) Make the area safe. (3) Give first aid (primary survey first).
  • Scene Assessment Factors:
    • Safety: Identify ongoing dangers.
    • Scene: Identify mechanisms of injury and potential number of casualties.
    • Situation: Identify what happened.
  • Helicopter Rescue Safety: Keep bystanders 50 yards (45 m)50\,\text{yards}\,(45\,m) away. Do not smoke. Kneel as the helicopter approaches and wait for crew instructions. Stay clear of rotor blades.
  • Traffic Accidents:
    • Safety Steps: Park away, use hazard lights, wear high-visibility vests. Set warning triangles/flares 50 yards (45 m)50\,\text{yards}\,(45\,m) away in both directions.
    • Vehicle Safety: Switch off ignitions. Apply emergency brakes. Do not right a vehicle that is on its side.
    • HAZMAT Signs: Stay upwind and clear if hazardous substance symbols are present.
  • Fires:
    • Triangle of Fire: Ignition (spark), Fuel (wood/gas), and Oxygen (air). Remove one to stop the fire.
    • Procedures: Call 911. Evacuate via stairs (no elevators). Stop, Drop, and Roll if clothes on fire. Wrap in a fire blanket or heavy fabric (not nylon).
    • Smoke/Fumes: Stay low (air is clearest at floor level). If trapped, block door gaps with rugs and stay in a room at the front of the building.
  • Electrical Incidents:
    • High-Voltage (Power lines): Can arc up to 20 yards (18 m)20\,\text{yards}\,(18\,m). Contact is often fatal (9,000∘F / 5,000∘C9,000^{\circ}F\, / \, 5,000^{\circ}C). Do not approach until power is confirmed off.
    • Low-Voltage (Home/Office): 110−120V110-120V or 220−240V220-240V. AC current causes "tetany" (muscle spasms) locking the casualty to the source. Break contact at the circuit box or wall switch.
    • Lightning: Clear the site as strikes can repeat in the same spot. Start CPR immediately if the pulse/breathing is absent.
  • Water Incidents:
    • Rescue Priority: Get the casualty to dry land with minimal danger to yourself. Use sticks or ropes. If the casualty is unconscious, lift with their head lower than their chest to protect the airway.
    • Secondary Drowning: Always send to the hospital as lungs can swell hours later from irritation.
  • Major Incidents/Mass Casualties: Declared by emergency services. Perimeters (inner/outer) are established.
    • Triage System:
      • Red (Priority 1): Immediate/cannot walk.
      • Yellow (Priority 2): Urgent.
      • Green (Priority 3): Minor injuries/walking.
      • Gray/Black: Dead or critically injured.

ASSESSING A CASUALTY

  • The Primary Survey (ABC):
    • Airway: Is it open and clear? If the casualty talks, it is clear. If unconscious, use head tilt–chin lift.
    • Breathing: Check for normal breathing (not agonal gasps). Start CPR if absent. Treat difficulties like asthma.
    • Circulation: Check for severe bleeding. Control bleeding to minimize shock.
  • Secondary Survey: A detailed head-to-toe examination performed once life-threatening conditions are stabilized.
    • Taking a History (AMPLE): Allergy, Medications, Previous history, Last meal, Event history.
    • Symptoms: What the casualty tells you (pain location, type, nausea).
    • Signs: What you see, feel, hear, or smell (swelling, deformity, bleeding, crepitus/grating bone ends).
  • Head-to-Toe Examination Steps:
    1. Head: Feel for bleeding/swelling. Check ears/nose for clear fluid or watery blood (skull fracture sign).
    2. Eyes: Check pupil size (unequal size suggests head injury).
    3. Mouth: Check for obstructions; leave tight dentures.
    4. Skin: Note color (pale/clammy = shock; flushed = fever; blue/cyanosis = hypoxia).
    5. Spine: Feel along from skull base without moving the casualty.
    6. Chest: Check expansion and feel for rib cage tenderness.
    7. Abdomen: Feel for rigidity (internal bleeding sign).
    8. Pelvis: Check for incontinence or bleeding from orifices.
    9. Limbs: Check movement, sensation, and look for medical alert bracelets or needle marks.
  • Vital Signs Monitoring:
    • Level of response (AVPU): Alert, Voice, Pain, Unresponsive.
    • Breathing Rate: Adult normal is 12−16 breaths per minute12-16\,\text{breaths per minute}; babies/children are 20−30 breaths per minute20-30\,\text{breaths per minute}.
    • Pulse Rate: Adult normal is 60−100 beats per minute60-100\,\text{beats per minute}. Check radial (wrist), carotid (neck), or brachial (infant arm).
    • Temperature: Normal is 98.6∘F (37∘C)98.6^{\circ}F\,(37^{\circ}C). Fever is >100.4∘F (38∘C)>100.4^{\circ}F\,(38^{\circ}C).

THE UNCONSCIOUS CASUALTY

  • Physiological Priority (C-A-B): Circulation (chest compressions), Airway, Breathing. Compressions are prioritized in adults because blood oxygen remains constant for the first few minutes after arrest.
  • Resuscitation Action Plan (Adult):
    1. Check response: Shake shoulders, shout. No response = Unconscious.
    2. Check breathing: Look at chest for 1010 seconds. Agonal breathing (short, irregular gasps) counts as not breathing.
    3. Call 911 and get an AED.
    4. Give 30 compressions: Heel of hand in center of chest, depress 2 in (5 cm)2\,in\,(5\,cm), rate of 100−120/min100-120/min. Allow full recoil.
    5. Give 2 rescue breaths: Use head tilt–chin lift, pinch nose, blow for 11 second until chest rises.
    6. Continue cycles (30:230:2).
  • Chest-Compression-Only CPR: Recommended for untrained rescuers or those unable to give breaths. 911 dispatchers give instructions for this.
  • Child Resuscitation (11 year to puberty):
    • Check response by tapping shoulder.
    • Compressions: Heel of one hand, depress 1/31/3 of chest depth (≈2 in / 5 cm\approx 2\,in\,/\,5\,cm). Rate at least 100/min100/min.
    • Breath: cycles of 30:230:2. If alone, perform 22 minutes of CPR before calling 911.
  • Infant Resuscitation (under 11 year):
    • Response: Flick sole of foot. Never shake.
    • Airway: Very gentle head tilt; use rolled towel under shoulders if needed.
    • Compressions: Two fingertips in center of chest, depress 1/31/3 depth (≈1.5 in / 4 cm\approx 1.5\,in\,/\,4\,cm).
    • Breaths: Form seal over mouth AND nose.
  • Recovery Position: Used for breathing unconscious casualties to prevent airway obstruction by the tongue or vomit.
    1. Arm closest to you at right angles, palm up.
    2. Far arm across chest, back of hand against cheek.
    3. Far leg pulled up, foot flat.
    4. Roll toward you. Tilt head back.
    5. Check every 3030 mins, roll to other side after 3030 mins.
  • AED (Automated External Defibrillator) Use:
    • Steps: Switch on, attach pads (top right below collarbone, left side below armpit), clear everyone for analysis, deliver shock if advised, resume CPR for 22 minutes.
    • Considerations: Shave excessive hair if it prevents contact. Dry the chest. Move one or both breasts in pregnant women to place pads correctly with dignity.
    • Children: Pediatric pads preferred for ages 1−81-8. If unavailable, use adult pads. Position one on chest and one on back if the child is small.

RESPIRATORY PROBLEMS

  • Hypoxia: Low oxygen in tissues. Symptoms include rapid, distressed breathing, cyanosis (gray-blue skin), confusion, and restlessness.
  • Airway Obstruction (Choking):
    • Adult/Child: Ask "Are you choking?" If they can't speak/cough/breathe, give up to 55 abdominal thrusts (fist between navel and breastbone, pull inward and upward). Repeat until cleared or unconscious.
    • Infant: 55 back blows (head low, face down), then 55 chest thrusts (two fingers). No abdominal thrusts.
  • Asthma: Inhaler (usually blue or white) with a spacer. Sit the casualty slightly forward. Call 911 if they become exhausted or talking is impossible.
  • Croup: Viral infection in children. Create a steamy atmosphere. Do not put fingers down the throat (risk of epiglottitis spasm).
  • Penetrating Chest Wound: Air entering the pleural space can cause pneumothorax (collapsed lung). Cover with foil/plastic, tape 33 sides (leave one corner untaped to act as a valve).

CIRCULATION AND WOUNDS

  • Shock: failure of the circulatory system. Occurs when >2 pints (1.2 dm3)>2\,\text{pints}\,(1.2\,dm^3) of blood or fluid is lost.
    • Recognition: Cold, pale, clammy skin; rapid pulse; weak/thready pulse; gray-blue lips.
    • Treatment: Lay down, raise and support legs. Keep warm. Do not give food or drink.
  • Bleeding Types:
    • Arterial: Bright red, spurts with heartbeats.
    • Venous: Dark red, gushes profusely.
    • Capillary: Brisk at first, then slight oozing.
  • Severe External Bleeding: Direct pressure with sterile dressing. Raise limb above heart. Secure with bandage (not too tight). If an object is embedded, pad around it; do not remove it.
  • Internal Bleeding Signs: Fresh red blood from ear (perforated eardrum) vs. watery blood (skull fracture). Vomiting red or "coffee ground" blood (digestive system bleed). Black, tarry stools (melena).
  • Amputation: Control bleeding. Wrap severed part in plastic wrap, then soft fabric. Place in container with crushed ice. Mark with name/time. Do not wash.
  • Crush Injury: If trapped <15<15 minutes, release immediately. If trapped >15>15 minutes, leave in place and wait for specialized help (risk of "crush syndrome" - sudden release of toxins causing kidney failure).

BONE, JOINT, AND MUSCLE INJURIES

  • Fractures:
    • Closed: Skin intact.
    • Open: Bone protrudes; cover with sterile dressing and build padding around bone ends.
    • Stable: Ends do not move.
  • Strains and Sprains (RICE): Rest, Ice (1010 mins on, 55 off), Compression (elastic bandage), Elevation.
  • Spinal Injury: Suspect in falls from a height or motor accidents.
    • Symptoms: Loss of control, burning/tingling in limbs, loss of bowel/bladder control.
    • Management: Manual In-line Stabilization (MILS). Hold head still in neutral position. Use jaw thrust to open airway. Log-roll if the victim must be turned.
  • Pelvic Fracture: High risk of internal bleeding and shock. Immobilize legs by padding between knees/ankles and bandaging them together.

ENVIRONMENTAL EFFECTS

  • Burns:
    • Superficial: Redness, swelling (sunburn).
    • Partial-thickness: Blisters. Hospitalize if >10%>10\%. Do not burst blisters.
    • Full-thickness: Waxy, pale, charred. Pain sensation may be lost. Urgent hospital care.
    • Cooling: Flush with cool water for at least 1010 minutes (2020 for chemicals). Remove jewelry before swelling.
  • Heat Exhaustion: Sweat-induced loss of water/salt. Symptoms: Pale, clammy, dizziness. Treatment: Shade, lie down, raise legs, small sips of water/rehydration salts.
  • Heatstroke: failure of brain thermostat. Symptoms: Hot, dry skin, temp >104∘F (40∘C)>104^{\circ}F\,(40^{\circ}C). Treatment: Urgent cooling (cool water spray + fanning, ice packs in armpits/groin).
  • Hypothermia: Body temp <95∘F (35∘C)<95^{\circ}F\,(35^{\circ}C). Severe at <86∘F (30∘C)<86^{\circ}F\,(30^{\circ}C). Wrap in survival bag/blankets. Rewarm the room to 77∘F (25∘C)77^{\circ}F\,(25^{\circ}C).

MEDICAL CONDITIONS

  • Heart Attack: Vicelike chest pain, breathlessness, profuse sweating, "ashen" skin. Treatment: Call 911, sit in half-supported position with knees bent. Give one adult aspirin (325 mg325\,mg) to chew.
  • Stroke (FAST): Facial weakness, Arm weakness (can't lift both), Speech problems, Time to call 911. Do not give food/drink.
  • Diabetes:
    • Hyperglycemia: develops slowly, fruity breath, dry skin.
    • Hypoglycemia: develops rapidly, sweating, hunger, confusion. Give 10 g10\,g sugar (sugary drink, sweets).
  • Seizures: Protect head, note start time. Do not restrain. Febrile seizures (children with fever) - cool by removing clothes/bedding.
  • Meningitis: High temp, headache, stiff neck, sensitivity to light. Non-fading rash (test with glass press). Call 911 immediately.
  • Anaphylactic Shock: Severe allergy. Treatment: Epinephrine auto-injector (EpiPen) into outer thigh. Call 911.
  • Childbirth: Cervix dilates to 4 in (10 cm)4\,in\,(10\,cm). Three stages. In emergency birth, do not pull baby. Let birth happen naturally. Do not cut or pull the umbilical cord.

FIRST AID MATERIALS AND REGULATIONS

  • Home First Aid Kit: Identifiable watertight box, 2020 adhesive bandages, 66 medium sterile dressings, 22 large dressings, eye pad, 66 triangular bandages, 66 safety pins, disposable gloves, 22 roller bandages, scissors, tweezers, cleansing wipes, tape, face shield, notepad/pencil.
  • Slings:
    • Arm Sling: Supports forearm in horizontal position. Knot at shoulder.
    • Elevation Sling: Keeps fingertips at shoulder level for bleeding/swelling control in the hand/arm.
  • Regulations (US):
    • Health and Safety (First Aid) Regulations of 1970.
    • Occupational Safety and Health Act (1970) mandates incident reporting (deaths, major injuries, absence >3>3 days).
    • Employers must keep an Accident Book recording date, person's details, injury description, and treatment given.