First Aid Instructor’s Manual
of
The Orange Cross
© 2013
Date: January 1st, 2014
This First Aid Instructor’s manual accompanies the 26th edition of the “Orange Cross Book” and the
4th edition of the “Child First Aid” book.
It was commissioned by and compiled under the supervision of the Dutch “Stichting Koninklijke
Nationale Organisatie voor Reddingwezen en Eerste Hulp” (the Dutch National Association for
Rescue Services and First Aid), “The Orange Cross”
©The Orange Cross, The Hague, December 2013.
All rights reserved. No part of this publication may be used, reproduced and/or published for
commercial purposes. For educational purposes, this publication is free to use but it may not be
altered and the source should always be mentioned.
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Contents
Preface..................................................................................................................................................... 4
Additional information for the 26th edition of the Orange Cross Book ............................................. 4
Part I General........................................................................................................................................... 5
1.0 Introduction Part I ......................................................................................................................... 5
1.1 Providing first aid: five important rules......................................................................................... 6
1.2 Emotional and legal aspects .......................................................................................................... 9
1.3 Providing first aid and the risk of infection ................................................................................. 11
Part II Altered vital signs ........................................................................................................................ 13
2.0 Introduction Part II ...................................................................................................................... 13
2.1 Impaired consciousness .............................................................................................................. 15
2.2 Breathing difficulties ................................................................................................................... 22
2.3 Resuscitation ............................................................................................................................... 25
2.4 Active blood loss.......................................................................................................................... 31
2.5 Shock ........................................................................................................................................... 33
Part III Injuries ....................................................................................................................................... 35
3.0 Introduction Part III ..................................................................................................................... 35
3.1 Wounds ....................................................................................................................................... 35
3.2 Electrical injuries ......................................................................................................................... 38
3.3 Bruises and sprains ...................................................................................................................... 41
3.4 Bone fractures and dislocations .................................................................................................. 41
3.5 Eye, nose and ear injuries............................................................................................................ 43
3.6 Tooth injuries and tooth through the lip ..................................................................................... 44
3.7 Overheating (hyperthermia) ....................................................................................................... 45
3.8 Hypothermia................................................................................................................................ 45
3.9 Frostbite ...................................................................................................................................... 46
3.10 Poisoning ................................................................................................................................... 47
3.11 Stings and bites.......................................................................................................................... 48
Part IV Dressings bandages and other material .................................................................................... 50
Appendix 1: The Human Body ............................................................................................................... 54
1. Cells, tissues and organs ................................................................................................................ 54
2. Organ systems ............................................................................................................................... 55
3. The senses ..................................................................................................................................... 62
Appendix 2: Special characteristics of the child .................................................................................... 65
1. The development of the child ....................................................................................................... 65
2. Prevention of accidents in children ............................................................................................... 69
3. Child abuse .................................................................................................................................... 71
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Preface
According to the Orange Cross Book, the first aider can provide assistance relevant to the most
urgent needs of a casualty during, or shortly after a sudden health disorder.
This manual for first aid instructors is intended as a tuition tool. The background information is
meant to extend and broaden the instructor’s knowledge in preparing his lessons.
Instructors who have acquired the background information in the Orange Cross Book and understand
why it has been chosen will be better able to teach the course material to their students. However,
the information in this manual is not intended as student course material.
Whenever a course book page is mentioned in this manual, it is preceded by the abbreviation TOCB,
followed by the page number.
This manual can be used in combination with the 26th edition of the Orange Cross Book and the 4th
edition of the “Child First Aid” book. The text is based on the most general first aid possible.
Appendix 2 addresses the first aid specific to children. The anatomical information in the Orange
Cross Book is limited to the minimum necessary to first aiders. However, the first appendix in this
manual provides an extensive description of anatomy.
Additional information for the 26th edition of the Orange Cross Book
We have opted for an approach specifically based on symptoms: this is key to diagnose and remedy
problems. The exact causes are usually of lesser importance. Compared to the previous edition, this
manual contains more information on the rationale behind the first aid interventions. Background
information is limited to the absolute necessary.
The flap contains a first aid flow chart which provides a structure and the most general interventions
and decision steps. To keep a clear overview, not all exceptions have been included in this flow chart.
The starting point in the flow chart is the question whether the casualty is conscious or not. High
priority has been given to stemming severe and active external blood loss by exerting pressure on
the wound, preferably by a bystander, to leave the first aider free to provide other assistance.
Pressure on the wound should not delay the potentially necessary chest compressions. During
circulatory arrest, blood loss will not be very severe anyway.
An arterial bleed clearly indicates the functioning of the blood circulation. After all, the pulsing
bleeding is caused by the contraction of the heart.
The next step with an unconscious casualty is to check the breathing. Absent or abnormal breathing
means you need to start chest compressions.
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Part I General
1.0 Introduction Part I
The course material for the First Aid Certificate is based on the following definition of the concept of
first aid:
“ First Aid is the necessary help that should be given to a casualty, whether or not awaiting organized
professional help, as assessed by the first aider in a way consistent with professional health care.”
This definition means that the first aid cannot go beyond that which, from a medical viewpoint, can
be provided by the first aider, in a responsible way, considering his knowledge, experience and skills.
The most important changes in the Orange Cross course material were made because of:
- comments on previous editions
- the issue of new guidelines with respect to resuscitation (NRR) and first aid (EFAM)
- specific expertise of organizations such as the Dutch Burns Foundation, Dutch society for
Dentistry, Dutch National Institute for Public Health and Environment (RIVM), the
Netherlands Institute for Safety (NIFV) and the Dutch hyperventilation foundation
- advancement in scientific knowledge
- general social or other external developments
- newly developed materials
- target groups
The Board of Experts of the Orange Cross has decided on the changes and observed three levels of
emergency in this context:
1. immediate changes: if there is proof of risk to casualties and/or rescuers
2. waiting till the next issue of the book: this concerns minor alterations, often with respect to
textual and sometimes inadvertent mistakes. Page numbers may not be changed
3. waiting for the new edition of the book: new guidelines will then be included as well as
general improvements
The course material itself is based on the following assumptions:
- Under normal circumstances, professional help arrives quickly in The Netherlands. This
means that first aiders in The Netherlands need fewer skills than first aiders in remote areas
of some other countries.
- The emphasis is on the vital signs since they are of immediate vital importance.
The vital signs are brain function (which manifests itself in the consciousness), breathing and
circulation. In providing first aid in acute situations, these vital signs are of essential
importance. Consciousness is checked first. Impaired consciousness may indicate a disorder
of the airway, breathing or circulation (ABC). There is no immediate threat to the ABC if the
casualty responds adequately, at least not for the time being. The vital signs need to be
assessed first and, if necessary, need to be followed by intervention. Injuries should only be
attended to after this first intervention.
- The first aider is the first link in the chain of emergency care.
Depending on the casualty’s injury, the first aider will in some cases transfer the further care
to the casualty himself (as the second link). The casualty himself decides (afterwards)
whether professional help, often provided by his own general practitioner, is necessary. In
other cases, the first aider will hand the casualty over in as good a condition as possible to
the paramedics or the general practitioner, once the necessary interventions have been
performed. The first aider will then provide as much information as possible about what has
occurred and the casualty’s condition.
The casualty should be able to count on optimal care. Therefore, the aid given during one
stage should be consistent with the next stage. For this reason, the interventions described
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in the course material do not interfere with the care provided by the medical health
professionals (physicians and paramedics).
1.1 Providing first aid: five important rules
First aiders end up almost always in unexpected situations whereby they need to provide first aid. If
well prepared as a result of a first aid course and by means of the five important rules, he may avoid
being overwhelmed by the situation and getting lost in details.
1: Beware of danger
The first aider determines first whether he can safely give help in the current circumstances.
Generally speaking, the more extensive the accident, the more serious the danger that threatens
casualties and rescuers. Examples are new explosions that may occur in a factory that has collapsed
because of an explosion, a train in precarious balance after a railway accident which may tumble
from the track, but also traffic accidents during fog or on a motorway whereby traffic is still rushing
by.
Under such circumstances, the first aider has to wait or cooperate with the services trained and
skilled in dealing with such danger, for example the police and fire brigade or, in some countries,
road inspectors. The first aider has to follow their instructions, even if he would prefer giving first aid
immediately. In a car accident, the engine has usually stalled and the first aider does not need to
switch it off himself. It is important not to remove the car key from the ignition when the engine is
switched off. Certain electrical systems may still need to function when the fire brigade has arrived to
free the casualty.
2: Assess the situation and then the casualty
To provide first aid adequately, the first aider must consider the way the accident has occurred (the
accident mechanism) and the situation in which the casualty is found. For example, it is not likely that
overheating will take place in a cold environment.
A severe accident or a fall from a great height is always a reason to call 1-1-2, even though the
casualty has no apparent injuries. In connection with this, special attention is asked for electrical
injuries. The photograph (TOCB page 14) shows a small wound, but after contact with electrical
current, this may be a sign of more severe internal injuries.
Casualties should be assessed systematically: first the vital signs (consciousness, breathing and
circulation), then attention should be paid to injuries that are not (immediately) life-threatening.
Once the casualty’s consciousness has been assessed, the first aider collects information by:
- observing breathing movements, posture, symptoms, injuries, “silent witnesses” at the place
of the accident, the accident mechanism
- listening to the casualty or the person who asked for help, bystanders who can relate what
has happened and what the symptoms are, but also by listening to breathing sounds
- feeling the unconscious casualty’s breath on the cheek when his breathing is being assessed
Usually, the casualty is the best source of information on what has happened to him and what is
wrong. If the casualty´s consciousness is impaired, bystanders may be able to provide information.
The first aider responds to symptoms without having to know exactly what is happening inside the
casualty´s body. It is not necessary to perform an extensive physical examination (head-to-foot) as
this will be carried out by the medical professional. This examination is necessary to detect other
potential injuries which may be obscured by the main symptom. There needs to be a reason for such
an examination, for example a serious traffic accident or a fall from a great height. The medical
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professional also uses this examination to determine whether the casualty should be admitted to
hospital after an accident. This assessment is not done by the first aider. A serious accident and/or
altered vital signs is a reason to call 1-1-2. If there is no serious accident and/or there are no altered
vital signs, it is enough to address the casualty’s symptoms and the visible signs.
In addition, the medical professional uses the extensive physical examination to assess the level of
consciousness more closely by means of the so-called AVPU score (Alert, Verbal, Pain, Unresponsive).
If necessary, he can administer a pain stimulus.
The first aider does not administer pain stimuli because it does not provide information that would
result in a different way of providing first aid.
The first aider does not enquire after the casualty’s medical history or his use of medicines. This
information does not lead to a different way of giving first aid either. In addition, there is a risk that
incorrect information be passed on because the first aider has not enough medical knowledge.
3: Reassure the casualty and provide protection
The casualty may have been caught unawares by an event therefore finding himself in mental
distress. This means that the first aider not only has to perform the correct intervention but also
needs to reassure the casualty. It seems self-evident but in practice it is too easily forgotten. This is
undesirable because incorrect behaviour of the first aider may interfere with the first aid.
Reassuring a casualty requires personal dedication and tact. Although no two situations are alike, the
following suggestions may be useful:
- Never leave the casualty on his own and tell him that you will not leave him alone. If
applicable, do tell the casualty that you will return immediately after calling 1-1-2.
- Give honest answers to the casualty’s questions. It does not inspire confidence to present
the situation more favourably than it actually is. Do not make any predictions, even a
physician has difficulty doing this.
- Exercise restraint with information about the situation of any other casualties.
- Look friendly, speak quietly and clearly. Stay in the casualty’s field of vision. Interventions
that are performed behind the casualty’s back are unpleasant and often frightening.
- At all times, tell the casualty what you are going to do and whether it will hurt. Telling this
creates confidence and serves as a memory aid for yourself in not forgetting anything.
Perform your interventions in an organized way and, if possible, ask bystanders for
assistance.
- Keep in mind that children are not miniature adults and therefore require a different
approach and different methods. For example, it may be necessary to demonstrate to the
child what you require him to do when you ask him to perform a specific action.
- If the casualty wears glasses, let him keep these on if possible.
- Make the casualty as comfortable as possible. Provide the necessary shelter from rain, wind
and cold.
- Ask the casualty who should be called.
- Touching him may help, for example holding his hand.
- If possible, keep bystanders at a distance; their remarks may be far from reassuring to the
casualty.
- Be empathetic if family members or other acquaintances of the casualty arrive at the place of
the accident. Understand that people may be upset and sometimes aggressive when
confronted with a casualty with severe injuries.
4: Get professional help
This has become considerably simpler due to the availability of mobile phones, but must of course
not be forgotten. Please make sure that an emergency call has actually been made or is actually
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being made. If you ask a bystander to call the professional rescuers, it makes sense that the caller
repeats the message to avoid inaccuracies. It may be difficult to indicate the exact location of the
accident, for example in recreation areas or woods. It is then important to agree on a place where
the caller will meet the professional rescuers. On motorways, it is important to mention the direction
of the traffic flow where the accident took place. The place can often be indicated by means of the
number of the emergency telephone from which the call was made or with the information on the
hectometre post (TOCB page 17).
If technical tools are necessary to free the casualty, the caller should mention that the casualty is
trapped. The same applies in case of fire, when there is risk of fire or in the presence of hazardous
substances. Objects on the road that may hinder traffic should be mentioned as well.
When describing the nature of the injuries, only the most important aspects should be mentioned,
such as impaired consciousness, breathing difficulties, severe blood loss, fractures, skull injuries and
burns. The caller should be asked to return after the call to be certain that the professional rescuers
have been called (besides, you may need support). Providing instructions to the caller takes time.
When to do this depends on your assessment of the casualty. As a rule, professional rescuers should
be called as soon as possible.
If necessary, ask the person who called the paramedics to meet them and guide them to the casualty.
If there are many casualties, it is difficult to mention the exact number and the nature of the injuries;
besides, it is also less relevant:
- It is more difficult because if the number of casualties is large, it is hard to keep track of the
injuries of individual casualties
- It is less relevant because too much time is required to list all the details; all this time, the
injuries would be left untreated
In such cases, it is better to provide a global indication of the extent of the accident and then to start
working. The professional rescuers who have been alerted can form a tentative picture of what has
happened and decide which interventions they should perform. By way of an example: the message
“collision of a bus with a lorry, the bus has tipped over and rolled off the road, approximately 40
people who cannot leave the bus”, provides more useful information to the emergency services than
“the first casualty’s left lower leg is trapped, the second has a nosebleed, the third…” and so on.
The moment at which the message is given or has to be given is also influenced by the circumstances.
If there are several casualties, it is important to establish priorities in the assistance after the
emergency call has been made. If there are not enough rescuers, it is hardly useful to give all your
attention to a casualty who needs resuscitation. Resuscitation is time-consuming and hardly useful in
situations like this. It is a fact that chances of survival are slim if people need to be resuscitated after
serious accidents. On the other hand, the first aider may be able to help as many casualties as
possible by concentrating on those who require brief, life-saving interventions. Examples are placing
casualties in the recovery position or exerting pressure on wounds with active blood loss.
During the transfer to the medical professional, the first aider only needs to answer his questions.
The transfer does not need to be structured in the same way as with the medical professionals
(MIST). This type of transfer (Mechanism, Injuries, Signs, Treatment given) is mainly intended to
inform medical professionals who are not present. The paramedics have been trained in such a way
that they can deduce a lot from the dispatch and from the encountered situation. The only
information they may require is what happened between the dispatch and their arrival. In some
situations, there may be no time or no need for a transfer. In these situations, the first aider will not
be asked any questions. The first aider who is “ignored” should not take this personally.
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Referral
In less urgent cases (for example suturing or when there is doubt as to whether the casualty will
require medical treatment), the first aider refers the casualty to the general practitioner or the Outof-Hours GP service (evenings/nights and at weekends). If the casualty has developed symptoms or
has persistent or recurrent symptoms, he should contact the general practitioner himself. The first
aider always provides the option to see a medical professional, even though the casualty may not
follow this advice.
5: Help the casualty at the place where he lies or sits
The first aider must realize that moving the casualty after a serious accident places the casualty at
risk. Therefore, first aid should be provided at the scene of the accident. However, if there is danger
to the first aider or the casualty, the casualty obviously has to be removed from the danger zone.
It can be quite difficult to perform the Rautek rescue manoeuvre with a casualty who is entirely limp.
The casualty is unable to sit independently and may fall over if he sits upright. It is important that the
grip is tight enough and that the arm is pulled towards the torso as tightly as possible.
The Rautek rescue manoeuvre may put the first aider’s body under strain if he cannot stand straight
behind the casualty. This may be the case with a casualty who has to be removed from his car. The
first aider should take hold of the casualty’s most distant arm to pull him closer to him. The closer to
the casualty’s spinal column he is held, the less effort it will take to move him.
An additional advantage of taking hold of the most distant arm is that it will not get stuck between
the car seats. However, always pay attention to what happens to the “free” arm. This arm should not
get trapped by anything.
Obviously, this can best be practised with a real car. If this is not available, a solid chair without an
arm rest may provide a solution.
In conclusion
The points addressed in the five important rules take place almost simultaneously. After the first
aider has gained an overview of the situation, he immediately starts assessing the casualty. This
assessment includes addressing the casualty to reassure him somewhat. The first aider should keep
talking to the casualty while continuing his assessment. Professional rescuers are alerted as soon as
the situation allows. While waiting for the arrival of the professional rescuers, the intervention of the
first aider concentrates on responding to altered vital signs and preventing worsening of the injuries.
1.2 Emotional and legal aspects
Providing assistance may evoke strong emotional reactions in first aiders.
This is especially the case if the casualty needs to be resuscitated. For many people, this will be the
first and only time that they will have to put into practice what they have learnt. The decision to
make a start is a difficult one; but deciding to stop may be even more difficult.
Therefore, a first aider cannot be blamed if he chooses to continue resuscitating until the
professional rescuers (paramedics) take over, even if he found a Do Not Resuscitate certificate after
having started the resuscitation.
If it is clear beforehand that the casualty does not want to be resuscitated, it is also difficult not to
start resuscitating. The first aider may feel that he is letting someone die.
If the resuscitation is not successful, the first aider should not feel that he has failed. If he has drawn
the correct conclusions and has performed the actions correctly, he has provided optimal care.
Unfortunately, it is a fact that in many cases, this optimal care does not lead to the casualty’s
recovery.
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In most cases, resuscitation takes place at the casualty’s home or at an acquaintance’s home. In
many cases, the casualty is an acquaintance and, more often, bystanders are acquaintances. During
the lessons, the instructor needs to be alert to emotional experiences when resuscitation is being
discussed.
A certified first aider should be able to get help, if needed, at the organization where he followed the
course. Reliving the experience after a couple of months or even years is a normal phenomenon and
no reason for worry. However, it is a reason for after care to help the first aider cope with the events.
The first aider can make enquiries with the paramedics about the result of the assistance; this may
contribute towards eliminating insecurity about the actions performed.
Legal aspects
There are many stories about liability after providing assistance or of having to pay for the
ambulance that arrives unnecessarily.
However, which legal issues does the first aider face in reality?
1. Is a layperson allowed to perform “medical interventions”?
2. Is the layperson liable for damages that may result from his intervention as a first aider?
3. What needs to be done if a Do Not Resuscitate certificate is found on the casualty?
1. Is a layperson allowed to perform “medical interventions”?
So-called “reserved actions” can only be performed by health care professionals who are listed in the
register of the Dutch Health Care Professions Act, for example physicians and nurses. However, the
interventions described in the Orange Cross Book (including resuscitation) do not fall under these
“reserved actions” and anybody in The Netherlands is allowed to perform these interventions.
Irresponsible and reckless interventions cannot of course be justified.
In the context of informal care, certain medical interventions can be taught to people in the vicinity
of a patient, for example giving medicine by injection. This is under the responsibility of the attending
physician (often a GP) and is no part of the First Aid curriculum.
Even if you have had training in certain medical interventions as an informal caregiver, you are not
allowed to teach these to participants within the context of a first aid course.
Article 450 of the Dutch Penal Code prescribes that someone who is in danger of losing his life (for
example due to circulatory arrest) must be helped, in so far as the caregiver is not placed in danger
by providing this help. For example, this means that who has learnt to resuscitate is not only allowed
to provide resuscitation but is also obliged to do so if necessary and possible.
If he fails to provide help and the casualty dies, he may incur a punishment of at most three months
imprisonment or a fine of the second category. In practice, this criminal liability is mainly theoretical.
For example, it is hard to prove that someone has failed to provide help to somebody else who is in
danger of losing his life while he could have provided this help without incurring danger to himself or
third persons.
2. Is the layperson liable for damages that may result from his intervention as a first aider?
If the first aider is competent, has acted meticulously and according to the guidelines whilst giving
aid, he cannot be held liable for damage. However, if aid was provided inaccurately, the first aider
may in principle be held liable (under civil law).
A first aider with a valid First Aid Certificate is insured against liability via the liability Insurance of The
Orange Cross.
In The Netherlands, a so-called “free call” system is in operation. This means that anybody is allowed
to call an ambulance. Anybody can call 1-1-2, the central emergency number, if he thinks, to the best
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of his knowledge, that there is an emergency. Should it become apparent afterwards that “things are
not as bad after all”, the first aider is not liable for the ambulance costs involved. He acted as an
authorized agent in accordance to the Dutch Civil Code, Section 6:198.
3. What needs to be done if a Do Not Resuscitate certificate is found on the casualty?
If it is clear beforehand that the casualty does not want to be resuscitated, the first aider does not
start providing resuscitation. Resuscitation is often performed in a domestic setting. In this situation,
the first aider may know the casualty and that he carries such a certificate. The first aider acts
accordingly and does not start resuscitating.
If the first aider is not acquainted with the casualty, he should not waste time searching for a Do Not
Resuscitate certificate. He should start resuscitating as soon as possible.
It is difficult to stop resuscitating once started. Once resuscitation has started and when the clothes
have been removed from the chest, a pendant is found with the message Do Not Resuscitate, the
first aider is allowed to stop. This means that he should decide whether or not to respect the
casualty’s wish. Alternatively, he could leave this decision to the professional rescuers. This decision
will have no legal consequences for him.
1.3 Providing first aid and the risk of infection
If the casualty suffers from a contagious disease, the transfer of germs to the caregiver cannot always
be prevented. Even the use of equipment cannot always prevent this. Most caregivers do not avoid
the risk of catching a common cold as a result of providing assistance. However, they may fear being
infected by the HIV virus (AIDS) or hepatitis B or C (jaundice). Studies show that this risk is extremely
small. Still, everyone will have his own opinion about this. The Orange Cross has a brochure in Dutch
on this subject. The contents of this brochure has been drawn up in consultation with the Stichting
Werkgroep Infectie Preventie (WIP) (Foundation Working Group Prevention of Infection) of the Leids
Universitair Medisch Centrum (LUMC) (Leiden University Medical Centre).
Below is the entire text of the NAI protocol (protocol of the Dutch Ambulance Institute, version LPA
7.2) for hygiene. This is exclusively intended as background information for the instructor.
5.4.Hygiene
- keep in mind that all patients may pose a risk of infection
- preferably use disposable material
- avoid punctures from needles and other sharp objects
- do not place needles back in their protective cover but dispose of them in a puncture-proof
container
- always keep wounds and other skin injuries covered with a waterproof plaster
- always wear protective gloves and a disposable plastic apron if you expect to come into contact
with blood, wounds, amniotic fluid or other bodily fluids (secretions)
- If there is a risk of these fluids splashing, protect:
the mucous membranes of the mouth with a mouth/nose mask
the eyes with goggles
- provide artificial breathing only with a mask or a balloon or by means of intubation or with a
pocket mask with a one-way valve
- wear work gloves in situations whereby thin gloves can easily tear or if there is a risk of getting cut
or stung
- every contact with infected patients should be reported to the executive in charge so that further
measures can be taken
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Before and after patient contact:
- wash your hands with water and regular soap or disinfect with 70% alcohol
- if non-disposable materials, stretchers or the car interior have been contaminated:
remove them as soon as possible
clean with domestic detergent
disinfect with alcohol 70% (inflammable!) or chlorine 250 ppm (corrosive!)
- keep material that has been contaminated with blood or other sources separate (container,
laundry bag)
- deliver linen and clothes, contaminated with blood and such like, in a closed laundry bag which is
marked and recognizable as such to the laundry department
Open tuberculosis:
- patient and rescuers need to wear a suitable mouth/nose mask
SARS (proven and/or suspected):
- use a mouth/nose mask with a good fit (preferably range 1 micron), OR cap, apron and gloves
- also provide the patient with a mouth/nose mask
- after treatment and transport, treat used materials and clean them according to the guidelines
(washing at 60° C) or dispose of them. Ventilate and clean the patient compartment thoroughly
according to the MRSA protocol
Puncture or cut injuries:
- let the wound bleed thoroughly
- wash damaged skin parts or exposed mucous membranes with running water
- disinfect the skin with alcohol 70% (do not disinfect mucous membranes in this way)
- use PVP iodine for wounds
- report all needle-stick injuries
NBC:
- decontaminate patients who have been contaminated with nuclear (radiological), biological or
chemical substances according to the “Decontamination”” protocol
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Part II Altered vital signs
2.0 Introduction Part II
The three vital signs – consciousness, breathing and circulation – are closely connected and
interdependent.
People with unimpaired consciousness are aware of their own existence and environment and can
react adequately to stimuli.
Consciousness depends on a well-functioning and coordinated brain structure. The brain can only
function well if it has an unimpaired supply of oxygen and nutrients (glucose) and if carbon dioxide
and other waste products are removed. For this reason, it is essential that breathing and circulation
function appropriately.
Life is only possible providing the cells in the body receive a constant supply of oxygen and the
carbon dioxide they produce is expelled continuously. Oxygen from the atmosphere has to travel a
long way before it reaches the cells. Carbon dioxide from the cells travels an equally long way in the
opposite direction before being released into the atmosphere.
In the lungs, oxygen from the atmosphere is absorbed into the blood. The heart pumps the blood
through the blood vessels to the cells in the body. For the absorption of oxygen and transport to the
cells to be sufficient, three conditions needs to be met:
1. breathing should be undisturbed
2. the blood vessels should contain enough blood
3. the heart should function correctly
If any one of these conditions fails to be met, oxygen transport to the cells is jeopardised. In these
circumstances, not enough carbon dioxide is removed from the body either.
Brain cells are particularly sensitive to this. Therefore, a disturbance in the oxygen supply and the
removal of the carbon dioxide will soon result in consciousness disorder.
As mentioned before, consciousness, breathing and circulation are interdependent. In circulatory
arrest, the cells (including the brain cells) are almost immediately deprived of their oxygen supply.
Carbon dioxide cannot be removed from the body either. This will first impair brain cell function,
which will result in impaired consciousness. The neurons in the brain stem, which control breathing,
will stop functioning as well. Circulatory arrest will therefore result in unconsciousness within five to
fifteen seconds. Complete respiratory arrest will follow one or two minutes after circulatory arrest.
If the first disorder is a severe respiratory problem, gradually less and less oxygen will be absorbed in
the body and increasingly less carbon dioxide will be removed. This may result in an impaired
function of the brain cells, with impaired consciousness as a possible consequence. A little while
later, the oxygen deficiency in the muscle cells of the heart may become so severe and so much
carbon dioxide may accumulate in those cells that they will no longer be able to function properly
either. Eventually, the heart comes to a stand still. Therefore, impaired breathing may result in
impaired consciousness (decreased level of consciousness, unconsciousness) followed by circulatory
arrest. This explains why a drowning person who is removed from the water in a state of
unconsciousness may still have a (slow) pulse.
If consciousness is lost due to impaired brain function, people are no longer able to save themselves
from life-threatening situations. When the casualty lies on his back, the airway may become
obstructed because the tongue and the relaxation of the epiglottis . This will result in breathing
difficulties. Therefore, the brain, mainly the brain stem, will no longer be able to perform its
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coordinating function properly or will stop functioning completely. Eventually, this will lead to
circulatory arrest.
From the effects described, it becomes clear that disorders in the vital organs form an immediate
threat to the casualty’s life. Injuries without disorders in the vital organs may be severe, but they
hardly ever threaten the casualty’s life within a short period of time. Therefore, the vital signs must
be assessed repeatedly in all casualties.
There is one situation in which the assessment of the consciousness level and other vital signs has no
priority. This is when casualties suffer severe active external blood loss. This should be stemmed first.
As soon as the bleeding is under control, the first aider focuses on the further assessment of the vital
signs. This is why in the first aid flow chart the assessment of the vital signs and ABC has been
included as the first point and the assessment of injuries is the last intervention to be performed.
Severe active blood loss and shock are a section of part II: altered vital signs.
When assessing the vital signs, the consciousness level should be determined first. Impaired
consciousness means that there is a serious problem - the ABC may be at risk.
If possible, the first aider concentrates on solving the ABC problem. Some examples are freeing a
severely obstructed airway after choking (back slaps and abdominal thrusts), resuscitating a
drowning casualty with respiratory arrest or switching off the power source when a casualty is in
contact with electrical current. In addition, impairment in consciousness itself should not lead to
problems with the ABC. For this reason, the casualty should be placed in the recovery position or the
airway should be kept open by means of the chin lift.
Causes of altered vital signs
The assessment of the vital signs starts with the consciousness assessment. Someone who responds
adequately has no vital organ disorder (yet).
Impairment in consciousness can have several causes:
- oxygen deficiency
- injuries to the skull and/or brain
- brain haemorrhage or infarct
- disorders of the brain (like epilepsy) and the meninges
- toxaemia in pregnancy
- too high or too low blood glucose level
- too high or too low body temperature
- toxic substances
- electricity
Impairment in consciousness is a threat to the airway, breathing and circulation (ABC). Subsequently,
ABC disorders may result in impaired consciousness.
Causes in ABC disorders
Causes of airway disorders (A)
The airway can be obstructed by:
- tongue and epiglottis (in unconscious casualties who lie on their backs)
- blood, vomit or saliva
- foreign object (choking)
- the head is buried, for example in sand or snow
- hanging or strangulation
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-
submersion in a fluid (often water)
swelling as a result of injury (such as breathing in hot air or irritating gases) or disorder
(asthma for example)
Causes of breathing disorders (B)
Restricted exchange of oxygen and carbon dioxide in the lungs because of:
- obstruction of the airway
- superficial breathing because of pain due to broken ribs
- penetrating chest wound
- compression of the chest
- lungs disorders
Causes of circulation disorders (C)
Impairment in effective blood circulation because of:
- impaired oxygen exchange
- heart attack or cardiac arrhythmia
- internal or external blood loss (shock)
- severe allergic reactions
- electrical shock
- dehydration
2.1 Impaired consciousness
Impaired consciousness is a manifestation of a decrease in brain function. The greater the loss of
consciousness, the less responsive the casualty will be to stimuli. The reflexes will disappear as well.
Food and such like in the mouth and the upper airway will no longer prompt a swallowing or a cough
reflex.
Assessing consciousness
When determining whether resuscitation is required, two consciousness levels are distinguished. If
the casualty is conscious, he will respond for example by opening his eyes or moving.
An unconscious casualty will not respond when shaken gently or spoken to. Obviously, the casualty
should be shaken gently so as not to worsen any injuries in the neck , back or limbs (shake the
casualty’s shoulders, not his head).
Unconsciousness can have many causes ranging from extensive injuries and asphyxiation to
circulatory arrest. In all casualties with impaired consciousness, the next thing to evaluate is the
breathing.
In addition to full consciousness or complete unconsciousness, there are other states of
consciousness such as sleepiness and confusion.
For the attending physician, the development of the casualty’s consciousness level may be important
from the moment that the first aider started providing assistance. Has the disorder become worse or
improved?
Procedure in casualties with impaired consciousness
The consciousness level can be influenced by implementing the correct intervention (for example
helping someone to lie down in case of an impending fainting fit).
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If it is necessary to place an unconscious casualty with potential spinal injuries into the recovery
position, this should be done with the utmost care. Once he has been placed in the recovery position,
he should be moved as little as possible.
The fear of sore spots is no longer a reason to move him frequently. Any ensuing pressure places
(decubitus) constitute an inconvenient complication but are of course of a totally different order
than spinal cord lesions. Since 1-1-2 will be called, the casualty will not remain in the recovery
position for long. The guideline that prescribes that the casualty should be turned on his other side
after 30 minutes, as mentioned in the European Resuscitation Guidelines of the ERC, has not been
adopted in The Netherlands.
There is hardly any chance of survival when an accident casualty has to be resuscitated on account of
the severity of the accident. Therefore, it is no priority to turn this casualty onto his back in
preparation for a possible resuscitation. For the same reason, resuscitation is no priority if there are
several casualties and not enough rescuers.
At first, except in case of a severe accident, an unconscious casualty who lies in a prone position
should be turned onto his back for the following reasons:
- there may be severe breathing difficulties in a prone position
- it is difficult to observe the casualty if he is in a prone position, particularly his complexion,
breathing movements and responses to stimuli
- if the casualty’s breathing is inadequate or absent, in a supine position resuscitation can be
started immediately
If the casualty must be turned from a prone position onto his back, in principle, turn him away from
you, according to the 26th edition. The first aider lifts the casualty by the shoulder and rolls him onto
his side. Then he rolls the casualty further with one hand, the other hand supporting the head. The
first aider remains on the side of the casualty’s face.
This method is faster than walking around the casualty first. Moreover, there is more unity in the way
the first aider approaches a casualty. For all other interventions, such as placing the casualty in the
recovery position, the first aider positions himself at the side of the casualty’s face. This uniform
approach is easier to remember for people who rarely have to deal with such situations after the
First Aid course. Besides, in practice, something may go wrong if the inexperienced first aider walks
around the casualty. In the confusion of the moment, the first aider may inadvertently kick or step
over the casualty. Apart from that, stepping over the casualty is not something that should be
avoided at all times, and certainly not in confined spaces.
In the end, the purpose of the action is key, which is that the casualty is laid on his back as quickly as
possible. There is nothing wrong if a experienced first aider can do this perfectly by walking around
first. The objective of the chosen method is to make the interventions as simple and as structured as
possible for the beginner.
For example, the same applies to the recovery position. If the casualty who is on his back vomits, the
most important thing is that he ends up on his side as soon as possible, even if the first aider has
forgotten how to do the recovery position.
When performing this intervention, the lower body lags behind compared to the upper body
(torsion/distortion of the lower back). An unconscious casualty will not feel this. If this intervention is
repeatedly practised with the same person, the torsion may cause problems. If so, after lifting the
shoulder, the ‘casualty’ may also be rolled further by pushing at the same time against his hip or by
lifting his knee using it as a lever. If possible, a bystander may help turn the ‘casualty’. This solution is
also applicable if the method in a real casualty fails. The method can also be practised with a fellow
course participant.
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Anyway, chances are that the unconscious casualty has no spinal injury. That casualties are
unconscious is not a rare occurrence; however, that one sustains spinal cord lesion as a result of your
intervention is indeed rare.
The recovery position also causes torsion of the lower back. However, there is more strain on the
lower back, because of active pulling the knee while placing the casualty in this position.
Because of this, casualty simulators are allowed to help along with the techniquess that are a burden
to them.
There is hardly any chance of survival if the accident casualty has to be resuscitated because of the
severity of the accident. Therefore, there is hardly any added value in placing beforehand a casualty
with spinal injury on his back should he need to be resuscitated. This is also why resuscitation is not a
priority if there are multiple casualties and not enough help.
Recovery position
A free airway is essential. An unconscious casualty cannot take care of this himself. Therefore, he
must be placed in the recovery position if he breathes normally. If a casualty vomits while lying on his
back, he must be turned rapidly onto his side. Then wipe as much of the vomit as possible from his
mouth and place him back on his back very carefully.
In principle, an accident casualty is not turned. It is possible that loose objects are present in his
mouth (dental fragments). By preference, remove these objects while leaving the casualty in his
original position.
Sometimes, an unconscious accident casualty can make loud breathing noises. If so, the casualty may
remain in the position in which he is found. The breathing may become less noisy during the chin lift.
It is recommended to maintain the chin lift until the paramedics are ready to take over.
If there is doubt whether such a casualty is breathing, the casualty is turned onto his back to check
his breathing. Just as with other unconscious casualties, chest compressions are started if the
casualty does not seem to breathe normally.
In case of a broken jaw, the chin lift may also be performed to keep the airway free. Therefore, the
casualty does not always need to be unconscious to perform the chin lift.
If it is necessary to place a casualty with possible spinal injury in the recovery position, this should be
done with the utmost care. After that, the casualty should be moved as little as possible.
With these casualties, fear of sores because of lying too long in the same position, is no reason to
turn the casualty. The occurrence of any pressure sores (decubitus) is an annoying complication, but
obviously of a totally different order than the occurrence of paraplegia. Because 1-1-2 must be called
in all consciousness impairments, the casualty will not stay long in the recovery position. In the
Netherlands, the directive to turn the casualty on the other side after 30 minutes, as found in the
European Resuscitation Guidelines ERC, is therefore not included.
Fainting
Sometimes, a person suffers a sudden decrease in consciousness level, up to a complete loss of
consciousness. If the first aider places the casualty with decreased consciousness in a horizontal
position, and after a couple of moments the casualty opens his eyes, he has apparently fainted. If he
remains in a state of impaired consciousness or if his consciousness level decreases, act according to
the guidelines for such a case. Fainting is the result of a sudden decrease in the blood supply to the
brain which results in a shortage of oxygen transported to the brain. This often occurs because of a
deceleration of the heart in combination with a dilation of smaller blood vessels elsewhere in the
body. Refer to TOCB page 32 for possible causes.
Skull and brain injuries
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Skull and brain injuries are often accompanied by spinal injuries (especially in skull fractures and
blunt trauma). Therefore, these casualties should not be moved.
Skull fractures
Casualties of skull fractures run the risk of spinal injuries as well. Therefore, they should not be
turned. If the casualty has a skull base fracture, blood may leak from his ear. Frequently, a contusion
around the eyes is visible (raccoon eyes) or behind one of the ears (battle sign). In some cases, these
symptoms of a skull base fracture only develop after a couple of days after the accident. This is why
the casualty who responds adequately often does not see a physician until later. Should you come
across such a casualty, send him to a physician if he has not been yet.
Facial injuries
Facial injuries are often accompanied with fractures of nose, jaw, cheekbones or eye sockets.
Casualties who have sustained these injuries are often restless because of breathing difficulties and
damage to the frontal lobe of the brain. The first aider should ask the casualty to lean forward
slightly to prevent blood leakage from the mouth and nose into the pharynx as this may cause
nausea and vomiting.
Sharp trauma (open wound)
In casualties with sharp trauma, the scalp is damaged. The wounds may bleed profusely because of
the extensive blood supply to this part of the body. As with other wounds, leave objects that may be
present in the wound and apply a dressing over the object or around it. Depending on the object and
the impact that gave rise to the wound, there may also be fractures and/or brain injury. Do not push
back protruding brain tissue. Never turn a casualty onto the side from which an object protrudes.
Blunt trauma
Blunt skull trauma (concussion, brain contusion) is the most common head injury. Because the brain
mass is compressed, it may suffer permanent damage. This may result in short-term or prolonged
loss of consciousness, often accompanied by memory loss. Memories from a shorter or longer period
of time before the accident may be lost as well. This may cause the casualty to repeat his questions
because he keeps forgetting the answers. Headache, nausea and/or vomiting often occur as well.
Haemorrhage between skull and brain
A haemorrhage between the skull and the brain leads to a gradual increase of pressure within the
skull, which is then transferred to the brain and brain stem. The first symptoms are headaches
followed by (increasing) loss of consciousness.
Epilepsy
Epilepsy is a brain disease which causes seizures (convulsions): the casualty suddenly loses
consciousness, makes jerking movements with his arms and/or legs, sometimes has (blood stained)
foam on the mouth and may release urine involuntarily.
Consciousness is restored after some time. Many casualties complain of headaches. In The
Netherlands, approximately 0.5% of the population suffer from epilepsy. The seizures are caused by
a sudden change in the electrical activity of the brain. The attacks can often be suppressed by
medication or – if this does not work – by operation. Seizures can also be a manifestation of severe
disorders such as brain tumours. Severe skull or brain injuries may also be accompanied by epileptic
seizures.
There are many manifestations of epilepsy, each with its own name. For the first aider, a global
distinction between two types of epileptic seizures is sufficient.
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Major epileptic seizure
- Some people have a premonition, called aura (unexpected sound/smell/light).
- This is followed by acute loss of consciousness, which causes the casualty to fall, followed by
10-30 seconds of convulsions of all the muscles (sometime accompanied by a scream).
- Tongue bite (blood stained foam around the mouth) and involuntary loss of urine.
- This is followed by jerky movements caused by alternate contractions and relaxations of the
muscles; this period ranges from half a minute to several minutes.
- Both the fall and the uncontrolled movements at this stage pose a risk of damage to the head
and limbs. Because these movements are performed with considerable strength, thwarting
them would result in instant fractures.
- The casualty’s breathing is often inadequate (because of the muscle spasms).
- Afterwards, the casualty gradually regains consciousness but may be confused for some
time.
- Then, the casualty is often tired, has a headache and aching muscles and may feel as if he has
a hangover.
The first aider immediately calls 1-1-2 and does not wait until it has become clear that he is
confronted with an epileptic state (a series of seizures whereby the casualty does not regain
consciousness). It is possible that the ambulance or motorcycle ambulance arrives for nothing but if
the call is delayed, greater damage may ensue because of oxygen deficiency.
An epileptic patient can make other arrangements with carers in his surrounding about the way he
may wish to be helped if he has a seizure. However, these do not pertain to the official first aid.
If someone has had a seizure for the first time in his life, he needs to be checked up in hospital.
Not all patients are equally sensitive to stimuli. For example, it is possible that light flashes from
television or in a discotheque prompt an epileptic seizure.
Minor fit
- These consist of a decrease in the consciousness level for a few seconds to minutes whereby
the patient stares ahead with a dazed look, is unreachable and is “absent”. After the attack,
the patient resumes his normal activity.
- Jerky movements may occur in one or several muscles, sometimes accompanied by
impairment in consciousness.
Most cases do not require first aid. However, if this happens for the first time, refer the
patient to his general practitioner.
Febrile seizure
Fever is a general response of the body, for example to infections or infectious diseases. Fever can be
recognized by a somewhat red complexion, sweating, headaches and sometimes shivering.
The suspected fever can be confirmed by taking the casualty’s temperature.
Some children react to a fast increase in body temperature with febrile seizures. The fast and
substantial increase in body temperature causes the brain cells to be overstimulated.
This may lead to a short loss of consciousness, accompanied by muscle spasms; after a short while
these spasms turn into an attack of uncontrolled movements of muscles, so-called clonic convulsions
or fits of the entire body or limited to a part of the body. For the observer, febrile seizures and
epileptic seizures are very similar.
Febrile seizures do not cause brain damage.
In some cases, children will be admitted to hospital to exclude the possibility that they suffer from
meningitis. Therefore, all children with febrile seizures need to see a physician (GP).
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Parents of children who had febrile seizures will be informed by the GP about the preventative use of
anti-fever agents if the fever returns and suppositories to counter the febrile seizures.
In these cases, first aid focuses on:
- preventing the child from being injured during the seizures because of the fierce and
uncontrolled movements
- making sure that the airway is free after the seizures, as long as the child is unconscious
(recovery position).
In case of febrile seizures, the first aider always needs to call 1-1-2
Meningitis (inflammation of the membranes of the brain)
An ambulance or a GP has to be called immediately if a child suddenly becomes ill, develops a fever,
if his consciousness level has decreased and particularly if he has developed spots that do not fade
when pressed with a glass (petechia, see photograph TOCB page 35), if he has developed a tendency
to look upwards or has a stiff neck/head.
Diabetes mellitus
A human being has a certain amount of glucose (sugar) dissolved in his blood. This serves as an
energy source to the cells of the body. Insulin, a substance produced by the pancreas, ensures that
the amount of glucose in the blood remains within a narrow range.
Diabetic patients produce no or not enough insulin. Patients with untreated diabetes are unable to
absorb enough glucose into the cells and convert it into energy. An excess of proteins and fats is then
converted to supply the body with energy, whilst the glucose present is not utilized as a result of
which the patient will have a high blood glucose level. The patient loses this glucose via the urine
(diabetes mellitus means “excessive discharge of sugar rich urine”). In order to dispose of all the
excess glucose, the patient has to urinate a lot and therefore drink a lot. Because the glucose
metabolism fails, often, the patient is tired.
Diabetics have to keep their blood glucose level within the appropriate range by sticking to a diet and
administering by injection or tablets a dose of insulin which is adjusted to their food intake. Often a
diabetic carries a medic alert pendant.
We distinguish:
1. The blood glucose level is too low (hypoglycaemia). This occurs when a diabetic takes his
medication and does not eat enough. This causes the blood glucose level to decrease to such
an extent that it may lead to unconsciousness, sometimes very quickly! This disorder is often
preceded by a period of yawning and sweating (and at times aggression).
2. The blood glucose level is too high (hyperglycaemia). This occurs when the diabetic’s blood
glucose level rises too much because he has eaten too much, has not taken enough
medication or when fluid loss is excessive (sweating profusely or severe diarrhoea). The
patient becomes gradually drowsy and eventually loses consciousness.
In diabetic casualties, the first aider’s intervention should be focused on the impaired consciousness:
the diabetic must be placed in the recovery position and 1-1-2 must be called. If the diabetic is aware
of the upcoming hypoglycaemia, he often solves the problem himself by ingesting dextrose, a sugar
cube or sugared water. If his consciousness is impaired, he will not be able to do so. At this stage, the
first aider cannot give sugar either, because no food or drink may be given in case of impaired
consciousness.
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It is almost impossible to establish whether an unknown casualty suffers from hypoglycaemia or
hyperglycaemia. This may be otherwise with people you know. The acquaintance may anticipate the
hypoglycaemic attack and may be able to solve the problem himself. Within the context of informal
care, agreements may have been made, such as examining the blood glucose level. This form of help
is beyond the scope of first aid.
Stroke (CVA: cerebrovascular accident)
A stroke is an acute disruption of the blood circulation in the brain, often accompanied by function
loss. Two forms can be distinguished.
1. A blood clot may suddenly obstruct an artery. This may manifest itself by sudden, often
unilateral paralysis and often by speech impediments as well. The casualty usually remains
conscious but does not always understand what is happening. Therefore, a clear explanation
by the first aider is important. If the casualty recovers completely within 24 hours, he has
suffered a temporarily impaired circulation (TIA: transient ischaemic attack).
2. In a brain haemorrhage, the casualty complains of severe headache, sometimes a “pop” is
felt in the head (SAH: subarachnoid haemorrhage caused by a ruptured brain artery), often
followed by unconsciousness. The casualty then breathes by blowing from a lopsided mouth.
In all cases, 1-1-2 should be called immediately. If the casualty is unconscious, the remainder of the
first aid consists of the measures that should be taken for all casualties with impaired consciousness.
80% of strokes are caused by an obstructed blood vessel (by atherosclerosis or by a blood clot
fragment that has come loose). 20% result from a haemorrhage (often because of a congenital vessel
defect which results in a ruptured vessel, for example if the casualty falls or exerts himself). The
function of the affected area is lost resulting in paralysis, speech impediment, blindness and mental
confusion. Because the nerve pathways cross, the paralysis occurs on the opposite side of the body
to where the haemorrhage or obstruction has happened in the brain. Blindness, deafness and
paralysis of the facial muscles occur at the same side, because these nerves are located above the
level of the pathway crossing.
These symptoms usually arise suddenly; in a haemorrhage, rapid loss of consciousness is often
accompanied by a blowing or snoring type of breathing and the casualty’s complexion turns red.
When approaching such a casualty, keep in mind that he may have lost sight in one eye and hearing
in one ear. Because these symptoms occur on the same side as the haemorrhage/blood clot, stand
on the paralysed side to be able to communicate with the casualty. The first aider cannot do much
beside calling 1-1-2 and (continuing) to check the airway and breathing. If the casualty is unconscious
and breathes normally, place him in the recovery position.
Keep in mind that the casualty may easily lose his balance because he is paralysed on one side and
unable to correct this.
It is very important to recognize a CVA as fast as possible. Nowadays, the death of brain cells due to
oxygen deficiency in stroke casualties can be prevented by administering certain medications.
Therefore, an ambulance needs to be called immediately.
FAST
The patient, his relatives or bystanders can recognize a CVA themselves quickly by means of the FAST
test (Face, Arm, Speech, Time test).
- Face. Ask the patient to show his teeth. Pay attention to the mouth: is it lopsided and has
one corner of the mouth dropped?
- Arm. Ask the patient to stretch both arms horizontally in front of his body simultaneously
and to turn both palms up at the same time. Watch whether one arm drops or drifts about.
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Speech. Ask whether the patient’s speech pattern has changed (speaking unclearly or
inability to find the right words anymore).
- Time. Ask the patient at what time the symptoms started or try to find this out in some other
way.
The acronym FAST may also be understood as a concept. Respond fast: call 1-1-2.
-
As an extra comment: Time is not always mentioned in the explanation of FAST. People then speak of
the Face Arm Speech Test. The Dutch Heart Foundation nowadays speaks about Mouth, Arm and
Speech. Whichever memory aid is used, the principle of calling the ambulance quickly is always key if
these symptoms occur.
Medical alert pendants
Many people suffering from disorders that may give rise to unconsciousness wear medical alert
pendants or in the Netherlands pendants issued by the White Cross Foundation
(http://www.whitecrossfoundation.org/nl). Medical alert pendants contain a note with medical
information. The front of the medical alert pendant shows the “Star of Life” symbol; the back shows
the international emergency phone number, the patients’ number and the most important medical
information. Via the phone number, authorised medical professionals can obtain medical
information at any hour of the day or night.
The first aider does not look for a medical alert pendant before starting to provide first aid. This
would only mean loss of time, which can be better used to react on altered vital signs.
If at a later stage, the first aider finds a medical alert pendant, he should point it out to the medical
professional on arrival. There is no need to open the medical alert pendant to see which information
it contains – the first aider cannot do anything for the casualty with this information. If there is no
need to call the medical professionals, the contact information can be used to alert the family if the
casualty has physical or mental impairments.
2.2 Breathing difficulties
If the airway is free, the air may pass freely and close to the mouth and nose, breathing sounds are
audible. Breathing should be regular. If the airway is partly obstructed, the sounds will be abnormal,
whereas if the airway is completely obstructed, no sound will be heard any longer.
Breathing difficulties may have many causes, each of which requires a specific response. An
important determining factor for the intervention is whether the casualty is conscious or not.
If the casualty is (still) conscious and has a partly obstructed airway, it may be caused by factors that
the first aider cannot remedy or can only partially remedy (for example, swelling of the airway or
burns to the face). Timely recognition and calling the ambulance are of the utmost importance, while
the casualty can determine himself in which position he will be able to breathe more easily.
Breathing assessment
Performing the head tilt and the chin lift
The first aider places a hand on the unconscious casualty’s forehead and tilts the head backwards.
Then, he lifts the point of the chin with the fingertips of his other hand to open the airway. In
casualties who may have spinal injuries, the head tilt is performed in tiny steps until the casualty is
able to breathe freely. Tilting the head and lifting the chin ensures that the neck muscles and thereby
the soft tissues (tongue, epiglottis) in the mouth/pharynx are contracted. This frees the airway.
When assessing an infant’s breathing, the head is kept in the neutral position (face straight up).
Because an infant’s head is large in proportion to its body, the chin touches the chest when the
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infant lies on his back. In order to bring the head into a neutral position, it should in fact be slightly
and carefully tilted backwards.
In infants, the risk of airway obstruction is especially great if pressure is exerted on the soft tissues
under the chin. For this reason, the head tilt and chin lift should be performed with the utmost care
in infants.
Breathing
The first aider keeps the airway open, looks, listens and feels whether the casualty breathes
normally. The first aider:
- observes respiratory movements of the chest
- listens for breathing sounds close to the casualty’s mouth
- feels the exhaled air on his cheek
Normal breathing produces normal breathing sounds (without additional throaty or wheezing
noises). The abdomen and/or chest rises and falls regularly at a quiet pace. A flow of air can be felt
and the casualty does not seem to be short of breath.
Impaired breathing may mean:
- absent breathing
- breathing too quickly
- breathing too slowly
Breathing is absent when the airway is obstructed completely or when the respiratory centre in the
brain has stopped functioning.
If the casualty breathes too quickly, this is usually a sign of oxygen deficiency. However, it does not
provide any information as to the cause. Breathing too quickly may mean that there is a severe
disorder somewhere in the body.
The casualty breathes too slowly if the respiratory centre in the brain does not function properly.
This may be caused by direct damage to this centre (a blow on the skull, compression of the brain
because of increased pressure caused by haemorrhage or a tumour) or by indirect damage of the
centre (such as poisoning or a final stage of severe oxygen deficiency).
Agonal gasps
The first aider should start resuscitation if the casualty is unconscious and does not breathe normally.
During the first minutes after a circulatory arrest, the casualty may produce gasping respiratory
movements (slow, irregular, often audible breathing). Gasping is often explained incorrectly, which
causes resuscitation to be started too late.
Gasping is in fact a sign of approaching death and should therefore be a reason to start giving chest
compressions.
Choking
Choking casualties who lose consciousness must be resuscitated immediately; this means 30 chest
compressions alternated with 2 rescue breaths (irrespective of whether they are effective or not). If
the rescue breaths turn out to be ineffective, inspect the mouth. If the food morsel is released and
visible in the mouth, remove it with a scooping movement.
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The act is somewhat complex described in The Orange Cross Book (TOCB P56). The intention is that
the hand, with which the mouth was opened, scoops the mouth empty. Once the mouth is open, it is
further kept open by the thumb in the cheek.
The first aider should not scoop blindly in the casualty’s mouth. The mouth may be damaged if the
first aider does not pay attention and there is a risk of injury for the first aider due to contact with
the casualty’s teeth. Nor should scooping be repeated if the object is visible in order to prevent it
from becoming lodged more deeply inside the throat. The chest compressions may not be
interrupted for too long either. Giving chest compressions has the additional advantage that it may
release an object that has become stuck (often a food morsel). In addition, an unconscious casualty
has a low muscle tone which may cause the food morsel to be released as well.
Resuscitation is continued as long as the casualty has not regained normal breathing and has not
opened his eyes.
Other injuries and disorders that cause breathing difficulties
The first aider has a modest role with casualties of breathing difficulties caused by disorders or
injuries. Immediate involvement of professional rescuers is necessary if the airway keeps swelling.
The casualty may require oxygen to be administered or intubation or a coniotomy (an external
opening of the windpipe).
Coniotomy is not part of first aid. The puncture is given in an area with an extensive blood supply and
is therefore regularly practiced by the professional rescuer. If coniotomy were to be included in first
aid training, the risk of death would outweigh the chance of rescue.
In view of the effect of chest injuries on breathing, this topic has been placed under the section
about breathing difficulties (it is no longer discussed in combination with abdominal injuries).
All penetrating chest wounds are covered with non-stick compresses with airtight material on top
(plastic). The compress is then taped up on three sides. The airtight material on the compress
prevents air from being sucked in through the wound. During inhalation, the compress would be
sucked in against the wound. For the sake of clarity, it is not the wound that is taped up with airtight
material but the compress. Because one of the sides is left open, the wound is airtight during
inhalation (because the compress is sucked against the wound) but any excess pressure can escape
during exhalation.
Chest wounds are not the only way air can enter the space around the lung, but also through a hole
in the lung. If this hole acts as a one-way valve, air can only enter the chest cavity and cannot leave
this cavity via the airway. Excess pressure builds up. By taping up the compress on three sides, the
excess pressure/accumulation of air in the chest cavity (pressure pneumothorax) can escape via the
side of the compress that has been left open.
Position
Casualties with broken ribs generally assume the position in which breathing is least painful. This is
usually a sitting or half-sitting position. If the casualty cannot do this on his own, help him and ask
what the best position is. If he loses consciousness because of additional injuries, put him in the
recovery position, just like any other unconsciousness casualty. Place him onto the affected side.
There is controversy as to which side an unconscious casualty should be turned. Lying on the affected
side could mean that gravity would cause the blood supply to the higher unaffected lung to become
insufficient, which would result in inadequate gas exchange. On the other hand, it is possible that
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placing the healthy lung lower would restrict respiratory movements. Besides, haemorrhage could
threaten the unaffected lung.
For this last reason, the casualty is turned onto the affected side.
In exceptional cases, the casualty’s condition may deteriorate. The casualty should then be turned
onto his back. The Orange Cross Book does not mention this because the casualty should be turned
onto his back again anyway if there is any doubt of his breathing normally.
If necessary, the airway may be kept open by means of the chin lift.
In no case should the casualty be placed on the side from which an object protrudes.
Hyperventilation
It is not advisable for casualties of hyperventilation to breathe into a bag or similar object. After all, it
is not always possible to distinguish between people who actually suffer from hyperventilation and
people who suffer from oxygen deficiency. For this reason, other causes need to be excluded first.
The physician may have told the casualty to breathe into a plastic bag. As a result, the casualty will
carry such a tool with him and will indicate this to the first aider. It is then allowed to use this.
2.3 Resuscitation
In principle, the Orange Cross follows the resuscitation guidelines issued by the Dutch Resuscitation
Council (NRR). This implies that the Orange Cross does not make any difference between
resuscitating adults, children or drowning casualties. Learning one method has been chose as the
preferred option because every exception would increase the threshold and therefore would cause
delay.
However, there are other methods for children or drowning casualties. These differences are only
relevant for first aiders with special tasks in relation to these target groups. For example, the module
Child First Aid addresses this subject.
Chain of survival
All activities pertaining to the resuscitation of casualties are consistent with the approach mentioned
in the chain of survival found in the European Resuscitation Guidelines. This consists of the following
steps:
- Early recognition and call for help (to prevent cardiac arrest).
This may have an important effect during the stage preceding cardiac arrhythmia, because it
may prevent the situation from getting worse.
- Early resuscitation (to buy time).
In casualties with ventricular fibrillation, the survival rate may double or triple.
- Early defibrillation (to restart the heart).
If done within 3 to 5 minutes, the survival rate increases by 49-75%. Every minute delay
means a decrease of the survival rate by 10%.
- Post resuscitation care (to restore quality of life).
This results in improvement to the care given by medical professionals (including therapeutic
cooling), to improve the quality of life.
The Orange Cross endorses the importance of this structure and applies it in the course material
without specifically referring to it. The chain of survival has been compiled from a resuscitation
background and the first aider is faced with more issues than resuscitation alone.
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Early recognition
Should lay people provide aid, the most important point to remember is that early recognition must
occur, an ambulance must be called immediately and resuscitation must start quickly (with an AED, if
available).
The casualty may have his eyes open. Therefore, the eyes closed is not a condition for having a
circulatory arrest. The eyes may be open, but the casualty looks without seeing. This way of looking
may support the conclusion that the casualty is unconscious, in addition to no reaction when shaken
by the shoulders or spoken to.
The AED
AED stands for Automated Electronic Defibrillator or (preferably) Automated External Defibrillator.
Sometimes the A stands for Automatic or Active.
Many studies on the risk of the AED have shown that it is absolutely safe, even if there is inadvertent
contact with the casualty during the shock and even if this should occur in a humid environment.
During one study, the leakage of current was measured when defibrillating a turkey in a puddle of
water. The current was just measurable and did not exceed a tingling sensation. Moreover, this
sensation is not to be felt if wearing latex or vinyl gloves.
In spite of this, the guideline remains in force to let go of the casualty during the time the shock is
given.
The electrodes should be applied according to the illustrations on this pads. Because they are more
advanced nowadays, it is possible to place them in a way that is different from the traditional
method (for example, in electrodes that simultaneously measure whether chest compressions are
deep enough). In fact, the exact location is not all that important, as long as the heart is
approximately in between the electrodes. Therefore, a placement lower right and higher left is
possible too.
It is important to remember that the current is between the electrodes. For this reason, it is not
useful to apply the electrodes on one side of the body. So, the exact location of the electrodes is not
essential; this is also an advantage for people whose heart is situated on the right-hand side of the
thorax (dextrocardia), which is the case in 3-7 cases in 10,000 (source: Nederlandse Tijdschrift voor
Geneeskunde –NTVG). Although the placement does not have to be accurate to the millimetre, the
guideline still is to place the electrodes according the illustrations. Not only is this the place
determined by the manufacturer whereby defibrillating provides the best result, but it is an aid for
people learning to use the AED. It also serves as a memory aid in stressful situations. During the
examination, the location of the illustrations have to be complied with.
However, the position of the wires in the illustrations does not have to be followed. With some pads,
the AED should be placed near the casualty at hip level. It is of course more practical if the AED is
closer to the first aider, nearby the casualty’s head. The exact location of the AED is not in the
guideline. Sometimes, it is necessary to improvise, for example in a confined space. Then all places
within reach are a good solution, for example placing the AED on the legs of the casualty.
The only important thing when placing the wires is that they do not run across the middle of the
casualty’s chest to avoid being under the first aider’s hands during the chest compressions.
Chest compressions
In unconscious casualties who do not breathe (normally), the start of the resuscitation is with chest
compressions. This choice was made because many casualties with acute cardiac arrest initially have
enough oxygen in the blood.
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The ratio of chest compressions to rescue breaths is 30:2. Chest compressions result in a (limited)
blood circulation thus maintaining the oxygen supply to the heart muscle and brain. Chest
compressions increase the chance of successful defibrillation. This latter point is even more
important when defibrillation after cardiac arrest is somewhat delayed. At the moment the first aider
releases pressure, the pressure in the chest cavity is reduced, causing blood to flow back into the
chest cavity. This pressure reduction also causes some of the air in the lungs to be refreshed. For
these two reasons (blood circulation and oxygen supply), pressure on the chest should be released
completely after each compression (do not lean on the casualty’s chest).
Focus points for chest compressions
- Each time the chest compressions are resumed, the first aider places his hands in the centre
of the casualty’s chest without delay. To do so, there is no need to look for the correct place.
According to the Dutch Resuscitation Council, a further description of the place has been
deliberately excluded from the course material because a demonstration from the instructor
illustrates much more clearly where the hands should be placed.
- The correct tempo is at least 100 and at most 120 chest compressions a minute (because of
the interruption for the rescue breaths, the number of chest compressions per minute is
fewer than 100).
- Make sure that the full depth of 5-6 centimetres is reached.
- Let the chest rise completely. Leaning on the chest causes a constant pressure inside the
chest cavity, which complicates circulation.
- During resuscitation, compression and relaxation should take equal amounts of time, while
contact with the place of the chest compressions should not be interrupted.
- Interruption of the chest compressions should be avoided.
- For all rescuers, checking arterial pulse, for example in the neck, is an inaccurate method to
determine whether there is active circulation. Unconsciousness in combination with
abnormal breathing is supposed to mean absence of circulation, even though it is possible
that the heart is (still) beating. It has been proven that applying chest compressions if the
casualty’s heart is still active is not harmful. However, not performing resuscitation whereas
this is necessary, is harmful.
It also means that it is not necessary to search for a palpable pulse; if the first aider doubts
whether the circulation has resumed, he can continue the chest compressions.
The resuscitation could be terminated too early because the casualty shows some movement. For
this reason, the Dutch Resuscitation Council has revised the circumstances in which resuscitation can
be stopped: there can be no doubt as to whether the casualty has moved, has opened his eyes and is
breathing normally. It is of course possible that a casualty cannot open his eye due to a handicap.
Such a casualty may receive unnecessary resuscitation. However, this exceptional situation is so rare
that it has not been included in the guidelines. In addition, this situation will not last very long
because an ambulance will soon arrive. The paramedics will decide that the resuscitation has been
successful on the basis of the ECG and blood pressure.
In confined spaces, the chest compressions may be applied whilst the first aider is positioned on the
side of the casualty’s head or even straddling the casualty. This is better than no chest compressions
at all.
Effective chest compressions can only be given on a hard surface. The Rautek rescue manoeuvre is a
suitable way to remove the casualty from a bed or couch, although it is quite difficult to move
somebody who is completely without muscle tone.
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If the casualty lies on a soft surface, feedback equipment (CPR-ezy for example) will not provide
correct readings. In this case, it is not certain if the chest compressions are given adequately.
Rescue breaths
If oxygen deficiency was not the cause of the circulatory arrest, the oxygen level in the blood will
remain high during the first minutes after the arrest. However, the oxygenated blood is no longer
pumped around. For this reason, in casualties of sudden cardiac arrest, it is of less importance to give
rescue breaths than to begin performing chest compressions. Once it is determined that an
unconscious casualty is not breathing (normally), chest compressions need to be started.
It is recommended to give (mouth-to-mouth or perhaps with a mask) enough air in approximately 1
second to make the chest rise somewhat with each rescue breath. Fast and forceful rescue breaths
should be avoided. The pressure with which the rescue breaths are given interferes with the return
of blood to the chest cavity. Using a lot of force for the rescue breaths or blowing a large volume of
air into the casualty’s lungs would hamper the blood circulation. It is sufficient if the casualty’s chest
rises to such an extent that it is just visible.
In mouth-to-mouth breathing, the casualty’s nose should be pinched with the thumb and forefinger
to prevent the air that is blown through the mouth from escaping via the nose.
Under normal circumstances, inhalation is caused by active muscle contraction. By contracting the
diaphragm and the intercostal muscles, the space in the chest cavity is expanded and air is sucked in.
If a casualty receives rescue breaths, inhalation is passive. Inhalation is caused by the pressure with
which the first aider’s exhaled air is blown into the casualty’s airway.
Therefore, the first aider’s mouth has to enclose the casualty’s mouth entirely and close it off in such
a way that it is airtight when air is being blown in. While doing so, he observes whether enough air
reaches the casualty’s lungs by checking whether his chest rises.
First aiders may use CPR breathing masks/pocket masks (often to be found inside an AED bag) and
CPR face shields (often to be found in first aid kits). Course participants should practice with this
equipment in order to prevent loss of time during an actual resuscitation. Practice is also necessary
to prevent mistakes, such as applying the breathing valve the wrong way around so that no air can be
blown into the casualty’s lungs or tearing the filter.
If the chest does not rise during the rescue breaths, this equipment needs to be removed.
It is not mandatory to use these tools. The candidate is allowed to use a mask during the exam but he
cannot be obliged to do so. If he does use it, effective rescue breaths must be given with the
equipment. If he does not succeed in giving effective rescue breaths and the candidate does not
remove the mask or shield, he is not competent.
Special training and practice is required for the use of ventilation equipment such as an oxygen
cylinder with a hose and face mask.
Using a bag valve mask when applying rescue breaths requires experience and skill. Therefore, this
technique is not suitable for the first aider and there is no need to teach artificial respiration using
these tools. However, specific training is required for first aiders who work in highly specialised areas
where there is a risk of cyanide poisoning or where other poisonous substances are present. Other
first aiders are only allowed to use this technique if they have had sufficient training, namely the
same training as the professional rescuers.
Moreover, it is hardly possible for individual first aiders to maintain this type of equipment (such as
responsible storage and check of the oxygen cylinders).
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Drowning casualties
In drowning casualties, the air should be blown into the lungs with slightly more force since water
have made the airways less pliable. For the first aider, the rest of the resuscitation of a drowning
casualty is the same as in other cases of resuscitation. During the course First Aid for Water
Accidents, first aiders who work in the vicinity of water (rescue teams, lifeboat institutions and
lifeguards in swimming pools) are taught to start resuscitation by giving five rescue breaths. This is
because the casualties suffer from oxygen deficiency. If they have trained this skill, they can already
start giving rescue breaths in the water.
Second rescuer takes over resuscitation
If more than one first aider is present, the first aiders need to alternate every two minutes to prevent
exhaustion and therefore continue effective resuscitation. In changing turns, they should take care
not to lose time. It is recommended to perform the switch over whilst the working first aider
performs the rescue breaths. At that time, the first aider who takes over can prepare to start the
chest compressions immediately during the second exhalation. In fact, the first aider presses air out
of the lungs.
Then, this first aider can perform the resuscitation on his own for two minutes. The other first aider
can take over the resuscitation again for two minutes after having rested. If an AED is available, the
moment of analysis can be used for the switch over because the analysis by the AED is performed
every two minutes as well.
The first aider who was the first to operate the AED continues to do so until the paramedics indicate
that he can stop (this is often the moment at which the defibrillation can be continued with their
own instruments and other preparations have been finished).
The Dutch Resuscitation Council states that the 2 rescue breaths should be given in 5 seconds. This is
more easily accomplished when the chest compressions are resumed without awaiting the second
exhalation.
Chest compressions without rescue breaths
In practice, a first aider may have his reasons for not giving rescue breaths. These may include:
- psychological threshold to give rescue breaths
- fear of contracting infections by giving rescue breaths
- the casualty’s facial injuries
- unhygienic circumstances for example blood and/or vomit
It is important that course participants learn to perform resuscitation including giving rescue breaths.
If in actual practice the first aider is unable or unwilling to give rescue breaths, it is certainly useful to
give chest compressions alone. Chest compressions by themselves may improve the effectiveness of
early defibrillation. The chest compressions should then be performed at a rate of 100 – 120 times
per minute.
Rescue breaths and resuscitation in children
Circulatory arrest in (young) children is usually caused by breathing difficulties. These include: cot
death, respiratory diseases, choking and drowning. Circulatory arrest as a result of a heart problem is
usually caused by congenital heart defect.
The most logical solution for circulatory arrest caused by oxygen deficiency seems to be to start the
resuscitation by giving rescue breaths. However, the choice was made to teach basic resuscitation
without creating exceptions. This choice was made to simplify the instruction and limit the number of
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skills to be trained. For people who want to know more about the resuscitation of children, the
differences below are discussed in Child First Aid .
Important differences with the rescue breaths to adults:
- in infants, the mouth-to-mouth/nose method is applied
- air is blown into the infant’s lungs during 1-1,5 seconds instead of during 1 second
- in children with circulatory arrest due to oxygen deficiency, first start by giving 5 rescue
breaths
Important differences while giving chest compressions:
- for infants, chest compressions are given with two fingertips
- use one hand for small children. The first aider has to determine for himself whether he
needs to use one or both hands for the chest compressions in order to press the chest deeply
enough
- the chest is compressed for one third of its depth (4cm for infants, 5 cm for children)
For children, a ratio of 15:2 is maintained between the number of chest compressions and rescue
breaths. It is not wrong to revert to 30:2 if the first aider finds it difficult to alternate between chest
compressions and rescue breaths or when the AED prescribes 30:2.
If only one first aider is present, he starts giving resuscitation for 1 minute before calling 1-1-2.
For children younger than 8 years, use preferably children ’s electrodes or adjust the AED to children.
Especially in small children, the electrodes are applied to the front and back of the body. Keep in
mind that the electrodes must not touch each other.
Cardiac arrhythmia
Circulatory arrest is usually the result of cardiac arrhythmia, which is mostly caused by ventricular
fibrillation; less frequently, there is complete cardiac arrest (asystole).
Untreated ventricular fibrillation eventually leads to asystole.
In cardiac arrhythmia, the heart is unable to perform its pumping function effectively.
Ventricular fibrillation
In ventricular fibrillation, the muscle cells of the heart contract in a completely uncoordinated way.
Because there are still contractions, all be it uncoordinated, physiologically speaking, the heart is not
standing still. However, the pump function of the heart has become completely ineffective and this
means circulatory arrest. An ECG is required to make the diagnosis of “ventricular fibrillation”. The
AED is able to make this diagnosis with great accuracy. If the diagnosis has been made, the treatment
should consist of defibrillation. An electrical shock is then administered with the purpose of making
all heart muscle cells contract simultaneously. Because of this current surge, all the cells reach a
resting stage at the same time. During this resting stage, the normal rhythm of the sinus node can be
resumed. Fully automated AEDs provide the shock themselves. In other types of AEDs, the first aider
has to press the shock button immediately after the prompt. If the AED has not established that the
heart rhythm can be restored by defibrillation, it will not charge for a shock. In other words, the AED
will not give a shock inadvertently.
Complete stop of the heart (asystole)
When the heart is in asystole, the ventricular contractions (systoles) have stopped completely.
Casualties of ventricular fibrillation as well as casualties of asystole have no circulation. Asystole
arises when impulse generation has stopped completely or if impulse conduction is obstructed. Then,
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the heart literally comes to a complete stop: there is no (electrical) activity whatsoever. Resuscitation
is essential. The AED can distinguish between ventricular fibrillation and asystole. The AED will not
administer a shock if the casualty suffers from asystole.
Heart disorders
It is not easy to establish with certainty if someone has a problem with his heart. Chest pain may
have several causes. A heart attack on the other hand may manifest itself in various ways. It may be
accompanied by the classic symptoms (chest pain, radiation to the lower jaw and the left arm in
combination with vegetative symptoms such as sweating), but also by unexpected symptoms such as
an aching elbow or pain in the upper abdomen. Women especially may have atypical symptoms.
It is important to observe other symptoms as well, such as sudden symptoms without apparent
causes, like fatigue or tightness of the chest. If the first aider suspects heart problems, he must call 11-2 or in doubt the general practitioner. It is, however, quite conceivable that a heart attack is
overlooked: the silent heart attack.
2.4 Active blood loss
One of the functions of blood is to transport oxygen from the lungs to the cells of the body. Blood
loss means that less oxygen is available to the cells of the body. Casualties with uncontrolled blood
loss will eventually die.
Blood loss can be categorized according to the nature of the main blood vessel that ruptured (in most
cases, several kind of blood vessels are affected):
- arterial bleeding: pulsating, powerful, bright red
- venous bleeding: gradual blood flow (in many cases, the blood loss is still considerable), dark
red
- damaged capillaries: trickling flow, the amount of blood lost depends on the surface area of
the bleeding
Active blood loss should always be stemmed (preferably before it becomes severe). In severe blood
loss, additional measures should be taken, for example lying the casualty down. In fact, it is not
important from which blood vessel the blood flows. Admittedly, in arterial bleeding, the greatest
amount of blood is lost in a short period of time but other types of bleeding should not be
underestimated.
The term “active” means that the blood loss is still going on. The word “severe” does not have this
meaning. Severe blood loss may mean that the blood loss occurred earlier, for example if there is a
puddle of blood on the floor.
Blood loss may be external or internal.
External blood loss
As opposed to internal blood loss, external blood loss can be treated by the first aider. The blood loss
should be stopped as soon as possible. The severity of the blood loss depends on the amount of
blood lost and the time during which it occurred. This explains why an arterial bleeding is not always
more severe than a venous bleeding. The first aider should focus on stemming all active blood losses.
In principle, minor external bleedings are only treated when altered vital signs, if present, no longer
require attention. However, if the external bleeding is so severe that it could be life-threatening, it is
of course important to change the order of interventions. In fact, it will become the first immediate
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intervention after having checked the consciousness level and called for help. Assistance can also be
used for applying pressure to the wound.
Natural mechanisms to limit blood loss are:
- clotting
- decreasing blood pressure in the body
- running out of blood in the vascular system
If the blood is lost as a result of an object that protrudes from the body, this object must not be
removed (in some cases, the object works as a cork on a bottle). Pressure is applied on either side of
the wound as well as possible. In order to limit the internal damage, the object is fastened with rolls
of bandages and plaster tape.
Providing rest to the affected body part after the bleeding has been stemmed has the following
purposes:
- prevention of a recurrent bleed
- alleviation of pain
- improvement of wound healing
Moving the affected body part may cause the blood clots that formed to be released so that the
wound will start bleeding again.
It goes without saying that 1-1-2 should be called if the casualty suffers from major blood loss.
Casualties who take anticoagulation agents or haemophiliacs (casualties with a defect in the blood
clotting mechanism) have a greater risk of severe blood loss. Calls to 1-1-2 will be made more often
for these casualties because bleedings can only be stemmed by administering certain medications.
Internal bleeding
Internal bleeding may occur anywhere in the body, due to injuries or certain disorders:
- in the body cavities (abdominal, chest and skull)
- in the gastrointestinal tract, the urinary passages or the internal reproductive organs
- sub-dermally (in bruises and sprains)
- in the muscles (ruptured muscles)
- in the bones (especially in fractures of the pelvis and the femur)
If there is blood loss inside the cranial cavity (often between the brain and the inside of the skull), it is
not so much the amount of blood loss that is life-threatening, but rather the increasing intracranial
pressure. This cerebral compression may cause hernia of the brain.
With internal bleeding, the first aider will concentrate first and foremost on the following points:
- preventing the casualty’s condition from deteriorating
- ensuring that the casualty remains in as comfortable a position as possible (physically as well
as mentally)
- ensuring that the ambulance is alerted quickly and accurately
Although with internal bleeding no blood is visible, extensive and fast bleeding may occur, which
could result in a life-threatening situation.
The way an accident happened may lead to a suspected internal blood loss (for example a kick or
handlebars in the abdomen). The shock symptoms that the casualty develops may be the only
indication that blood loss is occurring.
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2.5 Shock
Shock involves the entire body; it is a highly severe disorder that will be fatal if not treated
immediately. Under normal circumstances, all cells of the body are provided with the amount of
oxygen they need. Some cells need more oxygen than others; cells of the same type may need
different volumes of oxygen depending on the amount of work they have to perform.
Several factors are important for a correct oxygen supply to the cells:
- the blood vessels need to contain a sufficient amount of blood
- the blood should be pumped around with enough pressure, in other words: the heart should
work effectively
- enough oxygen should be present in the blood
This “fine tuning”or adjustment of the oxygen supply to the cells becomes possible because the
smallest arteries are capable of dilating and constricting. If the transport process is disrupted, the
cells may develop an oxygen deficit and waste products may accumulate. Glucose is converted into
energy in a different way (anaerobic glycolysis), which produces lactic acid. Lactic acid is broken
down into lactate and hydrogen.
After a while , the hydrogen can no longer be neutralized by bicarbonate. Acidification occurs, which
results in muscle weakness, fast breathing (exhaling carbon dioxide), nausea/vomiting and sweating.
Some cells (for example skin and muscle cells) are more resistant to oxygen deficiency than others
(for example nerve cells). For this reason, the body tries to supply the brain with blood (and
therefore with oxygen) as long as possible. There are several mechanisms to achieve this:
-accelerating the heart
-constricting or even blocking the artery branches to cells that are less sensitive to oxygen deficiency
These compensation mechanisms are limited and if they cannot maintain the pressure within the
appropriate range, shock becomes more evident:
- the casualty will look poorly and be cold to the touch (less blood to the skin)
- he will be weak and feeble (less blood to the muscles)
- he will be sweating ( a response of the nervous system) and is therefore clammy to the touch
- he will be thirsty due to fluid loss
These are signs that not enough blood is being pumped through the blood vessels. The oxygen supply
to the brain is maintained at the expense of other organs in the body. If the shock lasts for a long
period of time, several organs such as the kidneys may sustain severe damage.
Despite all the efforts, the body supplies the brain with as much oxygen as possible; in many cases,
the body only partially succeeds in doing this. Most shock casualties are conscious but respond to
their environment to a lesser extent and may also be restless. Severe shock casualties may eventually
lose consciousness.
Shock may have various causes. Major causes are:
- not enough blood in the blood vessels caused by blood or fluid loss
- inadequate heart function because of cardiac arrhythmia or a decrease in strength
- excessive dilation of blood vessels, for example by allergic reactions
In practice, most cases of shock are caused by blood loss. There is already a risk of shock if 20% of the
original amount of blood is lost (for adults, this means a blood loss of approximately 1 litre). If 30% of
the blood is lost, the casualty will develop visible shock symptoms.
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Approximately 70% of the body consist of fluids. A small part of these fluids circulates in the blood
vessels. The larger part is present in the cells of the body and in the form of free fluid in the tissues. If
somebody loses a lot of fluid due to extensive vomiting or diarrhoea, this fluid is no longer available
to the body as a whole. As a result, the amount of fluid present in the blood vessels will decrease
eventually. If tissue swelling develops, for example due to extensive bruising or burns, the amount of
fluid in the tissue will increase. The additional amount of fluid is subtracted from the blood.
If the casualty is already in shock, stemming an external bleeding will not be a remedy. However, the
first aider will prevent the shock from worsening. This is also the intended effect of the “general
measures” to provide more comfortable circumstances for the casualty. The general measures may
result in a decrease in the oxygen consumption, so that more oxygen remains available to the heart,
lungs and brain.
The casualty is laid down, with as much shelter from the wind and rain as possible. By protecting the
casualty from getting cold, he is prevented from shivering (shivering is a muscle activity that takes up
a lot of oxygen). The casualty must lie down flat on the ground, preferably on his back. Is this
unpleasant or stressful, the casualty may be turned on his side with help. Make sure the casualty
does not exert himself while doing this.
Shock casualties are not allowed to drink. The blood supply to the intestines will have diminished as
well and they will not work properly either, causing the casualty to become nauseous and to vomit.
In addition, there is a risk of choking, which can cause gastric juices to enter and damage the lungs.
Besides, vomiting takes a lot of energy and the casualty already suffers from a lack of energy.
Shock casualties are in physical and mental distress. Therefore, the first aider should support the
casualty as best he can and should avoid leaving him alone.
To prevent anaphylactic shock, injectable epinephrine may have been prescribed. Giving injections
(auto-injector/epipen) is not part of first aid training, because it is almost impossible to recognize
anaphylaxis in an unknown person. Also, someone with an auto-injector could have other complaints
and wrongly receives medication. This is a risk for more types of medication, such as glucagon in case
of hypoglycaemia. Thatsomeone has medication with him or has been diagnosed with some kind of
disease makes you think that the present complaints are related.
In the context of informal care, someone with a first aid training also can be confronted with the
administration of medication. In schools for example, employees can be asked to administer
epinephrine, if necessary. The school can make special arrangements with a GP. Administering
medications is then under supervision of the GP. The GP perhaps can sign a competence certificate.
If within an organisation (in this example a school) agreements are made for using an auto-injector, it
is recommended to register this in writing for insurance reasons.
Note: all this is no part of the First Aid certificate.
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Part III Injuries
3.0 Introduction Part III
It is important to form a general impression of the situation. Many injuries are clearly visible, the
casualty’s facial expression will give you an idea of the amount of pain he is in. In some cases, the
abnormalities are subtle (for example, the lopsided face in CVA casualties) and should be examined
separately. Because some CVA patients may benefit enormously if certain medications are
administered quickly, it is essential that this disorder should not be missed.
Much information can be obtained by asking questions and giving instructions, for example with
injuries to the vertebrae or the spinal cord.
If an accident casualty complains of pain in the neck, the first aider acts as if spinal injuries were
present and does not ask the casualty to turn his head. His neck may be in a forced position whereby
his head cannot be moved.
Pain in the neck can also accompany injuries in the ligaments and muscles around the neck
vertebrae. Such injuries often happen in (head-tail) collisions which cause cars to come suddenly to a
halt. The heads of the occupants may have been swung back and forth forcefully resulting in
ligaments and muscle damage. This is called a whiplash.
If a casualty complains of tingling in arms or legs, or if he cannot move his arms or legs, his spinal
cord may have been damaged.
These complaints may develop later due to bleeding in the spinal canal, causing pressure on the
spinal cord.
Breathing difficulties may often occur due to damage of the spinal cord.
In possible spinal cord damage, any movement should be avoided as much as possible – in principle,
leave the casualty in the position he finds himself.
3.1 Wounds
When a first aider assesses an external wound, he has to decide whether to treat it himself
(definitive treatment in small wounds, minor cuts, abrasions and splinter wounds) or, when extensive
and/or contaminated wounds are concerned, to just provide first aid and ask a physician to provide
follow-up treatment. In case of doubt, refer the casualty to a GP.
Assessing a wound includes looking at and into the wound, of course without touching it. This gives a
good idea of the nature and severity of the wound and of whether there are foreign objects in the
wound such as glass or dirt from the street.
The following principles apply to treat wounds:
- cleaning
- sterile coverage
- if necessary providing rest and support to the affected body part
If the first aider treats the casualty himself, it is necessary to clean the wound. The blood flowing
from the wound (so-called self-cleaning capacity of the wound) is decidedly insufficient.
Active cleaning by the casualty himself or by the first aider provides cleaner wounds. In The
Netherlands, tap water hardly contains any germs; therefore, flowing tap water is very suitable to
perform active cleaning. However, it is impossible to sterilize external wounds completely – that is to
say free from live germs. As long as the extent of the contamination is small enough because the
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wound was actively cleaned, the last remaining germs can be disposed off by the immune system
and the natural wound healing process without any problem.
Once the wound has been cleaned correctly, it can best be covered with sterile material or with as
clean a material as possible.
Once the decision has been taken to have the wound treated by a physician, the first aider only has
to protect the wound from further contamination. He does this by covering the wound.
Preferably cover wounds with non-stick, sterile dressings. Dressings that have been applied should
not shift over the wound in order to avoid further damage. The first aider should be able to secure
dressings in such a way that the part that covers the wound (wound pad) does not shift.
Burns
In The Netherlands, approximately 65,000 burns accidents occur per year. Approximately 50,000
casualties end up with the general practitioner, 11,000 to 12,000 are treated in outpatients ‘wards
and approximately 1,700 are admitted to hospital with “burns” as their main diagnoses. Each year,
nearly 200 people die from the effects of burns.
Children suffer from burns relatively often. Approximately 40% of burns occur in children from zero
to fourteen years of age; the group from zero till four years is by far the majority of this group.
Over 70% of accidents happen in and around the house and 70% of these are caused by hot fluids.
The skin is an important organ which forms a protective shell around the body. If part of this shell is
lost, fluid with essential nutrients is lost from the body. In addition, there is a great risk of infection
because immunity is impaired and moreover, shock may occur. After several hours, shock may occur
as a result of the loss of fluid and proteins. In addition, swelling of the tissue (oedema) may happen,
which is especially dangerous in the neck as it poses a risk of suffocation.
The formation and shrivelling of scar tissue in casualties with third-degree burns often means that
the casualty will be confronted with prolonged medical treatment such as skin grafts. Besides, there
is a great risk of permanent mutilation.
Transplanted skin does not keep up with growth, so growing children will have to undergo several
operations, especially if the burns are in the joints, hands, feet and face.
By cooling immediately, it is possible to prevent or limit a second-degree burn from turning into a
third –degree burn.
The severity of a burn is determined by:
- the temperature during burning
- the duration of exposure
- the location of the injury (burns to the face, hands, feet, reproductive organs and tissues
surrounding the joints are more severe than burns to other body parts)
- the specific heat or the melting point of the fluid that caused the burn. The specific heat of
hot water and molten metals is high while the melting point of lipids and tar products is
relatively low. Exposure to water at 60 degrees centigrade during 30 seconds will cause thirddegree burns if a thin part of the skin is involved.
- the depth of the burn
- the extent (surface area) of the burn. If over 10% of the skin area is severely burnt, there is a
risk of shock and in casualties with burns of over 50% of the total skin area, the chances of
survival are very slim.
- the casualty’s age (very young/old) and his general condition. These also determine the
chance of recovery.
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Degrees of burns
As you know, burns are categorized into three degrees.
In first-degree burns, the temperature and/or duration of the exposure to the heat is relatively low
and the heat has only affected the surface area of the skin. Only the cells of the epidermis and the
tips of the capillaries and nerve endings may have been stimulated. The blood supply to the dermis
increases. All cells remain alive. The capillaries of the skin are highly dilated and let out small
amounts of fluid. Therefore, the skin is not only painful but also red in colour and slightly swollen.
In second-degree burns, the epidermis and part of the dermis have been damaged. The walls of the
capillaries in the skin become porous and let out so much blood fluid (plasma) that fluid accumulates
between the cells. This fluid reaches the surface, accumulates between the dermis and epidermis
and elevates the epidermis (the part of the skin that is impermeable to water) and a blister forms.
The cells in the epidermis and dermis are damaged but they can recover providing no additional
damage such as infection occurs. The skin is painful, red in colour and shows blisters (in some cases,
only after some time).
In third-degree burns, the skin is damaged to such a depth that the cells, the capillaries and the nerve
endings die. In addition to cell death, coagulation of tissue protein occurs as well. The skin is not
painful because the nerve endings have been burnt. The skin around the wound can be painful if it
has first and second-degree burns.
The skin is greyish-white or black in colour and has lost its elasticity.
A greyish-white skin is caused by a burn with hot liquids – in this case, the skin has been boiled. A
black skin is a sign of charring caused by open fire. Depending on the substance that caused the burn
(chemical substance), other discolorations may occur.
Extinguishing the flames
The appropriate materials must be used for casualties who are on fire. Materials made from
(impregnated) wool, glass fibre, Kevlar or other hardly inflammable materials are preferred.
Synthetic materials such as nylon are highly flammable and cannot be used. The same applies to
survival/rescue blankets.
While extinguishing flames, do not let them shoot up along the neck. This would occur if the blanket
is folded around the body in the shape of a cylinder causing the hot air to rise, which the casualty will
subsequently inhale. This would cause the airway to swell to a dangerous extent. Therefore, the
blanket should be placed around the shoulders and from there downwards over the remainder of the
body. Any folds should be smoothed out and the flames should be extinguished by beating. This can
be done by tapping on the blanket. It may be painful but acting fast would limit the extent of the
burns. It is also possible to roll the casualty over the ground.
Make sure that extinguishing material is not sprayed into the casualty’s face. Powder extinguishers,
CO2 extinguishers or spray foam extinguishers can be found everywhere, for example in cars and
buildings. They (the red cylinders) always carry pictograms indicating for which type of fire they are
suitable. The first aider should be informed as to the purpose and effect of these extinguishers.
Cooling and dressing burns
The Dutch Burns Foundation uses the slogan:
“Water first, anything else can wait!”
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This means that the burn should be cooled immediately with running water for at least 10 minutes.
Cool with lukewarm water to ensure that deeper tissues are cooled as well. If the burn is cooled with
water that is too cold, the blood vessels in the skin will contract and heat will no longer be removed .
In addition, the casualty will experience too cold water as unpleasant and may find it more difficult to
bear the cooling process for the time required. If necessary, adjust the temperature if the casualty
thinks the water is too cold.
If no water is available, hydrogel dressings are highly suitable for cooling.
Provide cooling over items of clothing stuck to the skin if applicable. If possible, jewellery should be
removed because of the risk of swelling tissue. In case of extensive burns, the unaffected part of the
casualty’s body should be covered with blankets to protect him from hypothermia.
After cooling, second and third –degree burns should be covered in as sterile a way as possible and
with non-stick material such as metalline compresses. The plasma (blister fluid) that has flowed from
the wound coagulates on exposure to air and will stick to textile fibres. On removal, this will cause
additional damage and unnecessary pain. Synthetic padding and other types of sticking material
should not be applied immediately on burns.
Compresses should be applied loosely so as not to exert pressure to the wound and to avoid
damaging blisters. If the casualty has a more extensive burn, metallised blankets can be used, or
clean sheets, pillow cases, tea towels, one or more textile table napkins or handkerchiefs; paper will
disintegrate within the wound.
Fabric residues that have become attached to the burn should not be removed and must be kept
wet.
Casualties with severe burns must not be given anything to drink or eat. Hospital treatment may be
necessary for which the stomach should be empty.
All casualties with second and third-degree burns must be treated by a physician. Therefore, do not
apply anything on the burn so as not to interfere with the physician’s assessment. Treatment by a
medical professional is also necessary for casualties with (impending) breathing difficulties due to
smoke or hot gases inhalation, or casualties with burns caused by electricity or corrosive substances.
First-degree burns in the very young and the elderly should be assessed by a physician as well. Their
skin does not yet or no longer offers appropriate protection. Besides, intentional violence must be
excluded (consider neglect or abuse of these vulnerable age groups).
3.2 Electrical injuries
Contact with electricity may result in severe burns or may even be fatal. Because we encounter
electricity on a daily basis at home, at work and during leisure activities, it has become so selfevident that the dangers are often forgotten.
Effects of contact with electricity:
- muscle contraction
- heat development
- disruption of the electrical activities of the heart and brain
- fright which may cause other injuries
The severity of the effect of exposure to electricity is determined by a number of factors:
- voltage and type of current (alternating current - AC or direct current - DC)
- amperage
- duration of the exposure
- resistance (skin and tissues which the current ran through)
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-
path of the current through the body
environmental factors (humidity, insulation, et cetera)
Individual factors (gender, weight, physical condition)
Voltage
The unit of voltage is volt (V).
- Voltages up to 50 V alternating current or 12 V direct current (doorbell, telephone
installations, electrical toys) are considered to be very low voltage. These are so-called “safe
voltage”.
- Voltages up to 1000 V alternating current or 1500 V direct current (domestic appliances 230
V, industrial equipment often 380 V) are considered to be low. Although this is called low
voltage, it certainly is dangerous!
- Voltages over 1000V alternating current or 1500 V direct current are considered high voltage.
Such high voltages pose an additional risk. Notably, they may cause sparks or arcs, with
temperatures of 4000 to 20,000 degrees centigrade, at 1000 V over a distance of 1cm, at
higher voltage even over larger distances. High voltage may cause electrocution, even if
people do not touch the power source itself. In addition, people may sustain severe burns
because high voltages may cause items of clothing to catch fire.
Amperage
The unit of current intensity is the ampere. The extent of tissue damage is mainly determined by the
current intensity. This is explained by the fact that the amount of warmth produced inside the tissue
predominantly depends on the current intensity.
Frequency
Low frequencies tend to lead to muscle cramps and damage to the heart, leading to ventricular
fibrillation in particular. If muscle cramps occur, the casualty cannot let go of the power source. As a
result, the duration of the exposure increases and the tissue damage becomes more severe. Muscles
respond to high frequencies to a lesser extent. For this reason, high frequency currents are used in
physiotherapy (diathermy to generate heat) and in surgery (diathermy knife).
Resistance
Tissues differ as to their electrical resistance, which means that the same voltage may cause various
current intensities. This can be expressed in the formula: I = V/R (if the resistance decreases, the
current intensity increases). The resistance of the body as a whole is determined by the skin
resistance and the internal resistance. Skin resistance may vary as a result of environmental factors
and therefore is the main factor to determine the effect of exposure to electricity. The body
resistance can change if the path the current chooses through the body changes because of muscle
cramp or fright reactions. Sweating due to fright may lower skin resistance as well.
Current trajectory
Depending on the entry and exit points in the body, vital organs could have been in the trajectory of
the current (particularly the heart and brain). If the current ran through these organs, the
consequences will be most severe. At the entry and exit points, tiny second and third-degree burns
may be visible, while internal – and therefore invisible - extensive damage may have been caused (for
example charred bones).
Environmental factors
The most important environmental factor is humidity and particularly its effect on skin resistance. If
the skin is dry, the electrical resistance of the body may amount to 10,000 Ohm or more, in which
case a voltage of 220 Volt leads to a current intensity of 22 mA (I = V/R). Providing the casualty can
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let go of the live conductor, such voltages are safe (from 10 to 30 mA); in most cases, the casualty
has had a lucky escape.
If the skin is moist, (perspiration or working in a humid place), the electrical resistance is often less
than 500 Ohm, which causes the current intensity at 220 Volt to increase to 110 mA. This is fatal in
most cases.
Individual factors
Individual variations in the response to exposure to electricity are caused by the casualty’s age,
physical condition, possible heart disorders and gender. Women are 30% more sensitive to the
effects of electrical current than men.
Effects
The effects depend on the current intensity.
Current intensity
4.5 µA
0.5 – 1mA
4 mA
6 mA
15 mA
20 – 30 mA
over 50 mA
over 500 mA
Effects
perceptible with the tongue
perceptible with the fingers
pain
forceful muscle contraction
limit at which the casualty is still able to let go
forceful contraction of the respiratory muscles
risk of loss of consciousness
risk of ventricular fibrillation
severe burns, acute asystole
Lightning
Thunderstorm is a natural phenomenon that leads to huge voltage differences of millions of Volts in
the atmosphere. If these voltage discharges, rays of lightning are produced, brief electrical surges
ranging from tens of thousands to even hundreds of thousands amperes occur. One may be struck
directly or indirectly.
Examples of indirect strike:
- side flash, for example from a tree to a human being
- step voltage, where there is a potential difference between the casualty’s feet
- contact voltage, whereby someone is struck by lightning striking an object that is in contact
with the casualty
First aid focusses on altered vital signs and on treating burns and possible fractures (due to having
been hurled away).
Precaution may decrease the number of lightning accidents.
- move in to or stay inside a closed car
- do not stay upright, especially do not hold such objects as umbrellas, golf clubs or angling
rods but crouch down with both feet touching each other
- take some distance from other people, trees and metal objects
First aid for casualties of electrical accidents:
- be particularly alert to any potential danger to yourself
- break the current by switching off (emergency) switch, wall socket, main switch
- if this is impossible, improvise, but ensure that you are properly insulated
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-
if high voltage is involved: alert experts and leave the care to them; be aware of the risk of
electrocution at a distance
respond to altered vital signs; call 1-1-2 if necessary
take care of burns and other injuries
refer to a GP or hospital for additional examination and treatment
The current may be conducted through the first aider’s body if he is simultaneously in contact with
the earth whilst touching a power source. If the first aider is not earthed (for example standing with
his shoes on a non-conductive surface), he may pull the casualty away by his clothes. The casualty’s
clothes must be dry, so as not to conduct the current. By grasping the casualty by his clothes with
both hands, the first aider prevents inadvertently grasping something that is earthed.
3.3 Bruises and sprains
If the mechanical impact was not severe enough to cause a fracture or dislocation, we speak of
bruises, sprains or strain.
Bruises are caused by direct mechanical impact on tissues. Sprains (strains) are often the effect of
indirect mechanical impact on joints. Examples of bruises are a bump on the head after a fall or as a
result of having been kicked. Sprains commonly occur in ankles or wrists.
With bruises and sprains, the first aider must decide whether he will give the definitive treatment
himself (if the casualty has sustained slight injuries) or if he will refer the casualty to a medical
professional. If there is any doubt as to the severity, for example if there is doubt between a sprain
and a fracture, which is often difficult to distinguish in ankle and wrist injuries), a GP should always
be consulted.
If a bruise or sprain is so severe that treatment by a medical professional is deemed necessary, it is
advisable to limit the first aid to cooling the site of the injury and providing rest and support.
If the extent of a bruise or a sprain is so slight that it is safe for the first aider to decide that
professional treatment is not required, in most cases, the treatment can be limited to local cooling
and applying a pressure bandage. For support, fingers can be taped together; one finger serves as a
splint for the injured finger.
Local cooling will cause the blood vessels to contract thus limiting potential internal blood loss.
Cooling will also alleviate the pain. Local cooling is most effective if applied immediately after the
injury has occurred.
If the pain is aggravated by cooling, it should be stopped. Keep in mind that the most important
reason for cooling is alleviation of pain. Cooling has only a minor effect on swelling. Neither is there
evidence that elevating the limb has any effect on healing. Nevertheless, this guideline has been
maintained. By elevating the injured limb, the casualty is reminded that he should let the injured
limb rest.
Applying a pressure bandage has no demonstrable effect on recovery either. However, this bandage
provides support, which feels more comfortable than if the injury were not bandaged.
3.4 Bone fractures and dislocations
The reason to discuss fractures and dislocations in this section is that the difference between a
dislocation and a fracture or a combination of both is often difficult to determine. First aid is the
same in both types of injuries.
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Fractures that occur at the place of the impact on the skeleton are called direct impact. Fractures
occurring at some distance of the place of impact are called indirect impact. An example of direct
impact is bumper injuries of the lower leg resulting in a fracture of the lower leg. An example of
indirect impact is a collarbone fracture due to a fall on an outstretched arm or a spinal fracture
caused by having landed straight on one’s feet after a fall.
In fractures and dislocations, knowledge of the accident mechanism may give a clear indication as to
the injury that the casualty may have sustained. It is clear that the injury is more severe if more
energy is involved. Examples include collisions at a higher speed and falls from a greater height.
One of the signs of fractures is that the mobility range of the fractured limb may be greater than its
normal range. If a fracture results in abnormal mobility, it is called an unstable fracture – the bone
fragments are overriding. Other types of fractures are called stable. These do not show an abnormal
range of movement. The bone tissue may have been bent (elastic bone tissue in children) or
compressed (in the elderly with more brittle bone tissue). If the casualty is in pain and unable to use
the affected limb, he should be referred to a physician with suspicion of fracture or dislocation. It is
possible, that a standing casualty has a fracture, as the photograph (TOCB page 85) indicates.
When giving first aid to fracture casualties, it is key to immobilise the bone fragments in relation to
one another. This means that the joints on either side of the fracture should be immobilised.
In principle, the casualty supports his broken arm himself. Intuitively, he will find the position that is
least painful. If the casualty is unable to support his own arm, a broad-fold bandage or arm sling
needs to be applied.
In all fracture casualties, keep in mind that areas of bruising and swelling may extend beyond the
place of the fracture itself. Jewellery, rings and wrist watches may exert too much pressure if the
limb swells up, thus constricting blood circulation. Therefore, remove the jewellery from the injured
limb immediately, preferably ask the casualty himself to do so. If the first aider removes these items,
as a rule they should be returned immediately to the casualty. Experience teaches that this may be
forgotten in the confusion.
The possibility of spinal injuries (for example spinal fractures) should be kept in mind in all casualties
of severe traffic accidents, awkward falls or fall from considerable heights. Turning these casualties
over may lead to spinal cord lesions.
Within the field of ambulance care, it is a matter of controversy to which extent spinal cord
immobilization has added value. It takes quite considerable force/manipulation to cause spinal cord
lesions in casualties with unstable spinal fractures. Complete immobilization on a spinal board does
pose risks (interference with breathing, pressure wounds/decubitus). The criteria on whether to
apply complete immobilization may be made more stringent.
For the first aider, this discussion is not relevant. In principle, accident casualties who may have
spinal injuries may not be moved. You are only allowed to move the casualty in case of danger or to
turn him onto his side in case of (imminent) vomiting, or if he has blood in the mouth and if you have
to leave him alone to get help. The discussion may only provide you with the reassurance that
turning a casualty if necessary may be less risky than had previously been thought.
In these accidents with possible spinal injury, it is only allowed to immobilise the casualty’s head in
the position found. The thumbs are above the ears and the fingers support the back of the head.
Leaving the ears free allows for communication. The first aider may not straighten the head. If the
head is straight, the first-aider can immobilise it with Zäch’s manoeuvre. With this manoeuvre,
turning onto the side is more stable, if the casualty vomits. The head is clamped on the arm that
holds the casualty’s shoulder. The shoulder functions as an anchor point, because you only have to
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keep your arm straight. There is no anchor point when turning with the head immobilised or when
turning with Zäch’s manoeuvre on the side if your arm is not along the casualty’s head and neck. In
these situations, it is difficult to prevent change in the position of the head in relation to the body.
Also, you must bear the weight of the head on one hand. This weight is easier to bear by holding the
shoulder. You can therefore maintain this position longer.
The first aider approaches the casualty at the side of his face. If the casualty is in a car, the first aider
can place his hand on the windshield and ask the casualty to keep looking at this hand. This is not
done if the casualty has to turn his head to make this happen. In some regions, paramedics place a
sticker on the windshield for this purpose.
3.5 Eye, nose and ear injuries
Signs of eye injuries include:
- pain in one or both eyes
- red eye
- watery eyes
- squinting
- a haemorrhage and/or distorted pupil
- diminished eyesight
- in some cases, the casualty felt something “hit” the eye (for example a metal
splinter/fragment)
- in many cases, the casualty is frightened and restless
First aid is limited to referral and possibly transport to an (eye) doctor except if you have to remove a
speck of dust from the casualty’s eye or if the eye needs to be rinsed because of burns or contact
with chemical substances. Specks of dust that have become attached to the cornea can only be
removed by an eye doctor. Never try to remove contact lenses. Always prevent the casualty from
rubbing the injured eye.
Casualties of serious eye injury risk blindness. Acting quickly may decrease this risk. If there is any
doubt as to the severity of the injury, the casualty should be brought to an (eye) doctor or a hospital.
First aiders should not take any risks in these cases.
Keep in mind that the casualty may have a severe eye injury, even if nothing special can be observed.
Because eye injuries are often accompanied by a sudden partial or even complete loss of vision, the
casualty may be afraid and in panic. It is therefore important to reassure him. Keep talking to the
casualty and tell him what is going to happen.
Penetrating eye injuries
If someone forcibly has got something sharp into his eye (for example a metal splinter), or his eye has
been hit by a sharp object (for example a shard of glass or a pair of scissors), this casualty should be
brought to an (eye) doctor or hospital as soon as possible.
Reassure him and tell him not to rub the injured eye.
In order to avoid any pressure on the eye, it should be covered with a cap or the bottom of a
disposable paper cup (note, some edges can be sharp) or some such object. Any object that may still
be protruding from the eye (shard, nail, screw, et cetera) may not be removed. By covering both
eyes, the number of eye movements will be reduced.
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Small sharp objects that have entered the eye with force will cause a small opening in the eye
(penetrating eye injury). The casualty often says that he felt something “hit the eye”. If this opening
is in the white of the eye, a small haemorrhage will be visible locally. If the opening is situated on the
cornea and the iris has been hit, the pupil of the affected eye is distorted or may be larger than the
other one.
Pressure on the eye should be avoided in all penetrating eye injuries. The pressure may cause fluid
from the inside of the eye to leak out. Do not place a dressing directly onto the eye ball. If a dressing
is applied directly onto the eye ball, it may suck up the fluid. In either case, the eye will lose its
internal pressure causing the damage to increase which may even lead to blindness.
Corrosive substances in the eye
If the eye has been in contact with corrosive substances, these should be rinsed out as quickly as
possible with a lot of water. If possible, ask the casualty to lie down to be able to reach the eye more
easily. Keep the eye open or ask someone to do this. Flush the corrosive substance from the eye
quickly and carefully with a lot of gently flowing water, preferably lukewarm, for example
administered with the help of a jug. If an eye shower is attached to the tap, do use it. Such
equipment is often available in laboratories.
Make sure the corrosive substance is not flushed into the other eye or upon your own hand.
Do not waste any time. Continue rinsing for at least 30 minutes. If chalk has entered the eye, all the
pieces must be flushed away. After that, bring the casualty to an (eye) doctor or a hospital.
Welder’s eyes
Welder’s eyes are caused by the ultraviolet rays emitted by welding equipment, sun lamps, glaring
lights or blazing sunshine on snow. All these may cause damage to the cornea.
In some cases, symptoms only occur after several hours and include:
- severe stabbing pain
- red eyes, causing the casualty to squint and the eyes to water fiercely
Casualties of welder’s eyes should be brought to an (eye) doctor.
Blunt eye injuries
If the eye is hit, for example by a hard ball, there may be damage both to the eye itself and to the
surrounding structures (fracture of the eye socket for example).
In some cases, there are hardly any external signs. The casualty may complain of blurred vision and
should be brought to hospital.
Nosebleed
In most cases, it is enough to pinch the nose to stop the bleeding. Nasal tampons to treat nosebleed
are available over-the-counter. However, they have the disadvantage that they have to be removed
by a GP. Should a tampon be used in all cases of nosebleed, the GP’s case load would increase
unnecessarily. Therefore, the nasal tampon is not part of first aid. Casualties with severe and
frequent nosebleed may have been prescribed the use of tampons by their GP. This type of care
belongs to informal care.
3.6 Tooth injuries and tooth through the lip
Teeth that have been knocked out have the best chance of being saved if they are placed back within
15 minutes. It is (almost) impossible to reach a dentist within such a short period of time. It is selfevident that the first aider is the obvious person to place the tooth back. It is not necessary to clean
the tooth extensively. It is sufficient to rinse any visible dirt away with milk or saline solution.
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The chances of success when a tooth has been placed back are slim, because, in many cases, the root
has been broken off. However, failing to place the tooth back disadvantages the casualty who may
have had a chance of success.
A milk tooth will not be placed back by the first aider as there is a risk that it will damage the
underlying permanent tooth.
Plastic ampoules of 10 cc. saline 0,9% are available in which a tooth can be stored perfectly. If this is
not available, without doubt enough saliva of bystanders or fellow players can be collected in a cup.
For preservation of the tooth, it is not of concern from whom the saliva originates.
3.7 Overheating (hyperthermia)
It is important to keep in mind that overheating may also occur in cold weather. A standard example
is the marathon runner who gets overheated, even if the weather is cool, because he is clothed too
warmly and did not drink enough. Many casualties of overheating may not even notice this. The first
aider should consider the possibility of overheating if he notices the relevant symptoms and if the
circumstances could have given rise to overheating.
Heat exhaustion is difficult to recognize. Chances are that after physical exertion in a cold wind, the
casualty also looks pale and feels cold and clammy to the touch, while fluid loss due to a high
ambient temperature is limited. In addition to drinks, such casualties require blankets.
However, a casualty of heat exhaustion not only has a cold and clammy skin but also suffers from
headache and nausea. If a casualty wrongly has been brought into a cool environment, he will soon
start shivering with cold.
Heat accumulation is easier to recognize because the casualty is hot, red and does not sweat.
3.8 Hypothermia
A casualty suffers from “genuine” hypothermia when his core temperature is lower than 35 degrees
centigrade.
This may be caused by:
- a decrease in heat production (reduced thyroid function, malnutrition, inactivity, poor
physical condition)
- an increase in heat emission (alcohol, diseases, skin defects caused by burns or thin
subcutaneous layer of fat)
- ineffective temperature control due to alcohol or drugs, shock or brain tumours
- prolonged exposure to cold, wind, moisture/water, wind speed (wind chill)
- inadequate clothing (insulation value)
The body tries to maintain its core temperature by taking countermeasures. This is done by
decreasing the blood supply to the more peripheral parts (such as skin and muscles). As a result, the
blood that is still warm will keep circulating to the central parts of the body. The body will also try to
increase its heat production, which is noticeable by the fact that the casualty will start shivering. If
the temperature drops further, the shivering will stop.
Specific symptoms when the core temperature drops:
36-34° C: pale skin, shivering, fatigue
34-33° C: confusion, disorientation
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32-31° C: defective memory, shivering stops, muscle stiffness
31-30° C: decreased consciousness
30-28° C: unconsciousness, dilated pupils
28-25° C: ventricular fibrillation (circulatory arrest)
˂25° C: the heart stops functioning, death
First aid focuses on retaining the warmth that is still present in the core of the body by:
- keeping the casualty’s movements down to a minimum to prevent the cooler blood from
flowing back from the limbs to the heart, which may cause acute circulatory arrest
- wrapping up the torso, limbs and head separately in aluminium foil blankets (thermal
blankets), to use the casualty’s own body warmth and let it do the work
- if possible applying a wind break or a cap around the casualty’s head (approximately 50% of
the heat is lost via the head!)
- responding to altered vital signs (call 1-1-2)
- under no circumstances, allow the casualty to drink alcohol or to smoke; neither rub the
casualty
- if the casualty suffers from slight hypothermia, give him warm sugar liquids to drink
Hypothermia can be prevented by wearing appropriate, insulating clothing, preferably several layers.
Keep in mind that wet clothing does not provide insulation. In addition, enough high calorie nutrition
should be provided and alcohol should be avoided.
With (trapped) accident casualties, be alert to the possibility of hypothermia. Their chances of
survival depend in part on the extent of hypothermia.
Hypothermia may be categorized in several ways. For the first aider, it is important to distinguish
between mild and severe hypothermia because they respectively require different measures (active
and passive warming).
3.9 Frostbite
Frostbite casualties may have injuries to the fingers, toes, ears or nose.
Three degrees of frostbite can be distinguished (often, the signs do not become apparent until after
defrosting).
- first-degree frostbite: a palish-grey discoloration and stabbing pain
- second-degree frostbite: blisters and stabbing pain (often not until hours later)
- third-degree frostbite: the skin is as white as a sheet and numb
Frostbite to the eye manifest itself in the form of blurry vision.
All casualties, irrespective of the degree of frostbite, should be brought into a dry and warm
environment. Wet items of clothing should preferably be removed.
The affected body parts may be warmed carefully as a first aid measure. This is done in water at body
temperature. If there is no warm water, the casualty can be warmed by means of his own or the first
aider’s body warmth. Do not warm the affected body parts if there is a risk that they will again
sustain frostbite after warming. Warming should not start until this risk has been excluded.
Blisters should be left intact and covered loosely with a dressing. The affected part(s) should not be
rubbed because they would sustain additional damage.
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3.10 Poisoning
A poison is a chemical substance that, often in very small quantities, has a harmful effect on plants,
animals and/or human beings. The (harmful) effect depends on the nature of the substance and the
extent of the exposure. This in turn depends on the amount, concentration, duration of exposure
and, in some cases, on the surface area of the exposed body part.
There is a distinction between acute and chronic poisoning.
Poisoning is acute when a casualty has been exposed to a relatively large amount of a chemical
substance for a relatively short period of time. Acute poisoning may be caused by accidents whereby
chemical substances are suddenly released due to leakage or fire, for example. They can also occur
when children inadvertently ingest household or medical products that are lying around or when
adults ingest pesticides or too large doses of medicine.
Chronic poisoning is usually caused by frequent exposure to small quantities of such substances.
In all cases of poisoning, the symptoms will be more severe in casualties who have ingested larger
amounts of the poisonous substance. In acute poisoning, these symptoms may develop very quickly,
sometimes after a few minutes and sometimes only after several hours.
After exposure, the poisonous substance can:
- prompt local effects (irritation, inflammation)
- be absorbed in the blood via the skin, lungs or the digestive system
- be spread via the blood over tissues/specific organs
- be excreted via the lungs, kidneys, bile, sweat, salivary glands and mammary glands
- be stored, for example in the liver and in fat cells (DDT, PCBs, lead and such like)
All sorts of combinations of effects may occur.
Special attention should be paid to:
- skin: herbicides in agriculture (use not only breathing protection!)
- lungs: carbon monoxide poisoning by defective elimination of exhaust fumes from heating
equipment such as stoves and geysers; this type of poisoning has misleading signs: the victim
may look healthy but in fact be critically ill (carbon monoxide combines with red blood cells
200 times faster than oxygen does)
- stomach/intestine: sleeping tablets and such like
Depending on the substance, the dose and the way the substance entered the body, the effect may
be local or general.
Local
-
irritation (coughing, tears, tightness of the chest, excessive saliva production)
corrosion (chemical burns)
General
- effect dependent on the “place of impact”
- often effect via the central nervous system: loss of consciousness, seizures, muscle
weakness, blurred vision and so on
- specific symptoms: for example loss of hair after poisoning with parathion, diarrhoea
Focus points when providing first aid to casualties of poisoning are:
- first and foremost, be aware of your own safety
- be alert to the safety of bystanders as well
- call the professional rescuers
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-
follow the instructions of the ambulance dispatcher
companies where poisonous substances are present, usually have specific knowledge of
these substances
Poisoning in children is usually caused by drinking from bottles that contain corrosive cleaning
products. The injuries usually consist of burns or irritation of the mouth and pharynx, because after
one sip most children notice that the cleaning agent does not taste nice and hurts. They will then
stop drinking. Tablets on the bedside table or washbasin may look just as nice as real sweets.
It is important to bring empty tablet strips and such like to the hospital so that the amount ingested
can be determined. With poisoning, be aware that prevention is better than cure.
The ambulance dispatcher disposes of the most recent information about the measures that should
be taken; this information is issued by the Dutch Poison Information Centre of the Dutch Institute for
Public Health and Environment (RIVM). Drinking water is not a standard intervention in case of
corrosive substances. Namely, if the oesophagus is damaged severely, water is flushed directly in the
chest cavity.
The RIVM does not prescribe to stimulate vomiting; for this reason, this activity has been abolished.
In most poisoning casualties, there is enough time to leave the treatment to the medical
professional. First aid consists of alerting the rescuers and responding to altered vital signs. The first
aider may also take measures to limit the effects of the substances when instructed by professionals.
With casualties of cyanide poisoning, time is of the issue. Therefore, companies that work with this
substance have special protocols for accidents involving cyanide.
Chemical substances
If the skin has been in contact with highly corrosive (liquid) substances, these have to be rinsed away
for a long period of time (30 minutes) with a lot of water. Powders may react with water and should
be brushed from the casualty’s skin first. In addition, items of clothing (as well as shoes) must be
removed as soon as possible, especially if they have been in contact with the corrosive (liquid)
substance. Some types of fabric act as a sponge and may absorb the chemical liquids and therefore
have an effect on the casualty’s skin, even after rinsing. To keep rinsing for a long period of time
means in practice that the professional rescuers will take over until it has been done for the required
amount of time.
It is almost self-evident that the first aider sees to it that he is well protected (gloves that are
resistant to the chemical substance) and ensures that the corrosive substance does not run on
unaffected parts of the casualty’s body whilst rinsing. In addition, the first aider should keep in mind
that there is a risk he may inhale the hazardous substance, particularly in the presence of volatile
corrosive substances such as chlorine compounds.
3.11 Stings and bites
The stings of most jellyfish found along the Dutch coast do not really respond to vinegar. On the
contrary, the sting cells release their poison though contact with vinegar. On the other hand, the
poison of the Barrel jellyfish/Dustbin-lid jellyfish (Rhizostoma pulmo) seems to be neutralized by
vinegar; however, this jellyfish has such tiny stings that hardly anyone gets stung.
If the casualty has been stung by certain species of tropical jellyfish, vinegar may be life-saving.
Therefore, it is possible that treatment with vinegar will be reintroduced if these species appear
along the Dutch coast due to global warming. Obviously, with the side effect that treatment will
cause more pain for most other stings.
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Local irritation usually resolves itself. Rubbing with sand or towels would increase pain. There is no
real treatment for the irritation.
The pain is alleviated by immersion or showering in as hot water as the casualty can bear (up to 45°
degrees centigrade). If there is no hot water, the pain can be alleviated by rinsing with sea water (do
not use any other type of water) or by cooling.
Often in the past, ammonia was poured onto a compress and placed on the sting. This may cause
burns, particularly on damaged skin. If ammonia is applied in combination with hot water, it will be
diluted and therefore will not cause burns.
Sucking snake bites will have no effect whatsoever. The only effect will be tissue damage.
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Part IV Dressings bandages and other material
The instructions for covering wounds and bandaging as a separate subject has been abolished. A
minimum requirement is that the materials mentioned in the basic first aid kit should be present
during the examination (with the exception of the burn compress as this belongs to the optional
category). Without material, the first aider cannot demonstrate his ability to intervene.
It is compulsory to place a sterile and preferably non-stick compress/dressing on a wound. The
material should be secured; it must not shift. Additionally, it should cover the wound completely. The
first aider should not touch the part that will cover the wound. After all, it is the purpose of the
activity that matters rather than the means used to reach the objective. During the examination, the
course participants should show that they have learnt to perform the interventions correctly; but in
the end, it is the principle that counts. Therefore, it is not of overriding importance which type of
bandage is used.
Highly exceptional materials are available as well as various exceptional techniques to apply
bandages. The Orange Cross Book, however, is also intended for people who may give first aid only
occasionally but who still have to act adequately if required.
The course is based on the objective of teaching actions that are as generally applicable as possible.
Whenever possible, only one solution is taught to solve several problems. For example, only one
method to apply bandages. We abolished the use of separate methods for each part of the body or
for each type of bandage. First aid bandages are applied in a way that is similar to ideal bandages.
Pressure bandages are the same as wound pressure bandages but without the dressing. A separate
method has been depicted only if there are specific points for consideration.
For example, bandaging a hand and bandaging a joint are described separately.
Changes in the instructions for covering wounds and bandaging have a practical reason as well.
During a visit to the hospital or GP, the first action that will be performed will be to cut off the
bandage. Therefore, the bandage only needs to be functional and no major problem will occur if the
bandage has been applied too tightly.
Originally, many techniques were based on definitive treatment. Of course, these techniques are
suitable after treatment in hospital or by the GP. However, this does not pertain to first aid.
Bandage materials
Developments in materials may simplify actions.
The finger bob, for example, may replace the traditional finger bandage. The photograph (TOCB page
80) shows a step-by-step plan, starting with the little finger. Thanks to this solution, we only have to
include one photograph.
Generally speaking, there are three types of materials: materials to cover wounds, the dressings,
materials to attach a dressing and materials to provide support to the wounded body part.
Some materials are a combination of these various types.
A separate non-stick compress/gauze is in fact the only genuine dressing that we use. Other
materials intended as dressing are the sticking plaster and the emergency bandage. The main
purpose of these materials is to cover the wound; however, they also have the possibility to secure
the wound pad.
The triangular bandage is preferably made out of cotton, but another absorbing material is allowed
too. In first aid, using this bandage as a sling is becoming of less importance. On the other hand,
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using this bandage to cover wounds is of increasing importance. Protruding organs are preferably
covered with a moist dressing; this is not the case if the bandage cannot hold water. On the
wrapping, it is not always clear whether the bandage can retain moisture. The remark non-woven
refers to the production process and not to the kind of material used. Therefore, the material itself
may or may not be absorbing.
First aid bandage
Two types of rolled-up emergency bandages are available: one whereby one looks into the roll while
applying the bandage and one whereby this is impossible. The latter makes it more difficult to
unwind the bandage close to the skin. One must not disapprove such an emergency bandage
because it has DIN qualifications. This means that it has met strict German quality requirements. The
use of this type of bandage requires a slightly different bandaging technique. The bandage has to be
unrolled somewhat further before applying each turn. This technique is used in several countries.
If this is difficult, the bandage can be turned once before continuing bandaging.
Emergency bandage and Celox
This trauma bandage is even more advanced. It provides a combination of cover and fixation whilst
applying pressure and support. It is not a compulsory bandage for the examination. It may be
included in first aid kits for companies and sports matches/events if required. The trauma bandage
(emergency bandage, Israelian bandage) may be used during the examination and therefore can
replace a dressing, synthetic padding and ideal bandage (thereby saving space in the first aid kit/bag).
The trauma bandage is optional because the traditional pressure bandage is sufficient. The latter has
the additional advantage that the synthetic padding and bandage are also suitable to apply a
pressure bandage for casualties with bruises and sprains. The trauma bandage is also optional
because it is not widely available.
The trauma bandage is especially suitable in an organized context such as event first aid or disaster
relief. Wounds with active blood loss may be dressed without first applying pressure which makes it
possible to help several casualties in a brief period of time.
The same applies to Celox. As yet, this product is only of interest for organized aid, for some
companies or situations where it may take some time before help arrives (in shipping for example).
Chances that an individual first aider ends up in a situation with severe and active blood loss are very
slim. This means that the price of the product plays an important role. It is reasonable to assume that
the product will not be used and will stay in the first-aid kit until the use-by date has expired.
However, Celox may be immediately life-saving in case of deep bleeding wounds. In addition, it does
not interfere with the treatment in hospital; this is a problem with some similar products. It is
possible that this material will find its way in the basic first aid kit due to future (price) developments.
Burn dressings
Burn dressings are known for providing effective cooling and possibly may have an additional
advantage in terms of wound healing. Yet, cooling with water remains the preferred measure in case
of burns. This is effective and available virtually everywhere. Besides, the ambulance disposes of
these kind of materials. If there is no water, cooling should be provided in any other way.
Burn dressings can be used for small burns as a first choice. The size of the compress is then
(approximately) 10 x 10 cm.
According to the guideline, all second and third-degree burns must be treated by a physician.
However, it is likely that the casualty will not follow this advice if he only has a small burn. In that
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case, please ensure that the wound is well protected, for example with a blister plaster. A
hydrocolloid plaster with a so-called moist wound pad may be left on the wound for a few days. This
is important. If possible, blisters should remain intact. After a few days, the skin will have become
less sensitive to infection.
Normal sticking plasters should be replaced frequently and may damage the blister during removal.
This also applies to hydrocolloid plasters if they are removed too soon. Therefore, hydrocolloid
plasters should not be used if the casualty must go to the GP. The blister should then be loosely
covered with a sterile non-stick dressing.
Skin disinfectants
Clean water is suitable to clean wounds. The skin around wounds can be cleaned with skin
disinfectants. If there is no water, the wound can be cleaned with disinfectants as well.
Disinfectants in the form of sprays which can be found in many first aid kits are highly suitable to
disinfect the first aider’s hands.
Many types of disinfectants are available, often based on chlorhexidine or alcohol. Many of these
products are in fact not suitable for the inside of the wound but can be used around the wound.
These disinfectants may cause pain and damage cells (cytotoxic). However, the negative effect of
application inside a small wound is not very significant. Large wounds must only be covered with
sterile dressings because the physician must be able to access the wound.
Povidone iodine (Betadine: http//betadine.nl/) does not have these adverse effects. There is a
misconception about allergic reaction to povidone iodine. Allergies or skin irritations are rare and
despite its name, this also holds true for people who are allergic to iodine. Tincture of iodine, which
is painful when applied to wounds and which poses the risk of allergic reaction is not used and has
not been included in first aid kits.
Guidelines for first aid kits
The Orange Cross has issued guidelines to which new first aid kits should comply. These kits will carry
the logo and an approval number. This will tell the buyer that the contents of the kit is of good
quality. The guidelines do not apply to kits who have already been sold.
Many first aid tools are available on the market. Almost all materials are suitable to reach their
objective. First aiders are free to use these materials.
The materials that have been included in the guidelines for dressings and bandages are intended to
give adequate first aid in accordance with the guidelines of The Orange Cross. If injuries (wounds)
require extensive subsequent treatment, specialized materials may as yet be purchased. Should you
have a first aid kit containing all sorts of fancy and often expensive materials, you will probably find
that you need to throw them away because the use-by date has expired.
It is self-evident that bandages and compresses must be readily available. The guideline for
companies is that a first aid kit should be present within half a minute after an injury has occurred.
This does not need to be a complete in-company kit, but it can be a kit suitable (determined after risk
inventory) to provide first aid at that specific place. In the meantime, an emergency response officer
can go to the site of the accident with the complete kit to provide additional, less urgent aid.
It is of little use to have materials in the first aid kit that you do not know how to use. Only if a first
aider is present in each half-minute zone, is it useful to have a complete kit available. This will help
organise the help in that particular zone.
When deciding on how many first aid kits are required, the surface area of the company is more
important than the number of employees. A risk inventory should determine which additional
equipment the first aid kits should contain in addition to the compulsory contents; for example,
bottles to rinse eyes or more compresses than is usually the norm.
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It is important that somebody be responsible for the contents of the first aid kits. The kit should be
examined at least every six months to check whether the contents is still complete and to check
expiry dates. By means of a seal (for example a simple address label or a special label), the person
responsible may check which items were used in the interim. In addition to the first aid kit, a plaster
dispenser is most appropriate. This means that the seal does not have to be broken for each plaster
that is required.
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Appendix 1: The Human Body
1. Cells, tissues and organs
The cell is the smallest unit that possesses all basic life qualities: metabolism, reproduction,
differentiation (development of specific characteristics), regeneration (the ability to recover) and
excitability (ability to respond to stimuli). A cell consists of a cell wall which is permeable to certain
substances and has a gelatinous content (cytoplasm); most cells contain a nucleus. The nucleus
“controls” the cell and contains the hereditary properties.
Cell organs in the cytoplasm carry out several processes such as metabolism, energy supply and the
storage of fuels and nutrients. Cells that are similar in shape and function form a tissue.
Organs (the heart for example) consist of a combination of tissues. Various organs together form the
organ systems (for example the digestive system) and all the organ systems together form the
organism (for example a human being).
We can categorize cells and tissues according to their function, namely:
- epithelia
- connective tissue
- muscular tissue
- nerve tissue
Epithelia
Epithelia consists of one layer (airway, blood vessels) or of several layers of combined cells (skin,
certain mucous membranes). Epithelium lines the outside of the body, the inside of the body cavities
and of tubular structures (intestines, blood vessels).
Some types of epithelia undergo keratinization, others produce mucus. In some places, cilia can be
found. In others, the epithelium is folded (intestine, increased surface area). In several places, glands
have formed because of the accumulation of groups of epithelium cells.
Some glands release products into the blood (hormones like insulin), others release products into the
outside world (sweat, sebum and tears).
Connective tissue
Highly different tissues are classified as connective tissues , such as in the narrow sense of the word,
supporting tissues, adipose tissue and blood.
Connective tissue consists of a combination of cells, fibres and a gelatinous matrix. Depending on the
structure of the fibres and the matrix, we distinguish the following tissue:
- connective tissue in the narrow sense of the word forms a connection between different
tissues and acts as filling material between organs
- supporting tissues provide the body with support and shape. We distinguish cartilage and
bone tissue
- cartilage is smooth, hard and elastic. It forms the covering of the articular facets, provides
the nose and the ear with shape and, it is present in between intervertebral discs as a more
fibrous form of cartilage
- bone tissue is hard because calcium salts have been deposited in the matrix
- adipose tissue consists of connective tissue cells that are filled with lipids. It acts as filling
material in larger spaces between and around organs, among other things to protect these
organs
- blood consists of a fluid matrix in which cells with highly varied functions float
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Muscular tissue
Muscular tissue consists of muscle cells that have the ability to shorten/contract (active) and to relax
(passive). Often, the contraction of one muscle is accompanied by the relaxation of another to make
movement possible. Muscles have a tone or “rest tension”. They tend to shorten somewhat if they
are in a relaxed state. In fractured limbs, this may have unwanted effects (the tips of the bone
fragments override) which may lead to muscle and tendon injuries (retraction of the muscle or
tendon if they have been completely severed).
Nerve tissue
Nerve tissue consists of nerve cells (neurons) that are composed of a cell body, which contains the
nucleus and of short and long extensions. Nerve cells can elicit or receive stimuli which are
subsequently conducted through the extensions to organs or muscles or to the brain.
Organs
All organs consist of several tissues and have a well-defined function in the body (for example the
heart: pumping blood around). Organ systems, combinations of several organs, have specific
functions as well; these will be discussed in combination with the systems concerned.
Metabolism
Metabolism is the entirety of the breakdown and resorption of nutrients in the intestine, the
absorption of oxygen in the lungs, the conversion of these substances in the cells as well as the
transport and excretion of the waste products that were formed during the conversion of the
substances.
All organisms, from single-celled to more complex like human beings, need energy in order to
function. This energy is produced from aerobic intake of high-energy substances. In order to make
this possible, our food has to be broken down into “bite-size” units first. This takes place in the
gastrointestinal tract, followed by the resorption of the basic nutrients (glycerol, fatty acids and
amino acids) into the blood (fatty acids go through the lymphatic vessels of the intestines first), and
after conversion in the liver and other organs, transported to the cells. There, they are stored as
reserve food or they immediately undergo aerobic intake.
The intake process requires oxygen, which, once absorbed into the lungs, is transported to the places
where it is needed. This is also done by the blood. During intake, heat is released as a by-product. In
addition, waste products such as carbon dioxide, water and other substances are produced. These
waste products are removed from the body by the lungs, the kidneys and the intestine (some waste
products are released into the intestine by the liver).
It is worth mentioning that in contrast to reserve foods that we carry in the form of fats in fat cells
and glucose in muscles, oxygen must be supplied constantly.
Although not all cells have their own supplying capillaries, nutrients and oxygen will reach all the
cells, because they are bathed in interstitial fluid. The exchange of substances between the tissue
cells and blood takes place through the interstitial fluid. Lymph is drained by the so-called lymph
vessels and eventually returns to the blood circulation. In a number of places, the lymph vessels
contain lymph nodes (which are sometimes incorrectly called lymph glands).
2. Organ systems
Skin
The skin is our largest organ; the surface area of an adult’s skin is approximately 1.8. m2.
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Beside filling the space below the skin, the subcutaneous adipose cells also store energy. Initially, the
hairs on our skin served as heat insulation. This function became less important through evolution
and because we started wearing clothes. Yet, by contraction of the arrector pili muscle hairs, we are
still capable of responding to heat, cold and certain emotions (goose bumps, “my hair stood on
end”).
The skin plays an important role in heat regulation. In children, the ratio skin/body volume is larger
than in adults. This is why they run a higher risk of hypothermia or overheating.
Our nails are formed by highly specialized epidermis cells that show a great extent of keratinization
epidermis cells. They grow by approximately 0.1 mm a day.
Mucous membranes
Mucous membranes form the linings of body cavities, for example the digestive system and the
respiratory system.
Some mucous membranes consist of one single layer, particularly in organs where nutrients or
oxygen have to go across the membrane; others consist of several layers, where the covering has a
more protective function. Mucous membranes take their name from the fact that this type of
epithelium contains cells that produce mucous. In this way, mucous membranes protect the body
from dehydration, germs get caught in the mucous, air that flows along the membrane is warmed
and moistened.
Some mucous membranes contain cilia that transport trapped dust particles out of the airway by
means of the so-called ciliary function of the pharynx where mucous and dust are subsequently
swallowed.
Musculoskeletal system
The skeleton consists of over 200 bones that are connected by structures that may be immobile
(skull) or mobile (through joints or cartilage connections).
The skeleton provides shape and support to our body. It protects vulnerable organs and the bones
are places where muscles attach, so that bones can be moved in relation to each other.
Blood cells are formed in a number of bones, while these bones also function as storage place for
certain substances including calcium.
The core of many bones consists of spongy bone marrow (formation of blood cells), surrounded by
compact bone. The end of the bones near the joints are provided with a cartilage lining. The shafts
are surrounded by the periosteum, a sensitive membrane that contains nerve tissue. As for shape,
we can distinguish between long bones (in the limbs) and flat bones (breast bone, shoulder blade,
skull).
Although joints make it possible for bones to move in relation to one another, they still form a strong
connection between the bones concerned.
The cartilage covering of the articular facets diminish friction and distribute pressure. The capsule is a
broad covering that produces synovial fluid and keeps it within the joint cavity. The ligaments are
situated within or outside the capsule; they contribute to the stability of the joint and limit and
inhibit its mobility.
The various types of joints are:
- hinge joint (uniaxial, for example phalanxes)
- pivot joint (also uniaxial, for example between radius and ulna)
- maxillary/hinge joint (uniaxial, between upper and lower joint, is important to open the
mouth properly)
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-
saddle joint (biaxial, the thumb)
ball-and-socket joint (multiaxial, for example hip and shoulder)
The ribs extend from the thoracic vertebrae to which they are connected by means of articular
facets, in an oblique and downwards direction. When the intercostal muscles contract, the upper ribs
are drawn upwards and the lower ribs sideways. This increases the chest capacity to the greatest
possible extent during inhalation. At the front, they are connected with the breastbone or each other
by means of cartilage.
The shoulder consists of the shoulder blade and the collarbone.
The elbow has two joints: a hinge joint between the ulna and the humerus and a pivot joint between
ulna and radius.
The wrist joint consists of the ulna and three of the eight carpal bones. The wrist joint allows the
hand to move in two directions.
In order to distribute pressure better and to enable the knee to bend, each of the knee joints is
provided with two semilunar cartilage discs, the inner and outer meniscus. Although the knee can
bend, the lower leg still has to be firmly attached to the upper leg; for this reason, the knee joint is
provided with strong ligaments. These ligaments are situated on the inside and outside of the knee.
In addition, there are two ligaments within each knee joint, the so-called cruciate ligaments. The
kneecap is situated at the front of the knee. As protection for the knee joint, the kneecap is included
in the tendon which connects the greater muscles of the upper leg to the front of the tibia.
The ankle joint consists of the upper and lower tarsal joints. The upper tarsal joint consists of a
combination of the shin bone and the fibula. Shin bone and fibula form a two-pronged fork that
enclose the ankle bone. This joint can elevate and stretch the foot.
The lower tarsal joint is formed by the ankle bone and the heel bone and allows lateral movements
of the foot.
Most muscles are connected to bones by tendons situated on either side of the joint so that the joint
has some range of mobility.
Other muscles have no clear beginning and end; they are cylindrical structures. Examples of such
muscles are the orbicular muscle of the mouth and the eyes and the sphincter of the rectum as well
as muscles in the walls of blood vessels which make them dilate and contract.
There are various types of muscle tissue that derive their names from what can be observed under
the microscope. Several organs contain smooth muscle tissue including the intestine and blood
vessels. These muscles are controlled by the autonomic nervous system. Striated muscle tissue forms
the muscles that contract under the influence of the will. Our skeletal muscles particularly consist of
this type of muscle tissue.
Muscle tissues have other differences beside what can be seen under the microscope. Striated
muscles are strong but tire quickly, whereas smooth muscle tissue is less forceful but virtually
indefatigable.
Cardiac muscle tissue is an intermediary. The cardiac muscle cannot be controlled by our will and
combines properties of both types of tissues. It is forceful as well as virtually indefatigable.
Digestive system
The function of the digestive system is to convert food into nutrients and fuel substances as well as
to absorb these substances into the blood. In the mouth, the food is broken down by the teeth, the
tongue and byproducts from the salivary glands. In addition, the food is mixed with saliva (1 to 1.5
litre a day). In the pharynx, the food crosses the airway. When we swallow, the epiglottis closes off
the airway, after which the food ends up in the oesophagus (gullet). In the oesophagus, the food is
propelled by the kneading movements of the muscular wall (peristalsis).
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Gastric juice is produced and released by the stomach wall (approximately two litre a day). Gastric
juice is mixed with the chyme by the strong muscular stomach wall. After this preparation, small
portions of chyme are released into the small intestine. The small intestine is three to four metre
long. Here, bile and pancreatic juice are added to continue breaking down the food. Certain waste
products from the liver are released into the small intestine and dissolved in bile, later to be
eliminated in the faeces. In addition, in the small intestine, the end products of the digestion of
proteins, fats and carbohydrates are absorbed into the blood.
The intestinal wall is strongly enhanced in surface by folds and bulges. The epithelium of the
intestinal wall consists of only one layer of cells with an extensive network of capillaries underneath
for proper and rapid absorption of nutrients and fuels into the blood. In total, approximately 9.5 litre
of fluid is absorbed into the blood each day in the small intestine (that is approximately 1.5. litre of
fluid from ingested food and drinks and 8 litre from the juices secreted in the digestive system).
The large intestine is approximately 1.5. to 2 metre long. Here, approximately half a litre of fluid is
reabsorbed from the chyme, after which the remainder leaves the body through the rectum in the
form of faeces.
The abdominal cavity and its organs are lined with the peritoneum. The abdominal cavity is enclosed
by vertebrae and ribs, the diaphragm, the abdominal wall and the pelvic floor. It contains a number
of vulnerable organs with a rich blood supply: the stomach, liver and spleen.
The liver performs a number of important functions:
- storage of glucose, iron, fats and other substances
- production of proteins
- detoxification which means the conversion of waste products from the blood in such a way
that they can be removed from the body.
The pancreas produces insulin (of importance for glucose metabolism; insulin is released into the
blood) and pancreatic juice (breakdown of proteins, fats and carbohydrates; the pancreatic juice is
released into the small intestine).
Excretory system
Waste products of metabolism are removed from the body via:
- the lungs: carbon dioxide and water vapour
- the skin: water vapour, sweat
- the kidneys: substances that are soluble in water
- the liver and the intestines: dissolved in bile
More specific, the excretory system consists of the kidneys, the urinary passages and the bladder.
The lungs, the skin and the liver/intestines are discussed elsewhere.
The kidneys are two bean-shaped organs situated at the back, just behind the abdominal cavity
between the muscles of the lumbar region. Kidney tissue consists of a larger number of convoluted
kidney tubuli surrounded by blood vessels. These tubuli extend into the renal pelvis. Waste products
that are soluble in water are transported from the blood to the kidney tubuli and end up as urine in
the renal pelvis. Every five minutes, our entire blood volume passes through the kidneys so that
waste products and excess water can be removed. A ureter connects the renal pelvis of each kidney
to the bladder which is situated in the lower part of the abdominal cavity, behind the pubic bone.
From the bladder, the urethra, which can be closed by a sphincter, extends to the surface of the
body.
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Reproductive system
The major part of the female reproductive organs or sex organs is situated in the abdominal cavity.
They consist of two ovaries, two Fallopian tubes, the uterus and the vagina. Externally situated are
two pairs of labia, which cover the entrance to the vagina. They also cover the opening of the urethra
which is situated somewhat for the vagina.
The external male reproductive organs are the scrotum, which contains two testes and the penis. The
testes produce the sperm cells.
Glands
A gland is an organ which produces and excretes certain substances. There are various types of
glands:
- exocrine glands (which release their products to the surface of the gland)
- endocrine glands (which release their products into the blood).
- combined glands (a combination of exocrine and endocrine)
Exocrine and endocrine glands
Exocrine glands excrete their products via a duct to the surface of the gland. Endocrine glands do not
have a duct to drain their products but excrete directly into to the blood. The products of endocrine
glands are called hormones. In combination with the nervous system, hormones coordinate the
functions of various parts of the body.
Endocrine glands include:
- the hypophysis (pituitary), in which a number of hormones are produced that control various
processes such as growth
- the thyroid, in which a hormone is produced that contains iodine which among other things
influences metabolism and the heart function
- the islets of Langerhans in the pancreas, in which insulin is produced
Examples of exocrine glands are salivary, sebaceous, mammary, mucous and lacrimal glands.
The pancreas is in fact a combined gland.
- The exocrine excretions: mostly digestive enzymes and sodium bicarbonate (for neutralising
gastric acid).
- Important endocrine excretions: glucagon (increases blood glucose level) and insulin
(decreases blood glucose level); both hormones are produced in the islets of Langerhans.
Lymph nodes
The lymph nodes are component of the lymph system. Part of the blood plasma is squeezed through
the walls of the capillaries into the space around the cell, forming the interstitial fluid. The interstitial
fluid is the place of exchange of nutrients and oxygen as well as waste products. Fluid surplus is
absorbed in the lymph system where it is called lymph.
Lymph nodes are included in the lymph vessels as some kind of intermediate station. They consist of
connective tissue cells and white blood cells and act as filters. They clean the lymph and ensure that
germs and other contaminants are filtered and controlled. Lymph nodes are situated in the pharynx
(tonsils), the groin, the armpits, the chest and the abdominal cavity and along the muscles of the
neck.
Any infection can migrate from the place of contamination through lymph vessels and nodes. This
lead to characteristic inflammation symptoms such as red, painful lines under the skin (often
incorrectly called “blood poisoning”) and swollen painful nodes.
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Respiratory system
Inhaled air is moistened, warmed and cleaned in the airway particularly in the nasal cavity. This is
enhanced by the mucous membrane which lines the nasal cavity. The mucous membrane is provided
with cilia which transport caught particles to the pharynx. The olfactory organ is situated at the top
of the nasal cavity.
The vocal chords are situated in the larynx which is the narrowest part of the airway. The lungs
consist of the bronchi that branch off into increasingly finer branches.
Because of the space taken by the heart in the chest cavity, the left lung consists of only two lobes
whereas the right lung has three lobes.
The respiratory rate is influenced by exertion, emotion, by the composition of the air, by diseases
and certain medications. Human respiration involves a combination of thoracic and abdominal
respiration. In younger people and women, thoracic respiration prevails whereas men predominantly
breathe by means of abdominal respiration. For this reason, breathing is checked on the junction of
chest and abdomen.
Cardiovascular system
The cardiovascular system consists of a transport system, notably the heart and blood vessels and a
transport medium, the blood.
Functions of the blood include:
- transport of oxygen, fuels and nutrients to the cells
- transport of waste products to lungs, liver and kidneys
- protection from infections
- formation of blood clots (coagulation)
- distribution of heat
Adults have approximately 5 litre of blood (approximately 1/13 of the body weight). Nearly 55% of
the blood volume consists of plasma (blood fluid, composed of water, proteins and salts) and the
remainder consists of cells. Red blood cells are anucleate and biconcave (slighted “dented” on either
side); they live for approximately 120 days and their function is oxygen transport.
White blood cells have a nucleus, live only for a few days and fight germs, partly by producing
antibodies, partly by engulfing them, followed by digesting them. Platelets are cell fragments without
a nucleus. They disintegrate in contact with a damaged blood vessel wall. This initiates the
coagulation process. A network of fibrin threads (a type of protein) is forming in which other blood
cells get caught, become dehydrated and form a protective scab.
Blood serum is plasma without fibrinogen, the protein that is the soluble precursor of fibrin.
There are three types of blood vessels:
- arteries: strong, muscular (must resist considerable pressure)
- capillaries: walls consist of one layer of cells, exchange of gases, nutrients, fuels and waste
products
- veins: thin walls, soft, veins in the limbs are provided with valves
The lymph vessels have a special place. These absorb interstitial fluid and purify it in the lymph
nodes. White blood cells are also produced there, as well as in the spleen.
The heart
The heart can be regarded as two connected pumps. It can function independently of the nervous
system (autonomously) but in fact it is influenced by the nervous system.
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It has four chambers: the left and right atrium and the left and right ventricle. There is a valve
between the atrium and the ventricle to prevent the blood from flowing back from the ventricle to
the atrium. There are also valves between the ventricle and the artery connected to it (left, the great
artery/aorta; right, the pulmonary arteries). These valves prevent the blood from flowing back from
the arteries into the ventricle.
The muscular walls of the atria and the right ventricle are thin. The wall of the left ventricle is thick
and strong. The walls of the ventricles have a system of blood vessels of their own, the coronary
arteries. These originate from the aorta, immediately above the valve between the left ventricle and
the aorta.
The heart has a system of its own that causes the cardiac muscle to contract. The so-called
pacemaker is situated in the right atrium – this is a group of nerve cells which fire impulses
automatically. These impulses are conducted through a bundle located in the wall between the atria
and the ventricle. From there, the impulses are conducted over the walls of the ventricles.
The system is organized in such a way that both atria contract simultaneously. This causes the blood
to be squeezed from the atria into the ventricles, opening the valves between the atria and the
ventricles.
Then, both ventricles contract simultaneously while the atria relax. When the atria relax, they can
again be filled with blood at the same time that the ventricles contract. At that moment, the valves
between atria and ventricles close, the valves between ventricles and arteries open and blood is
pumped into the artery.
This is followed by relaxation of the ventricles by which the valves between ventricle and artery
close. In the meantime, the atria have been filled again and the cycle starts anew.
Circulation
In fact, there are two circulatory systems. One provides the whole body with oxygen and nutrients
and the other absorbs oxygen in the lungs (systemic and pulmonary circulation, respectively).
Both circulatory systems are connected in series. In the systemic circulation, oxygenated blood is
transported from the left ventricle through the arteries to the capillaries. In the capillaries, oxygen is
delivered to the cells of the body and the carbon dioxide produced by the body is absorbed into the
blood. Deoxygenated blood flows back through the veins to the right atrium to be subsequently
pumped into the pulmonary artery by the right ventricle. Carbon dioxide from the blood is delivered
into the lung capillaries of the alveoli and oxygen from the alveoli is absorbed in the blood. The
blood, which is now oxygenated, flows through the pulmonary vein back to the left atrium.
When the ventricles contract, blood is pumped into the arteries with a resting rate of 60 to 100 beats
a minute and a stroke volume (the amount of blood that is pumped away with each heart beat) of 50
to 70 ml.
In the systemic arteries that are situated at the surface, this can be perceived as a pressure wave,
similar to the wave-like motion of water. There, the pressure (normally) amounts to 120 mm Hg. The
pressure in the pulmonary artery is much lower (approximately 30 mm Hg). The pressure in the veins
of either circulation normally decreases to approximately 10 mm Hg.
The return of the blood (from the systemic and the pulmonary circulation) to the heart is enhanced
because it is sucked in as a result of the negative pressure in the chest cavity during inhalation. At the
same time, the return of blood from the arms and legs is increased of the so-called muscle pump in
the limbs, in combination with the valves in the veins.
Nervous system
The central nervous system is understood to be the combination of the brain and the spinal cord. The
peripheral nervous system consists of the nerves.
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The brain is surrounded by three membranes for its protection and for the supply of nutrients.
1. the dura mater (against the bone)
2. the arachnoid (large-mesh, containing cerebral fluid and blood vessels)
3. the pia mater (immediately on the brain, containing blood vessels)
The functions of the brain include receiving stimuli, processing them and if necessary initiating a
reaction. We are aware of only some stimuli.
The nervous system controls awareness, memory, mental processes, emotions and the will. In
addition, it coordinates the cooperation of the organs and controls such body functions as
respiration, heart rate, growth, pregnancy, wake/sleep.
The cerebellum controls the cooperation of several muscles and therefore plays an important role in
maintaining balance.
The cerebrum is divided into two hemispheres each of which having a relatively large surface area
because it contains a number of lobes and convolutions.
The cortex of the brain consists of nerve cell bodies; on some sections, it is visible as the so-called
grey matter. White matter consists of nerve extensions or tracts.
The brain stem is a junction of connections in the brain and to all parts of the body. It is the centre of
the autonomous nervous system where the autonomous functions are coordinated and
consciousness can be found. The brain stem includes the medulla oblongata which contains the
respiratory centre as well as the centres where heart function and blood pressure are controlled.
The spinal cord has a diameter of 1- 1,5 centimetre and is approximately 40 to 50 cm in length; it
extends to the upper lumbar vertebra. It mainly consists of nerve extensions but also contains cell
bodies and relay centres.
Our nerves can be subdivided into 12 pairs of cranial nerves and 31 to 33 pairs of spinal nerves. They
conduct impulses from the brain to all parts of the body and in the opposite direction. They can be
categorized according to both location and function:
- the voluntary (somatic) nerve system’s functions process sensory impulses, activating
skeletal muscles and initiating and processing activities such as thinking
- the involuntary (autonomous) nerve system, in combination with hormones, controls the
functions of the internal organs and usually functions without our conscious control
For its nutrition, the nervous system depends on glucose (a type of carbohydrate) which with oxygen
provides the energy required. The brain is supplied with blood by two carotid arteries and two
smaller vertebral arteries.
Reflexes are responses to stimuli that occur before or even without the stimulus (or response)
reaching our consciousness. Reflex tracts are located in the spinal cord and control muscle tone and
balance as well as other processes such as contraction of the pupil when more light enters the eye.
3. The senses
Our body disposes of a number of organs with which we perceive the outside world: the senses. The
senses receive stimuli from the outside world, which are conducted to the brain by the nerves. This is
the place where stimuli are processed and responses are initiated.
There are two possible types of responses:
- involuntary actions or reflexes, for example the pupil reflex in response to changes in light
intensity
- voluntary, conscious actions, for example placing the hand in front of the eye when light
intensity is too high
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Eyesight: the eye
The eye consists of the eyeball, the optic nerve and various auxiliary organs. These are situated
within and around the bony eye socket.
The eye ball consists of three layers.
1. The outermost layer is the sclera which provides support. At the front of the eye, this is
visible as the white of the eye with a transparent part in the middle: the cornea.
2. The middle layer is the choroid which contains many blood vessels. At the front of the eye,
behind the cornea, part of the choroid is visible. This is the iris which gives the eye its colour.
In the centre of the iris is an opening, the pupil, by which light enters the eye. The pupil looks
black in colour. The iris controls the amount of light that enters the eye by dilating or
contracting (diaphragm mechanism). This is visible because the pupil becomes wider or
narrower. The crystal clear lens is situated behind the pupil. The lens can adjust its convexity,
which is why we can see sharp images at distances ranging from approximately 30
centimetre to infinity.
3. The innermost layer is the retina. The retina contains the sensory cells which convert light
into electrical impulses that are conducted to the cerebral cortex by the optic nerve. In the
cerebral cortex, we become “aware” of what we see. The retina contains two kinds of cells:
the rods (75 to 125 million) with which we perceive black/grey/white; these cells require a
small amount of light and the cones (3 to 6 million) with which we perceive colour (red,
green and blue). Cones only become activated when the light intensity is high. The eye
contains the so-called optic disk or blind spot at the place where the optic nerve leaves the
eye. The blind spot derives its name from the fact that it contains no sensory cells. On the
contrary, the fovea within the macula is the most light-sensitive part of the retina and packed
with cones. This is the part of the retina with the sharpest vision. It is located in the centre of
the retina across from the pupil and the lens (surface area 5 mm²).
Because the eye is vulnerable, it is well protected, partly by the bony eye socket and the adipose
tissue within and partly by the lacrimal fluid (lacrimal gland/lacrimal duct) and the eyelids (eyelid
reflex = blinking).
The eye contains a gelatinous mass, the vitreous humour.
Eye muscles are attached to the eye; these make eyeball movements possible.
The front of the eyeball, with the exception of the cornea and the inside of the eyelids are lined with
a mucous membrane called the conjunctiva.
The upper eyelids of both eyes contain the lacrimal glands which excrete lacrimal fluid. This flows
over the cornea and is drained by the lacrimal ducts which drain into the nasal cavity. The lacrimal
fluid moistens the cornea and the conjunctiva and washes away small specks of dust.
Six eye muscles in each eye enable highly accurate eye movements; these muscles extend from the
sclera to the eye socket. The optic axes of both eyes should be parallel, otherwise the result would be
double vision. Because each eye conveys a slightly different image, we are able to see depth.
The following reflexes occur in the eye:
- pupil reflex (when light intensity increases, the pupil becomes smaller)
- eyelid reflex (when the cornea becomes dry or when an object approaches the eye rapidly,
the eyelids close)
- cornea reflex (eyelid reflex when the cornea is touched)
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Hearing and equilibrium: the ear
The ear allows us to receive aerial vibrations and to perceive them as sound. The auditory organ is
situated in the petrosal bone, a thickened part of the temporal bone. The organ of balance is located
there as well. The outer part of the ear consists of the cartilaginous auricle and the acoustic canal.
The lining of this canal is covered with hairs and produces earwax. The acoustic canal ends at the
tympanic membrane (eardrum). Sound waves make the tympanic membrane vibrate. Behind the
tympanic membrane lies an air-filled space called the tympanic cavity or middle ear. The middle ear
contains the three ossicles: malleus, incus and stapes. These bones transfer the sound waves to the
inner ear. This is situated in the petrosal bone and has the shape of a snail’s shell (cochlea). This is
where the actual sense of hearing is situated. In the cochlea, the sound waves are converted into
impulses that are conducted by the auditory nerve to the brain.
Tactile senses: skin, internal organs
The tactile senses are in part located in the skin (the dermis). They allows us to perceive pain, cold,
heat and pressure. A number of internal organs contain nociceptors as well. The brain and the spinal
cord, however, do not contain nociceptors. Sense organs sensitive to heat and cold are not only
located in the skin but in the mucous membranes of the mouth and oesophagus too.
Sense of smell: the nose
The olfactory sense is situated in the upper part of the nasal cavity. Only gases and vapours can be
perceived. The sense of smell (olfactory sense) plays an important role because it warns us of danger.
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Appendix 2: Special characteristics of the child
1. The development of the child
1.1. Physical immaturity
You often hear it said: “children are not miniature adults” (or small adults). What is it then that
makes children so unique?
Not only are children smaller than adults but they are also less mature and less experienced.
This makes the child more vulnerable and usually dependent on the parents’ care. The child is
physically as well as mentally less mature and less experienced. As for physical aspects, keep in mind
that the child’s stature and other physical proportions are different.
These differences in physical proportions especially play an important role in the treatment and risks
of burns, hypothermia and so on.
Also the immaturity of many reflexes in children may complicate rescue, or injuries may be
unexpectedly severe compared to adults. An example is the reflex that adults have when they start
falling: usually adults can break their fall by placing the arms around the head to protect it. This is a
reflex.
Young children who fall may not have developed this reflex and therefore, they fall more often on
the head and with greater impact. Another example of the immaturity of reflexes is the withdrawal
reflex upon contact with hot objects. A young child that touches a hot object will cry but will not
withdraw his hands until much later.
For this reason, contact burns in children may have serious consequences. The swallowing reflex has
not fully developed in young children either. Therefore, choking occurs relatively more often in
young children.
1.2. Mental immaturity
Mental immaturity predominantly manifests itself in communication. Babies (young children) and
toddlers cannot speak well or not at all. Feelings are expressed by laughing, crowing or crying or by
imperfect speech. Parents can generally determine what is wrong with the child by the nature of the
crying. For outsiders and rescuers, this is not easy. What does the child mean when he says “ouch,
tummy” and meanwhile points to his head? Not every question will produce a reliable answer. This
has consequences for how the rescuer will approach the child.
When dealing with children, a lot is required of the rescuer’s observational skills. For example: what
do you notice about the child’s behaviour? Which parts of the body still move normally and which
parts show abnormal or restricted movement?
Young children are capable of “hiding” injuries by adapting their behaviour. A young child who has
broken or severely bruised his arm may start using the other unaffected arm to spare the injured
one. Some toddlers may start crawling and refuse to walk after they have bruised an ankle or leg.
1.3. Normal development
Anybody who has children, looks after children or perhaps has only observed them knows that
children are curious and explore the world step by step. In his development, the child repeatedly
explores the boundaries of his abilities. The child learns to walk by way of trial and error, literally by
falling over and picking himself up again. By bumping into things, by burning his fingers, he discovers
his environment and gets to know his limitations and vulnerability. The child is able to develop
himself!
This is of course a very healthy situation. However, it is quite conceivable that the child inadvertently
brings himself or even other children into dangerous situations. Another possible cause of accidents
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is that toddlers and also school children can be completely absorbed in their play, to such an extent
that they do not recognize threatening dangers as such.
School age children often attach greater value to matching their peers than they do to dangers, even
if they have perceived them.
Each year, thousands of children end up in hospital because of accidents, severe or less severe and in
some cases because of a childhood illness. For this reason, it is important to know how to treat
children who are involved in accidents.
1.4. Structure and function of children’s bodies
The organ systems and the senses are not yet fully grown, which manifest itself in the way they
function.
The newly-born child has sufficient muscular strength but not yet enough control over his muscles.
The movements are still uncoordinated. His head is still too heavy for his rather untrained neck
muscles.
The various organ systems develop in harmony, but within the various stages of life, one organ
system develops rather more quickly than the other, while this order may be reversed later on.
1.4.1. Cardiovascular system
During birth, the baby’s circulation changes substantially to adjust to the fact that oxygenation of the
blood now takes place through the lungs instead of through the umbilical cord.
The baby’s heart rate in rest is almost twice as fast as that of the adult: 110-160 beats a minute. If
the baby is extremely active, for example when he cries, this rate may increase to 190 beats a
minute.
Therefore, a baby’ s heart rate is quite fast and highly variable.
During the course of months, the average heart rate decreases to approximately 110-120 beats a
minute.
During the toddler and pre-school years, the average heart rate decreases further to 95-110. At
school age, this ranges from 75 to 100 beats a minute.
The blood volume in circulation is primarily related to a percentage of the body weight.
In the newly born, this amounts to approximately 10% of his body weight and decreases to 7.5% of
the body weight during the development into adulthood. The oxygen carrying capacity of children’s
blood differs from that of the adult as well. During the period before birth, the child has a high
percentage of red blood cells in order to be able to take up enough oxygen through the placenta.
After birth, from the moment the child starts breathing for himself, the oxygen binding capacity of
the blood decreases.
1.4.2. Respiratory system
The baby starts breathing within one minute of birth. In this way, he oxygenates his blood and
eliminates carbon dioxide.
Within approximately three days after birth, the majority of the alveoli have unfolded. During the
first stage of life, breathing is irregular and fast. During the first weeks or months, breathing becomes
increasingly regular. The amount of air that the baby inhales remains variable and ranges from deep
to superficial breaths. This will continue until pre-school age. Only then will the breathing become
more stable.
Normal average breathing rates in children:
- babies: 30-40 times a minute
- toddlers: 25-30 times a minute
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-
pre-school children: 20-25 times a minute
school children: 15-20 times a minute
1.4.3. Nervous system
Although the number of nerve cells in the unborn child already starts decreasing halfway through
pregnancy, the nervous system’s functional capacities continue to increase; this goes on through old
age as well. In humans, the process of nerve cell death indeed begins quite early in life.
The cortex of the brain increases in thickness, the nerve fibres themselves increase in length and the
number of branches and connections increases.
The nervous system is fully grown at the age of approximately 7 years.
By contrast, the functional development increases substantially. We can remember ever more
information and the control and coordination of various functions become increasingly efficient.
1.4.4. The senses
At birth, the baby’s senses are usually already well-developed.
A baby recognizes his mother or carer by their smell.
The auditory function is already present in the womb. The unborn child has been listening to the
internal sounds of his mother, such as her heart beat and her bowel sounds.
Usually, the sound of the mother’s heart beat has a calming effect on the child.
The range of hearing of the young child is extensive and decreases as he ages.
It is also known that hearing remains intact the longest. For this reason, it is important to keep
talking to accident casualties whose consciousness is impaired and even to unconscious casualties.
As for taste, babies prefer sweet. The toddler learns to distinguish tastes better and will develop a
preference for certain tastes.
Taste, pressure and pain senses in babies have fully developed and beside hearing and smell, they
are the most important means of contact with the environment.
As for the eyes, babies can distinguish light from dark. Within the first 8 months, the eyesight will
develop further. From that age, the toddler can perceive depth as well as differences in colour and
form.
1.4.5. The skin
After a couple of days, a baby’s skin is soft to the touch.
Changes in body proportions during development have a considerable influence on a child’s heat
regulation and on the function of the skin in this process.
In this respect, the following two factors are of importance: the surface area of the body (skin) and
the body volume. During a child’s development, the body’s volume increases to a greater extent than
its surface area.
In principle, children have a skin surface per unit of volume that is twice as large. Because heat
regulation takes place through the skin. Babies can more easily develop hypothermia unless
precautions are taken.
This also explains why children get cold sooner than adults, for example in swimming pools.
Finally, a child’s skin is more elastic than an adult’s.
1.4.6. Digestive system
The contents of a baby’s stomach is only 50 ml. During his first year, it increases to approximately
350 ml and at toddler age, it increases to 500 ml. As of this moment, the stomach contents increases
more slowly.
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During the first years of life, the small stomach contents is not consistent with the extensive amount
of energy required for growth. Therefore, the child needs relatively large amounts of food quite
frequently.
As of the fourth month, the production of gastric acid has started properly and as of the first year,
the child can produce a sufficient amount of the various types of enzymes required for the digestion
of carbohydrates, fats and proteins.
Therefore, the change to solid food is made during the first year of life. Just after birth, the intestine
is approximately 3.5 m in length, sufficient to digest fluid food. The digestive system gradually keeps
up with the child’s growth.
1.4.7. Development of the teeth
Immediately after birth, no teeth are visible. Yet, the incisors and canines particularly are already
present in rudimentary form.
In combination with the molars, these teeth will form the first set of teeth, the milk teeth. The milk
teeth will gradually be replaced by the permanent teeth when the child is approximately 6 to 7 years.
The first teeth come through (the incisors of the lower jaw) at around 6 months.
1.4.8. The musculoskeletal system
The child’s growth is most visible in both the increasing height and the increasing control of the
skeletal muscles (motorics).
In young children, the head is relatively large and the torso is large in proportion to the limbs.
Because the body increases in height, the head becomes less prominent in proportion. In the toddler
and pre-school child, the torso is relatively large in proportion to the length of the limbs.
As of the third year, we have a relatively stable growth rate of 5 to 6 cm each year. During puberty,
the real growth spurt occurs. At this stage, the arms and legs increase in length considerably.
The size of the head increases somewhat of course, but considerably less in proportion to the other
body parts. We see the head change rather substantially, specifically by the growth of the facial skull.
During school age, the child’s facial features become more prominent.
At birth, the skull still has two apertures, which are covered by tough connective tissue, the small
posterior fontanelle and the larger anterior fontanelle. The posterior fontanelle is situated at the
back of the head, whilst the anterior fontanelle is located at the top of the head behind the forehead.
On average, the posterior fontanelle closes after two months – its connective tissue is replaced by
bone tissue.
The anterior fontanelle usually closes by the start of the third year of life.
In addition, most children who are just learning to stand and walk initially have bow legs. Around the
age of two, the legs appear straight, the legs then proceed to a knock-kneed position around the 3rd
year of age, which in turn disappears around the 6th year of age.
As mentioned before, the baby does not yet have control over his muscles and therefore, the muscle
movements are uncoordinated. Children do have a large number of functional reflexes such as the
sucking reflex, the sneezing reflex and the coughing reflex.
Babies are not capable of lifting their heads by themselves.
In his first year, the baby learns to lift his head and to keep it in an upright position. Following this, he
succeeds in rolling from a prone to a supine position and the other way around; and then, it will sit
up, crawl, stand and walk. Every child develops this way because of the development of his nervous
system and motor system.
As a toddler, the child develops control over his muscles and at the end of the toddler period, the
fine motor function has developed to a great extent. The muscle strength in general gradually
increases.
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2. Prevention of accidents in children
There is no such thing as complete safety. There will always be factors that give rise to additional
risks. We accept risks in our daily lives, but we want to minimize their effects and influences as much
as possible.
2.1. Risks factors for children
Many risks that threaten children can be eliminated by taking preventative measures, for example by
answering the following questions:
- How is the traffic situation around the house and garden?
- Which preventative measures have been taken in houses that the child visits regularly?
- Which arrangements have been made for sleepovers?
- What is the child’s attitude in traffic, which arrangements have been made for the child’s
accompaniment?
- Which preparations are made for holidays and outings?
- Has attention been paid to safety aspects during holidays?
- Does the babysitter know what to do in case of calamities?
- Who checks the aspects of prevention and preparation (and when is this done)?
- Which arrangements have been made for children who stay home alone?
- When is the busiest hour in the house?
- Which arrangements have been made for nights and mornings (children making their own
breakfast)?
- Which instructions do babysitters receive about measures and safety?
- Is the child himself – depending on his age - conscious of safety?
- Is the babysitter conscious of safety aspects?
- Does the babysitter know whom to call and when?
2.2 Improving safety at home, at the child care centre, at school
You can stimulate course participants to keep paying attention to these issues by assigning them to
draw a plan of action about safety issue.
You will find an example of a plan of action for a family with a six-months old baby below.
Room
Bathroom
All rooms
Garage
Action
Buy a medicine
cabinet, attach it to
wall, put all medicines
in it
Plan for fire alarm
systems, smoke
detectors
Store away cleaning
agents and poisonous
substances under lock
and key.
Fix lock first
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Priority
Low
Who
<name>
When
Within 3 months
High
<name>
This week
Low
<name>
Within 6 months
69
2.3 Preparing for accidents
In many instances, first aid measures in the home leave much to be desired. You will find a number
of points for consideration below.
2.3.1. First aid kit
Enough attention has been paid to this subject in the course material.
2.3.2. Detectors
Nowadays in the Netherlands, detectors are compulsory in newly-built houses but most of us live in
older houses. Give the course participants some assistance concerning the correct number of
detectors and where they should be placed, the various possibilities (smoke, warmth, carbon
monoxide and so on), maintenance and such like. In many cases, detectors have helped people leave
burning premises in time. Many people are caught unawares during their sleep (for example by
smoke emission).
2.3.3. Fire extinguisher
Spray foam extinguishers are recommended for use in the home. They need to be checked regularly
and they should be kept in a place that is easily accessible. Do all the occupants know how they
should handle the fire extinguisher?
2.3.4. Fire blanket
Beginning small fires can be extinguished with this blanket. It may also provide an additional escape
measure to leave the premises safely in case of fire. Fire blankets are highly suitable for use in the
kitchen (burning fat).
2.3.5. Escape routes
Make escape route maps of the house and is everyone aware of them?
Have the occupants ever had instructions as to which actions to take in case of fire. Have they
practiced leaving the premises if something goes wrong (during the evening/at night by wearing a
blindfold)? Sticker sets are available to indicate the escape route in the house.
Parents should know what arrangements have been made at the day care centre and at school and in
particular, whether children are trained in safety precautions.
2.3.6. Escape rope
This rope forms a connection to the front or back door so that everyone can leave the premises
quickly in case of calamities. Some practice is required for the use of these ropes.
2.3.7. Light rod
Light rods are made of material that will emit light once they are bent. They are very useful during
blackouts due to calamities, but they are also very suitable for use during common power failures.
2.3.8. Fire safety mask
The smoke from fires has an intoxicating effect. These safety masks will help you to endure the
smoke until you have escaped from the burning premises. The use of these masks requires
instruction and some training.
2.3.9. Life hammer and rescue knife
These are indispensable items in traffic to be able to leave a vehicle with blocked car doors
effectively. Or to escape from a car that has landed upside down? Life hammers can be used to
smash car windows, rescue knives can be used to cut seat belts in order to be free to act.
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Obviously, if you want to pay attention to this type of equipment, sufficient background information
is needed about the possibilities and materials available.
Demonstration materials will liven up the story for the course participants. Safety awareness can be
enhanced by taking inventory of the arrangements people have made at home.
Of course, you can call in external experts (fire brigade for example). In addition, it is important to
determine who in the house or the family will pay attention to these aspects. Otherwise, a situation
could arise whereby each parent would expect the other to pay attention to safety and take
appropriate measures. This could pose a risk that nothing gets done, which may lead to a dangerous
situation. Continuous attention is and remains necessary.
We would like to point out that this is not the only, complete and/or universal method to enhance
awareness with respect to prevention and preparation. Using your creativity, you will certainly be
able to stimulate the group further to pay attention to this subject during and after the course.
It remains necessary to work in a way that is suited to the target audience and to respond to
(current) developments.
3. Child abuse
You may be confronted to reactions that are beyond the scope of the course participants’ interest.
This may have several reasons.
1. The course participants is a victim of child abuse and has received therapy to deal with this.
2. The course participant is a victim of child abuse and has as yet taken no action with respect
to this problem.
3. When confronted with this subject, the course participant may wonder whether he, she or
the partner is taking good care of the children and whether nothing untoward is happening
at their home as well.
4. The course participant considers a situation in his own environment and wonders whether
he should take measures and, if so, which ones.
5. The course participant knows that he could be regarded as a perpetrator.
It is clear that this subject can be very confrontational for the people concerned if they have to
discuss child abuse. Even being a witness to such discussions may be difficult for them.
Here is some advice:
- If you discuss the subject, be brief and to the point.
- Never discuss matters that are (too) personal.
- Realize that a single signal does not necessarily prove anything.
- Never draw conclusions, but always refer to experts.
- If a discussion ensues, accept everyone at full value.
- Do not force anyone to say anything about this subject.
- Be aware of face-to-face conversations, i.e. no private discussions between individual
participants should be allowed.
- Please mind the people who do not participate in the discussion (this may be a signal as
well).
- If somebody becomes highly emotional, interrupt the lesson, take this person apart and offer
support.
- End the discussion when it seems to get out of hand (after all you are in charge of the
meeting).
- If you want to address someone about his contribution, it is best to leave it till after the
lesson during a private discussion.
- Make sure that you are available for questions after the lesson.
- Make sure that you have addresses and telephone numbers at hand for referral.
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Just to remind you: there are no hard and fast rules. A lot depends on the situation, your personal
attitude and your teaching method, the course participants’ age, your own position, your
presentation of this subject and so on.
If we examine the stages of coming to terms with apparent child abuse (victim or counsellor), we can
observe considerable similarities with dealing with bereavement. We can distinguish the following
phases:
1. astonishment/perplexity
2. 2 .anger/fear/sadness
3. denial/hiding
4. accepting the reality
5. feeling pain/intense emotion
6. adjusting life/sharing the events with others
7. learning to live with the events
In many cases, phases 2 to 4 are accompanied by guilt feelings and feelings of shame. It is good to
realize that the majority of course participants’ responses can be placed within one of these phases.
In addition to all the things that we discussed previously, there is one more aspect which occurs in
our multicultural society. Different cultures and religions may have different standards as to whether
something can be defined as child abuse or not, even if there are laws in force. In some cultures,
corporal punishment is accepted to a greater extent than in Western culture. You should consider
this and try to discuss the subject with respect for other people’s cultures and their dignity.
Suspicions of child abuse have a great impact, for the (alleged) victim and the (alleged) perpetrators,
as well as for the counsellors and instructors. Stigmatizing lie in wait. This subject requires you to
prepare well and to have extensive experience of guiding group processes and of discussion
techniques. Of course, you can try to keep the information purely business-like. However, this will
not guarantee that discussions will not take a direction that is not consistent with your choice. Make
sure that you are thoroughly prepared and dispose of ample background information. Make sure you
show sincere interest in people who are or will be confronted with such problems.
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