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First Aid

Q. What should be the content of First aid box?

First aid kit should contain the following:

  • Emergency telephone numbers for emergency medical services (EMS) 1092/102/108
  • Sterile gauze pads (dressings) in small and large squares to place over wounds
  • Disinfectants like dettol or savlon
  • Medicines like pain killers (ibuprofen) and antibiotics
  • Roller bandages to hold dressings in place 
  • Adhesive tape
  • Adhesive bandages in assorted sizes
  • Scissors
  • Tweezers
  • Safety pins
  • Antiseptic wipes or soap
  • Thermometer
  • Barrier devices, such as a pocket mask or face shield 

Heavy Bleeding

Q. What should one do if the patient is bleeding heavily?

  • Put pressure on the wound with whatever available to stop or slow down the flow of the blood.
  • Call local emergency numbers or ask for some body help to get to hospital.
  • Keep pressure on the wound until the help arrives.

Q. The person looks pale and feels cold and dizzy. What does this mean?
It means there isn’t enough blood flowing through the body. It can be life threatening because it can very quickly lead to other conditions, such as lack of oxygen in the body’s tissues, heart attack or organ damage. This physical response to an injury or illness is called shock.
If you suspect someone is going into shock, lie him down and lift his feet higher than the rest of his body. Such that the legs are higher than the heart in this position, which helps increase blood flow to their brain and heart.

Q. Should wound be washed?
For minor cuts and grazes, one can wash the wound to remove any dirt. Don't wash a wound that is bleeding heavily. If a wound that is bleeding heavily put under a tap, then all clotting agents will wash away and will bleed more.

Do's and Don'ts for heavy bleeding

Do’s for heavy bleeding 

  • Reassure victim that help is on the way
  • Call ambulance immediately
  • Check victim’s status regularly
  • Use direct pressure to stop bleeding
  • Check to see if victim’s airways are clear
  • If no pulse or respiration, start CPR
  • To prevent transmission of disease, use latex gloves
  • Raise head if bleeding in upper body areas
  • Raise feet if bleeding in lower body areas 

Don'ts for heavy bleeding

  • Don’t move the patient if not required
  • Always suspect “spinal injury” (and don’t move the victim)
  • Don’t set fractures and breaks (simply immobilize the victim)
  • Use “direct” pressure to stop bleeding
  • Don’t remove items imbedded in the eye
  • Don’t use burn ointments
  • Call emergency as soon as possible

Head Injury

Q. How does a cold compress work?
A cold compress reduces the swelling and lessens the pain of the injury.

Q. Can I give them painkillers for their headache?
No. Painkillers are not advised because they can mask the signs and symptoms of a serious head injury.

Q. What is concussion?
If a person suffers a blow to the head, the brain can be shaken inside the skull. This is called concussion. It tends to result in a short loss of consciousness (a few seconds to a few minutes). Most people make a full recovery from a concussion, but occasionally it may become more serious. If you think someone has concussion, call medical emergency.

Q. What are the symptoms of concussion? Symptoms of concussion include:
  • Dizziness
  • Headache
  • Confusion
  • Feeling sick
  • Blurred vision
  • Having no memory of what happened.

Burns

Q. Should I use ice to cool the burn?

No, use water only. Ice may further damage the skin.

Q. Should I put a plaster over a burn to make sure it doesn't get infected?

One should not use any adhesive bandages as it’ll stick to the skin and may cause further damage. Instead the burns should be covered with cling film or a clean plastic bag which will help prevent infection.

Q. If clothes are stuck to the burn, should I try to remove them?

No. Remove any clothing or jewellery near the burned area, but don’t try to remove anything that’s stuck to the burn. This could cause more damage.

Do's for burns

  • Call an ambulance for any serious burns. Burns to children or the elderly, electrical or chemical burns as well as burns to the face or genital area, should be attended to immediately.
  • Apply CPR if the person is not breathing normally.
  • Try to remove clothes and jewellery (from the area that has been burned) only if it is not sticking to the burned area.
  • Hold the burned area under gently running water, for about 10 minutes to half an hour.
  • To prevent corneal damage (in the case of chemical burns to the eyes), immediately irrigate the eyes with water or a saline solution.
  • For second degree burns on the limbs – elevate the limbs higher than the heart.
  • To reduce shock as well as loss of body heat, place clean, dry, non-fluffy cloths lightly over the burn.
  • Cover the person with a cool, wet, lint-free cloth, while waiting for an ambulance or when transporting the person to hospital.
Don'ts for burns

  • Apply lotions, butter, grease or oil to burned area.
  • Use ice, as it may cause frostbite.

Unconsciousness

Q. What should a person do if patient is unconscious?
If a patient is unconscious, his head should be tilted backwards. This is done to avoid tongue to fall backwards and block the airway. Tilting the head backwards and pulling the tongue forward will help to clear the airways.

Q. If I think the person has a back or neck injury, should I still turn them on their side?
If one suspect a back or neck injury, it is still advisable to move them onto their side. The priority is to keep them breathing. Try to keep their spine in a straight line when turning them. If possible, get someone's else to help to turn them.

Q. What should I do if someone is feeling faint?
If someone is feeling faint, advise them to lie down on their back and raise their legs to improve blood flow to the brain. Fainting is caused by a temporary reduction in the flow of blood to the brain and can result in a brief loss of consciousness. A person who has fainted should quickly regain consciousness. If they don't, treat them as an unconscious person.
 

Heart Attack

Do's during heart attack:
  • Patient should be made to  sit down, rest, and try to keep calm.
  • Loosen any tight clothing.
  • Ask if the patient takes any chest pain medication for a known heart condition, such as nitroglycerin, and help him take it.
  • If the pain does not go away with rest or within 3 minutes of taking nitroglycerin, call for emergency medical help.
  • If the person is unconscious and unresponsive, call for emergency and should begin CPR.
Don'ts during heart attack:
  • Do not leave the patient alone 
  • Do not allow the person to deny the symptoms .
  • Do not wait to see if the symptoms go away.
  • Do not give the person anything by mouth unless a heart medication (such as nitroglycerin) has been prescribed.
CPR(Cardiopulmonary Resuscitation): It is an emergency lifesaving procedure. It is a combination of:

  • Chest compressions that keeps patient's blood circulating.
  • Rescue breathing that provides oxygen to patient's lungs.
Chest compressions:
  • Place the heel of one hand on the lower half of the person’s breastbone.
  • Place the other hand on top of the first hand and interlock your fingers.
  • Press down firmly and smoothly (compressing to 1/3 of chest depth) 30 times.
  • Administer 2 breaths as described below in mouth-to-mouth,
  • The ratio of 30 chest compressions followed by 2 breaths is the same, whether CPR is being performed alone or with the assistance of a second person.
  • Aim for a compression rate of 100 per minute.
Effective chest compressions will be tiring. It is important to get help from others if possible, to allow changeover for rest and to keep the compressions effective.

Mouth-to-mouth Respiration:
  • If the patient is not breathing normally, make sure he is lying on his back on a firm surface
  • Open the airway by tilting the head back and lifting his chin.
  • Close his nostrils with your finger and thumb.
  • Put your mouth over the patient’s mouth and blow into his mouth.
  • Give 2 full breaths to the patient (this is called ‘rescue breathing’). Make sure there is no air leak and the chest is rising and falling. If his chest does not rise and fall, check that you’re pinching his nostrils tightly and sealing your mouth to his. If still no breathing, check airway again for any obstruction.
  • Continue CPR, repeating the cycle of 30 compressions then 2 breaths until professional help arrives. 
CPR for children aged 1-8 years:
  • Use the heel of one hand only for compressions, compressing to one third of chest depth.
  • Follow the basic steps for performing CPR described above.
CPR for infant (up to 12 months of age):
  • Place the infant on his back. Do not tilt his head back or lift his chin (this is not necessary as their heads are still large in comparison to their bodies).
  • Perform mouth-to-mouth by covering the infant’s nose and mouth with your mouth – remember to use only a small breath.
  • Do chest compressions, using two fingers of one hand, to about one third of chest depth.
  • Follow the basic steps for performing CPR described above.
Q. When should we stop CPR?

Generally CPR is stopped, when:
  • The patient's revives and starts breathing on its own
  • When medical help arrives
  • When the person giving CPR is exhausted

Nose Bleeding

Symptoms of nosebleeding

  • Bleeding from either or both nostrils
  • Sometimes bleeding from ears/ mouth too.

Q. What are the causes of nose bleeding

  • Dryness 
  • Blowing nose with force 
  • Use of medications, like aspirin 
  • Nose picking
  • Pushing objects into nose 
  • Injuries / blow to the nose
  • Infections of the nose
  • Atherosclerosis 
  • Blood-clotting disorders 

Q. How to manage nose bleeding?

  • One should not panic and should  make the patient sit in upright position with his head slightly forward.
  • With thumb and index finger, one should  apply pressure on soft part of nostrils below the nose bridge.
  • Continue applying pressure until the bleeding stops.
  • Ask the patient to breathe through the mouth while nostrils are pinched
  • Loosen the tight clothing around the neck
  • After 10 minutes, release the pressure on the nostrils and check to see if the bleeding has stopped
  • If bleeding persists, seek medical aid

Note: Ask the patient not to sniff or blow their nose for at least 15 minutes

Q. What to do if a child is having frequent nosebleeds?

If a child is having frequent nosebleeds, one should see the doctor to know the cause of bleeding.

External Links / References

Snake Bite

Snake bite

Snake bite is prevalent in our community for generations, and we are not able to prevent it. Education of the common man is required from snake bite, as well as measures to be taken after the bite. Snake bite may occur at any time during lifetime. WHO (2004) provided recommendations to reduce death due to snake bite as per international norms. A primary recommendation, based on evidence based procedures, was to establish a single protocol for both first-aid and treatment, and is relevant in Indian context as well.

Remember, traditional therapy have no proven benefit in the treatment of snake bite. Do not waste time and send the patient to hospital at the earliest.

 

First- Aid treatment protocol:

First-aid currently recommended may be remembered by mnemonic ‘’ CARRY NO R.I.G.H.T’’

CARRY: Do not let victim to walk even for short distance. Transport by conveyance, especially when bite is in legs.

NO:

NO- Tourniquet.

NO- Cutting.

NO- Electrotherapy.

NO- Pressure immobilisation, nitric oxide donor (nitrogesic ointment/nitrate spray)

R.I.G.H.T:

R: Reassure patient, since 70% of all snake bites are from non-venomous species. Only 50% of bites by venomous type of snakes actually envenomate (poison with venom) victims.

I: Immobilise limb in a fashion similar to a fractured limb, in case of bites on the limb. A bandage or cloth is used to hold the splints. Do not apply pressure and ensure that blood supply is not blocked. Compression in the form of tight ligatures does not work and may be dangerous even.

GH: Get to Hospital immediately.

T: Tell any systemic symptoms that manifest on way to hospital.

Do not waste time in first aid management by traditional methods which may dangerously delay effective treatment.

 

Diagnosis phase:

Resuscitation and treatment of breathing problem is a priority. Life threatening injuries should also be taken care of.

Patient is monitored for any worsening of symptoms, chiefly breathing or pertaining to cardiovascular system.

Look for fang (poisonous tooth) marks in the area of bite.

Limbs are divided into compartments of muscles, blood vessels and nerves. Compartment syndrome is a rare complication. It is seen in excessively swollen limbs. Severe swelling may cut off blood circulation to a particular compartment.

I. Diagnosis phase general assessment:

Diagnosis phase general assessment depends upon the type of symptoms. Depending upon the species, clinical features may include:

  • Local pain/ tissue damage. Bite area may show signs such as painful and tender wound, swelling, or blister formation.
  • Ptosis (drooping of upper eyelids)/ neurological signs. Local or systemic effect of venom may stop action of breathing muscles, resulting in death in untreated cases. Victim may have vision problem or difficulty in speaking.
  • Haemostatic abnormality leading to localised or diffuse bleeding.
  • Muscle death: Venom from certain snakes may produce muscle death. Debris of protein from dead muscle cells may affect kidney, since it may not be filtered out.
  • Renal damage.

Response to neostigmine and anti- snake venom (ASV) may be studied.

II. Diagnosis phase investigations:

  • 20 minute Whole Blood Clotting Test (20WBCT): This is most reliable bedside test of coagulation. A few milli-liter of fresh venous blood is taken in small test tube of glass. It is left undisturbed at room temperature for 20 minutes. After 20 minutes, tilt the test tube to check coagulability. If the blood is still liquid, then the patient has incoagulable blood. The test is carried out every half an hour for three hours and then at hourly intervals. If incoagulable blood is discovered, then six hourly cycle of ASV is adopted.

Send blood and urine samples to the laboratory to look for any evidence of bleeding, muscle death and for assessment of kidney function.

 

Management:

Management should be carried out under medical supervision.

Snakes can continue to bite and inject venom with successive bites till the venom is exhausted. Prevent a second bite or attack on another victim. Therefore, do not try to catch snake as this may lead to further bites. Identify the snake if possible but not at the cost of additional bite.

Every snake bite victim should attend emergency department in a hospital.

I. General:

  • Pain: Snake bite often causes severe pain locally. This may be treated with pain killers such as paracetamol.
  • Tourniquets: Though tourniquets are not advised, many a times these are still used. When used by someone, sudden removal of tight tourniquets may lead to massive surge of venom leading to neurological paralysis or hypotension. Tourniquet removal should be done under medical supervision, more so when pulse distal to it is absent.

Patients with local necrosis may be given antibiotics and tetanus toxoid booster.

Remove any constricting item such as ring which may cut off blood flow in case of swelling of bite area.

In past, suction was applied to remove toxin. It is no longer recommended, since suction may further damage local tissue.

II. Anti- snake venom:

When indicated, start ASV with whatever dose is available in hand (pending availability of full dose). In India, only polyvalent ASV is available. It is effective only against four common varieties of snakes (king cobra, Russells viper, saw scaled viper and common krait). Bites by other species, depending upon the geography, require special measures. These species need to be identified first.

Criteria for ASV administration:

ASV is a costly and scarce item. It should be administered only when there are definite signs of envenomation. Only free flowing and unbound venom, in tissue fluid or bloodstream can be neutralised.

ASV carries the risk of anaphylactic shock and therefore, should not be used unnecessarily.

Indications of ASV:

I. Systemic envenoming

  • Evidence of coagulopathy: Visible spontaneous systemic bleeding or coagulopathy is detected by 20WBCT.
  • Evidence of neurotoxicity: Victim is having muscle paralysis, ptosis, external ophthalmoplegia or is unable to lift head.
  • Abnormalities of cardiovascular system: Victim has signs of hypotension, systemic shock, cardiac arrhythmia or has abnormal electrocardiogram.
  • Severe and persistent vomiting or pain abdomen.

II. Severe current local envenoming

  • Severe current local swelling: Severe current local swelling involving more than half of the bitten limb, in the absence of tourniquet. In cases of severe swelling after bites on digits (toes and especially fingers) from species causing necrosis.
  • Rapid extension of swelling: Rapid extension of swelling (e.g. beyond ankle or waist within few hours of bites on hands or feet). Swelling arising after elapse of long hours of bite is not a ground for giving ASV.

Purely local swelling, even if accompanied by bite mark/s from an apparently venomous snake, is not a ground for giving ASV.

ASV administration:

Clinical decision is very important and the dose of ASV required varies from case to case. Ten to thirty vials are usually required. All victims do not require 10 vials of ASV. However, starting with 10 vials ensures sufficient neutralising power against average amount of injected venom. It also ensures neutralisation during next 12 hours of any free flowing venom.

No ASV test dose is given, since it does not have predictive value in detecting anaphylactic or late serum sickness reactions. Rather, these may pre-sensitise the victim and may pose greater risk.

Two methods of administration are recommended

  • Intravenous “push” injection: Reconstituted freeze-dried anti-venom or neat liquid anti-venom is injected by slow intravenous injection (not more than 2 ml per minute).
  • Intravenous infusion: Reconstituted freeze-dried anti-venom or neat liquid anti-venom is diluted in about 5 ml of isotonic fluid (isotonic saline or 5% dextrose) per kg of body weight, and is infused at a constant rate over a period of about 30- 60 minutes.

Recommended initial doses of ASV:

  • Neurotoxic/ haemostatic cases: Neurotoxic/ haemostatic 10 vials of ASV are needed, and the same amount of ASV is given to adults, children and even pregnant women. Snakes inject the same amount of venom in adults and children.

 

ASV is administered over 30- 60 minutes at constant speed. Liquid or reconstituted ASV in isotonic saline or glucose without any diluent fluid in volume overload victims is given.

 

Local administration of ASV near the site of bite is ineffective, painful and in fact raises intra-compartmental pressure.  Particularly, it is not injected in digits. 

 

How long anti-venom is expected to be effective after the bite:

Anti-venom should be given as soon as it is indicated. It may reverse systemic envenoming even when it has persisted for several days, and in case of haemostatic abnormalities, for two or more weeks. It is appropriate to give anti-venom as long as evidence of coagulopathy persists.

ASV reactions:

  • Anaphylaxis: Anaphylaxis is a life threatening emergency. Victim is monitored for features such as fever, chills, itching, urticaria, hypotension and bronchospasm. ASV should be discontinued in anaphylaxis. Adrenaline should always be at hand. An extra dose of adrenaline may be required in patients who do not respond to initial doses. Noradrenaline and nitroglycerine should be available to correct hypotension in elderly. Intravenous fluids may be required for any haemodynamic instability.

On recovery, ASV may be restarted slowly for 10- 15 minutes, keeping the patient under close observation. After that, normal flow is maintained.

  • Late serum sickness: Late serum sickness may be treated with oral steroids. Antihistaminics may provide additional symptomatic relief.

III. Neurotoxic envenomation:

  • Neostigmine: Neostigmine, an anticholinesterase, may reverse respiratory failure and neurotoxic symptoms by prolonging the life of acetylcholine.

IV. Anti-haemostatic repeat dose:

In case of anti-haemostatic envenomation, adopted ASV strategy is to keep six hour time period in which clotting time is repeated. Repeat ASV dose is given over one hour in case of persisting coagulation defect. Same cycle is repeated until coagulation is restored or the species of snake is identified against which polyvalent ASV is ineffective. Repeat dose may be ten vials of ASV similar in quantity to the first dose.

V. Haematotoxic repeat dose:

Normal guidelines are to administer ASV every six hours until coagulation is restored. What should be done when 30 vials have been exhausted and the coagulation abnormality persist. One study has shown that even up to 50 vials (500 ml) may be given for haematotoxic poisoning. Envenomation by certain species does not respond to ASV. Coagulopathy may persist for up to three weeks in those cases.

VI. Role of surgery:

  • Surgical debridement: Surgical debridement of necrotic tissue may be done.
  • Fasciotomy: Fasciotomy is required when intra-compartmental pressure is high enough to collapse blood vessels leading to ischaemia. The role of fasciotomy is questionable.
  • Multiple puncture technique: Multiple puncture technique with large bore needle may be done to reduce intra-compartmental pressure. Intra-compartmental pressure may be measured using saline manometers.

 

References

http://apps.who.int/iris/bitstream/10665/249547/11/9789290225300-eng.pdf

http://www.japi.org/august_2016/01_editorial.pdf

http://apiindia.org/medicine_update_2013/chap94.pdf

http://www.who.int/snakebites/en/

http://www.who.int/snakebites/disease/en/

http://www.who.int/ipcs/poisons/snakebite/en/

http://164.100.130.11:8091/nationalsnakebitemanagementprotocol.pdf

http://www.apiindia.org/pdf/medicine_update_2017/mu_113.pdf

https://www.ncbi.nlm.nih.gov/pubmed/28799310

https://www.ncbi.nlm.nih.gov/pubmed/27762105

https://www.emedicinehealth.com/snakebite/article_em.htm#snakebite_symptoms

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