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Combat Medic

Combat Medic. Pocket Manual.

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Combat Medic

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  1. Combat Medic Pocket Manual

  2. ANATOMY& PHYSIOLOGY Anterior or ventral - toward the front, or ventral (pertaining to the belly; abdomen), side of the body.Posterior or dorsal -toward the back, or rear, side of the body.Medial -near or toward the midline of the body.Lateral -farther away from the midline of the body.Internal -inside.External - outside.Proximal - nearer the point of origin or closer to the body.Distal - away from the point of origin or away from the body.Superior - higher than or above.Cranial - toward the head.Caudal - toward the lower end of the body.Inferior - lower than or below.Erect - normal standing position of the body.Supine - lying position of the body, face up.Prone - lying position of the body, face down.Lateral recumbent - lying position of the body on either side.Peripheral - the outward part or surface of a structure

  3. VITAL SIGNS Respiration • Respiration rate is the number of breaths a patient takes in 1 minute. • Normal respiration rate for an adult at rest is 12 to 20 breaths per minute. • Rapid respiration rate is more than 28 respirations per minute, and a slow respiration rate is less than 10 breaths per minute. • A rapid or slow respiration rate indicates that the patient is in need of immediate medical attention and should be transported to a medical treatment facility as soon as possible. Respiratory Rates Remember the following respiratory rates: Adult - 12-20 per minute Children - 20-40 per minute Infants - greater than 40 per minute PULSE The carotid pulse is taken at a groove along the casualty's larynx (Adam's apple) containing a carotid artery Other pulse sites that can be taken are: • Radial pulse = located on the inside of the wrist near the base of the thumb. • Temporal pulse = located at the temple near the ear. • Brachial pulse = located on the inside of the elbow. • Femoral pulse = located in the groin area. • Popliteal pulse = located behind the knee. • Dorsalispedis = located on the top of the foot. • Using a clock with a second hand, you will count the pulse for one full minute. • A normal pulse rate for an adult, when resting, is from 60 to 80 beats per minute. The average is 72 beats per minute. • A higher than normal pulse rate (a resting pulse rate of over 80 beats per minute) can be caused by several factors including shock, bleeding, excessive heat, dehydration, fever, pain, emotions, and vigorous activity (such as running). Tachycardiais an abnormal condition that exists when the casualty's pulse rate is over 100 beats per minute. • A lower than normal pulse rate (a resting pulse rate of less than 60 beats per minute) can be caused by several factors, including heart disease and medications. A pulse rate below 60 may also occur in a person who is physically fit. Bradycardia is an abnormal condition that exists when a patients pulse rate of less than 50 beats per minute.

  4. BLOOD PRESSURE The normal range: 100-140/60-90 for males 90-130/50-60 for females. If you do not have a blood pressure cuff, you can get an idea of the patient’s approximate systolic blood pressure by palpating the carotid, brachial, or femoral arteries. The approximate normal reading for the Carotid artery is 60, the Brachial is 80, and the Femoral is 70. • Level of Consciousness • A-if the patient is ALERT • V-if the patient responds to VERBAL stimulus • P-if the patient responds to PAINFUL stimulus • U-if the patient is UNRESPONSIVE Pupil Check Sample History S: SIGNS AND SYMPTOMS -Signs are conditions you can see, such as a hematoma (bruise) or laceration. Symptoms are what the patient feels and tells you about, as in “my head hurts.” A: ALLERGIES - When asking a patient about allergies it is important to make the distinction between medical allergies and non-medical allergies. Some allergies that may not seem medical in nature are important however, such as peanut allergies since many asthma inhalers contain peanut by-products.Common abbreviations used when recording that a patient has no allergies include NKA (No Known Allergies) and NKDA (No Known DRUG Allergies).Check the patient for a red medical tag describing the allergy. M: MEDICATIONS - A list of medications that a patient is on is important information to have, since the medications can give you an idea of what medical conditions a patient may have but hasn’t told you about, as well as ensuring that doctors don’t prescribe another medicine that conflicts with a medication that a person is taking. P: PERTINENT PAST HISTORY - A patient’s medical history is a valuable tool in identifying or diagnosing a medical condition. For instance, if a patient has a long cardiac history, you would tend to have a higher level of suspicion for a complaint of difficulty breathing when there are no other outward signs. L: LAST ORAL INTAKE - Knowing the last time a patient ate or drank, and what it was can help identify a patient’s condition. For instance with a diabetic patient who is behaving erratically and states they haven’t eaten in 8 hours, you might be prompted to check their blood sugar level. E: EVENTS LEADING UP TO THE INJURY OR ILLNESS - Having a clear history of symptom onset or how an injury occurred, helps in identifying possible life-threatening conditions.

  5. Head to Toe Survey • Cervical Spine • Anterior Neck • Scalp • Face • Eyes • Ears and Nose • Mouth • Chest • Abdomen • Lower Back • Pelvis • Lower Extremities • Upper Extremities • Back PATIENT ASSESSMENT • A=Airway. An obstructed airway may quickly lead to respiratory arrest and death. Assess responsiveness and, if necessary, open the airway. Insert airway adjuncts if needed and spinal immobilization if spinal injury is suspected. • B=Breathing. Respiratory arrest will quickly lead to cardiac arrest. Assess breathing, and, if necessary, provide rescue breathing. Look for and treat conditions that may compromise breathing, such as penetrating trauma to the chest. • C=Circulation. If the patient’s heart has stopped, blood and oxygen are not being sent to the brain. Irreversible changes will begin to occur in the brain in 4 to 6 minutes; cell death will usually occur within 10 minutes. Assess circulation, and, if necessary, provide cardiopulmonary resuscitation (CPR). Also check for profuse bleeding that can be controlled. Use a loose tourniquet if necessary to control the bleeding. Assess and begin treatment for severe shock or the potential for severe shock. • D=Disability. Serious central nervous system injuries can lead to death. Assess the patient’s level of consciousness by using the AVPU scale. • E=Expose. You cannot treat conditions you have not discovered. Remove clothing– especially if the patient is not alert or communicating with you–to see if you missed any life-threatening injuries. Protect the patient’s privacy, and keep the patient warm with a blanket if necessary. ONGOING ASSESSMENT The Ongoing Assessment allows for monitoring of a casualty’s condition and ensuring interventions are working as intended. NOTE: Vital signs should be checked every 5 minutes if unstable. Every 15 minutes if stable. • Repeat the initial assessment. • Reassess and record vital signs • Repeat focused assessment based on patient’s complaint • Check interventions

  6. AIRWAY MANAGEMENT POSITIONING THE PATIENT Step1 - Kneel to the side of the victim in line with the victim’s shoulders, but far enough away so that the victim’s body will not touch yours when it is rolled toward you. Straighten the victim’s legs, gently but quickly. Then move the victim’s closer arm along the floor until it reaches straight out past the head. STEP 1 Step2 - Support the back of the victim’s head with one hand while you reach over with the other hand to grasp under the distant armpit. STEP 2 Step 3 - Pull the patient toward you while at the same time keeping the head and neck in a natural straight line with the back. Resting the head on the extended arm will help you in this critical task. STEP 3 Step 4 - Roll the patient onto his back and reposition the extended arm STEP 4 Once the patient is supine with the arms alongside the body, you should position yourself at the patient’s side. By positioning yourself at the patient’s side, you can more easily assess whether the patient is breathing. If the patient is not breathing, you are already positioned to perform artificial respirations (also referred to as rescue breathing) and chest compressions. One of two maneuvers, the head tilt-chin lift or the jaw-thrust, may be used to open an obstructed airway. When performing these maneuvers, you may discover foreign material or vomit in the mouth that needs to be removed. Do not spend very much time to perform this task. Liquids or semi-liquids should be wiped out with the index and middle finger covered by a piece of cloth. Solid material should be extracted with a hooked index finger.

  7. HEAD TILT-CHIN LIFT MANEUVER • Kneel at the side of the casualty's head. • Place the fingertips of one hand under the bony part of his chin. • Place your other hand on his forehead. • Press on his forehead to make the head tilt back while lifting his chin forward. Lift until the teeth are almost brought together. The mouth should not be closed as this could prevent air from entering the casualty's airway. The thumb is usually not used in lifting the chin. In some cases, the thumb may be used to depress the casualty's lower lip slightly to keep his mouth open. Place one of your hands on the patient’s forehead and apply gentle, firm, backward pressure using the palm of your hand. PRECAUTIONS: When performing the head tilt-chin lift maneuver, do not press too deeply into the soft tissue under the chin. Undue pressure in this location may obstruct the airway. In addition, make sure the mouth is kept open so exhalation and inhalation are not hindered. JAW-THRUST MANEUVER • The jaw-thrust maneuver is considered an alternate method for opening the airway. To perform this maneuver, proceed as follows: • Kneel beside the casualty. • Rest your elbows on the same surface on which the casualty is lying. • Place your hands on either side of the casualty's head. Grasp the angles of the casualty's lower jaw. • Lift the casualty's lower jaw forward and tilt his head backward at the same time. • If you must perform rescue breathing, pull the casualty's lower lip open with your thumb and close the casualty's nostrils by placing your cheek tightly against his nostrils. NOTE: The jaw-trust technique without head tilt is considered the safest approach to opening the airway of patients with suspected neck injuries because it usually can be done without extending the neck.

  8. HEIMLICH MANEUVER WITH VICTIM STANDING • Make a fist with one hand. • Place the thumb side of the fist against the victim’s • abdomen, in the midline slightly above the navel and well below the tip of the xiphoid process. • Grasp the fist with the other hand and press the fist into the victim’s abdomen with a quick upward thrust. • Repeat the thrusts and continue until the object is expelled from the airway or the patient becomes unconscious. Eachnew thrust should be a separate and distinct movement. • Checking for Breathing • Check to see if the casualty is breathing. Many times, opening the airway is all that is needed to restore breathing in an unconscious person. While you are doing the check, maintain the casualty's airway using the head- tilt/chin-lift or the jaw-thrust method. • Place your ear over the casualty's mouth and nose and look towards the casualty's chest. For the best results, your ear should be touching his nose. • Look at the casualty's at the casualty's chest. If the casualty is breathing, you should be able to see the chest rise and fall. • Listen for the sound of breathing (air being inhaled and exhaled). • Feel for the flow of air on the side of your face, the air flow being caused by the casualty exhaling.

  9. CPR Cardio- Pulmonary Resuscitation • Rescue Breathing • Gently pinch the casualty's nose closed – • The casualty's nostrils must be closed so that air will not escape when you blow air into his mouth. Using the thumb and index finger of your hand on the casualty's forehead, pinch his nostrils closed gently. Keep the heel of your hand on the casualty's forehead and maintain enough pressure to maintain the head-tilt. Your other hand should stay on the casualty's chin or neck so the airway remains open. Give two full breaths within 3 seconds. • Take a deep breath. • Seal your lips around the outside of the casualty's mouth thus creating an airtight seal. • Blow two full breaths within three seconds into the casualty's mouth. • If your initial attempt to ventilate the casualty is unsuccessful, reposition the casualty's head and repeat rescue breathing. • After the second breath, break the seal over the casualty's mouth and release his nose. The casualty's body will exhale without effort on your part. • Check for breathing. • Rescue Breathing • Feel for the carotid pulse. Place the index and middle fingers of your hand that is not on the casualty's forehead on the side of the casualty's trachea. Use the side nearest you. • Slide your finger into the groove beside the Adam's apple (The • "Adam's apple" is actually the larynx. The Adam's apple is smaller in females than in males. • Gently feel for the pulse. Maintain the head-tilt with your hand on the casualty's forehead. • Send someone to get help. • If no pulse is felt, begin CPR immediately. If a pulse can be felt, continue with rescue breathing procedures given in the next paragraph. • Feel for the carotid pulse.

  10. Chest Compression • Locate the Compression Site -Determine proper hand position in this manner: • Using the middle and index finger of your hand which is nearest the casualty's legs, find the lower margin of his rib cage on the side of his body closest to you. • Move your fingers up the casualty's rib cage to the notch where the ribs meet the sternum in the center of the lower part of the chest. • Keep your middle finger on this notch and place your index finger next to the middle finger on the lower end of the sternum. • Your other hand has been on the casualty's forehead to keep his head in position maintaining the airway. Put the heel of that hand on the lower half of the sternum, close to the index finger that is next to the middle finger in the notch. The thumb side of that hand should be against the index finger of the other hand. The heel is now on the compression site • Position Hands for Giving Chest Compressions -Follow these steps: • Remove your hand from the notch and put it on top of the hand on the sternum. Locate the Compression Site Be sure both hands point away from the rescuer (toward the opposite side of the casualty). You may hold your fingers straight or interlocked. You will exert pressure with the HEEL of your hands; therefore, be sure your fingers and palms DO NOT touch the casualty's chest. • Administer External Chest Compressions -Proceed in this way: • Lock your elbows with your arms straight. This makes chest compressions more efficient and saves the rescuer's energy. • Position your shoulders directly over your hands so that the thrust for each chest compression is straight down. The casualty's torso may roll if you push other than straight down. If the casualty rolls, the thrust of the chest compression will be much weaker and less effective. Also, the rolling motion of the casualty can make the rescuer very tired and cause additional injury to the casualty. Possible injuries include fractured ribs, fractured xyphoid process, and lacerations (rips or punctures) of internal organs caused by sharp pieces of broken bone. Administer External Chest Compressions Push straight down on the sternum so that it goes down 1 1/2 to 2 inches for the normal sized adult. Use your weight when pushing down. Instead of pushing down using your arm and shoulder muscles only, let the weight of your body move forward and use that force to help depress the sternum. Remember to keep your arms straight and your elbows locked during the push. Give 15 compressions (10-12 seconds). A compression cycle consists of a thrust which compresses the heart and a release which allows the heart to refill with blood. These compressions are delivered at a rate of 80 cycles per minute (about 11 seconds for each 15 compressions). Delivering chest compressions at this rate will allow the rescuer to administer a total of 60 compressions per minute since some time will be required to administer two breaths after every 15 compressions.

  11. Relax and Allow the Chest to Rise Completely. • Releasing the pressure allows the heart to refill with blood. • Release the pressure completely so that the sternum resumes its normal position, but do not remove the heel of your hand from the compression site. If you do lose the compression site, repeat the procedures for finding the site. Repeat Until 15 Push-Relax Cycles Have Been Completed -(If One-Rescuer CPR is being performed) or five Push-Relax Cycles Have Been Completed (If Two-Rescuer CPR is being performed). • Establish a definite rhythm and compress at the rate of 80 cycles per minute (15 compressions in 10-12 seconds). • Spend half the time for each compression pushing down and half the time letting the chest rise. Keep the compression cycles regular, smooth, and uninterrupted. • Give Two Quick Breaths (3-5 seconds) • Immediately after giving the chest compressions, release the pressure, move your hands to the casualty's head, and open his airway. • Close the nose (or mouth) and seal the casualty's mouth (or nose or stoma). • Blow air in until the chest rises. Look out of the corner of your eye to be sure the chest rises. Break the seal, take a breath, and administer a second breath. • Administer Three More Cardiopulmonary Resuscitation Cycles (15 Chest Compressions and Two Breaths Per Cycle) • Before you do this, relocate the compression site over the casualty's sternum. Use the procedure previously discussed. DO NOT GUESS where the site is. • Check the Pulse (3-5 seconds). • Check the pulse after the first 4 CPR cycles. If the pulse is absent, give two breaths and resume one-rescuer CPR. If the pulse is present, perform rescue breathing. • Recheck the pulse every few (3-5) minutes after the initial pulse check. Checking for Breathing • Rescue Breathing Administer External Chest Compressions • Feel for the carotid pulse. Locate the Compression Site Step 3 Step 4 Step 5 Step 1 Step 2

  12. One Person CPR Two Person CPR

  13. SOFT TISSUE INJURIES • Protruding (Impaled) Object • Protruding (Impaled) Object AVULSION ABRASION Avulsion - An avulsion is a tearing away of tissue. The separated part usually contains epidermis, dermis and subcutaneous tissue layers. Abrasion - An abrasion is an injury caused by scraping the skin against a rough surface. The damage is usually confined to the epidermis and part of the dermis LACERATION Laceration - A laceration is a cut or tears in the skin. The wound may extend through the subcutaneous tissue and into the muscle tissues. Major blood vessels and nerves may also be involved CONTUSION Contusions - Contusions (bruises) are usually caused by a blow from a blunt instrument (from a stick, for example) or by the body impacting with an object (falling to the ground, for example). The site of the injury normally turns "black and blue." The discoloration (ecchymosis) is caused by blood from the injury which is trapped and, with time, changes color. The site of the injury often swells due to the presence of blood and fluid leaking from the injured tissue cells (edema). Pain usually accompanies the injury. PUNCTURE AMPUTATION Puncture - A puncture is caused by an object such as a splinter, bullet, knife, or shrapnel penetrating the flesh. If the object goes through the body part and exits on the opposite side, the wound is called a perforated wound. If the object remains in the wound and protrudes above the skin, the object is said to be impaled. Even if the wound appears to be small and the bleeding does not appear to be severe, the object may still have caused significant internal damage. • Amputation - An amputation is the complete removal of tissue from the body. It may start as an avulsion type wound with a tearing away of the tissue, but once it is completely severed, the part is considered amputated. An amputation can also be complete separation of a limb from the body. • Protruding (Impaled) Object If a foreign object is impaled in a wound, do not attempt to remove the object. Take measures to stabilize the object to prevent or reduce further injury and, at the same time, control bleeding. In some circumstances, it may be necessary to shorten the protruding object in order to move or evacuate the casualty. • Protruding (Impaled) Object

  14. Treat Soft Tissue Injuries If the part is no longer attached to the body (amputated), retrieve the amputated part, wrap it in sterile gauze, and evacuate the part with the casualty to the medical treatment facility. If possible, keep the amputated part cool, but do not freeze the part. • Apply a dressing to control bleeding and prevent further contamination of the wound. If the wound is a puncture wound, look for both entry and exit wounds. • If time and the situation permits, irrigate debris from the wound with 30 – 60 ML of normal saline or sterile water. • Stabilize any protruding objects (next section). • Immobilize the injured body part to reduce pain and further injury. • Ice - Apply cold (ice bag or chemical pack) to help reduce swelling and pain. CAUTION: Do not apply ice directly to the skin. Applying ice directly to the skin could result in cold injury damage to the skin and underlying tissues. Use an ice bag or wrap the ice in cloth material to protect the casualty's skin. • Compression - Apply localized compression (elastic roller bandage or pneumatic counter-pressure device) to help control bleeding and swelling. An elastic bandage can be applied to the injured limb. • Elevation - Elevate the affected body part. If a fracture is involved, apply a splint before elevating the limb. • Splint - Apply a splint to the affected limb. If a fracture is involved, applying a splint is a must. Even if the limb does not have a fractured bone, applying a splint to the limb may help to reduce pain and prevent further injury. The device will immobilize the suspected fracture and also apply pressure to help control internal bleeding.

  15. HEMORRHAGE CONTROL Elevate the Limb • Apply and Secure the Field Dressing • Obtain a Field Dressing • Remove the Field Dressing From the Wrappers • Apply the Dressing to the Wound • Secure the Dressing • Check the Circulation • Elevate Limb (IF NEEDED) • Check for a Fracture • Re-evaluate the Bleeding

  16. APPLY A PRESSURE DRESSING Prepare the Bandage - The wad is secured by a bandage, usually a cravat made from a muslin bandage or similar material. Other materials such as a handkerchief, sock, or strip of cloth torn from a shirt can also be used. Wire and narrow material (such as a shoestring) should not used since they are likely to damage blood vessels and nerve tissue. Cravats can be made from a muslin bandage or from a square of material about three feet on each side in the following manner. • Secure the Dressing • (A)Place one hand on top of the dressing to hold the dressing in place and to apply pressure to the bleeding blood vessels. If the casualty is conscious, you can have him apply pressure to the dressing while you secure it. • (B)Wrap one of the bandages around the injured limb with your free hand. • (C)As you wrap, cover one of the exposed sides of the dressing with the bandage. (The bandage can usually be wrapped around a limb more than once.) Bring the tail back over the dressing. • (D)Wrap the other bandage around the injured body part in the opposite direction • (E)As you wrap, cover the remaining exposed side of the dressing with the bandage. Bring the tail back to the dressing. • Prepare the Wad - Make a "wad" by folding material such as a muslin bandage (cravat) from your aid bag, a rag, material torn from clothing, or similar material. Fold the material several times. • (A)Fold the square of material along the diagonal and cut the material in half • (B). You now have two triangular bandages. One triangular bandage is used for the pressure dressing. The remaining triangular bandage can be used to make the tourniquet band, if needed, or used as a sling, swathe, or additional securing bandage. • Fold the top (apex) of the triangular bandage so it touches the base (cut diagonal) of the triangular bandage (C). This is a one-fold cravat. • (D and E).Fold the material two more times • (F).Tie the tails in a non-slip knot at the edge of the dressing

  17. Apply a Tourniquet

  18. APPLYING AN IMPROVISED TOURNIQUET • Select the Tourniquet • Apply Padding • Apply the Tourniquet Band • Apply the Rigid Object • (A). Tie the band with a half knot This is the same as the first part of tying a shoe. • (B).Place the rigid object on top of the half-knot • (C).Tie a full knot over the rigid object • Tighten the Tourniquet - (D) Twist the rigid object either clockwise or counterclockwise until the tourniquet is tight enough to stop arterial blood flow beneath the band. Secure the Rigid Object Tourniquet Band Tails (E)Wrap one tail of the tourniquet band over and around one end of the rigid object. (F).Bring the tails together and tie them in a nonslip knot under the injured limb Check Effectiveness of Tourniquet

  19. Apply the Dressing to the Stump • Lay the end of the bandage on the limb below the tourniquet and at an angle so one corner (apex) of the bandage is pointing upward. Wrap the bandage completely around the limb; then wrap the bandage around a second time. • Turn down the apex (A) so it lies on top of the second layer of the bandage and wrap the bandage around the limb a third time. The bandage is now anchored. Bring the bandage down diagonally across the front of the limb (A), over the dressing on the stump to the back of the limb. Hold the bandage in back so it will not slip. • (B). Bring the bandage from the back of the limb, over the dressing again, and to the front. Move diagonally up across the front of the limb, forming an "X" pattern with the downward diagonal • Bring the bandage around the limb and to the front. • (C). Form the first recurrent (running back to the source). Put your thumb on the top of the bandage to keep it in place, make a fold, bring the bandage down, over the far side of the dressing, and up the back • (D).Hold the dressing in place on the back of the limb with your index finger. • Form the second recurrent. Make a fold at the back and bring the bandage down, over the opposite side of the dressing, and up the frontContinue the wrapping procedure. Overlap each layer about one half the width of the previous layer. Continue to hold each succeeding layer securely in place with your thumb and index finger. When the dressing and stump end have been completely covered, reverse the direction of the bandage and make two circular turns to cover the gathered ends you have held with your thumb and index finger. This locks the recurrents in place. Move diagonally down and across the stump from the locking turn, encasing the edges of the recurrents. Then move back diagonally to form another "X" pattern. Overlap the "X" pattern with another circular turn. • (E). Secure the end of the bandage The bandage can be tied, taped, clipped, or pinned.

  20. TREATING INTERNAL BLEEDING IN AN EXTREMITY • Pressure - Apply pressure to the injured limb. • Immobilization • Check circulation in the limb • Apply a Spiral Wrap to the Extremity • (A).Lay the end of the bandage on the bottom of the limb to be wrapped and at an angle so one corner (apex) of the bandage will not be covered when the bandage is brought around the limb • (B).Wrap the bandage completely around the limb twice and past the apex • (C) Fold the apex over the bandage so that it lies on top of the bandage. • Continue wrapping the bandage around the limb a third time, covering the apex with the turn. The bandage is now anchored. • (D). Wrap the limb in a spiral manner On each turn, overlap about one-third of the previous turn. Keep the bandage tight enough to apply pressure to the limb, but not tight enough to impair blood circulation. • Continue wrapping until the entire portion of the limb has been wrapped. • (E).Secure the wrap with two circular turns at the top of the limb portion being bandaged. Then tape, clip, or tie the end of the bandage in a position that is easy to reach Check circulation below the bandage. If blood circulation was not impaired before the bandage was applied but is now impaired, loosen the bandage and apply the bandage again.

  21. BURN MANAGEMENT Degrees (Depth) of Burn. 1st Degree • First-degree burns - First-degree burns cause the skin to be red and painful (like a sunburn), but does not produce blisters. It involves only the superficial skin (epidermis). 3rd Degree Third-degree burns - Third-degree burns involve damage to or destruction of all three layers of skin. It usually involves damage to the fascia and may also include damage to underlying muscles, nerves, blood vessels, and/or bone. The skin may look leathery, dry, and discolored (charred, brown, or white). Clotted blood vessels may be visible under the burned area and subcutaneous fat may be visible. Third degree burns may not be painful because the nerves have been destroyed, but the surrounding area with second and first-degree burns may be painful. Third-degree burns involve a large loss of body fluid that can lead to shock. Inhaling heated air can damage the respiratory system. Check for respiratory distress and maintain an open airway, if needed. Continue to monitor the casualty's respirations closely since 30 to 40 minutes may elapse before edema obstructs the airway and causes respiratory distress. INHALATION BURNS 2nd Degree • Second-degree burns - Second-degree burns are more serious. The burn is painful and blisters are present. There is damage to the epidermis and the dermis. There may also be some swelling in the subcutaneous layer even though the layer is not actually damaged. INHALATION BURNS

  22. Chemicals in the Eye - Chemicals such as acid, alkali, and petroleum can destroy the tissues of the eye. Chemicals can cause pain, redness, watering or tearing, and erosion of the surface of the cornea of the eye. Some chemicals may stick to the eye. If chemicals are in the casualty's eye, the eye must be flushed with potable (drinkable) water as quickly as possible. If possible, use sterile water or sterile saline (sterile saline is preferable since it will cause less pain to the patient) to flush the eye. Fluid from an IV bag (with tubing connected), water from the casualty's canteen, or water from a shower can be used. Do not try to neutralize the chemical in the eye. ELECTRICAL BURNS • ELECTRICAL BURNS - Electrical burns are caused by an electrical current passing through the body. They can be caused by coming into contact with a charged ("live") electrical wire, lightning, or other source of electrical energy. Chemicals in the eye • CHEMICAL BURNS - Chemical burns are caused by contact with either liquid or dry chemicals. Most burns are caused by a reaction between the chemical and the casualty's body. Examples of such chemicals include ammonia, caustic soda, quick-lime and white phosphorus (WP). White phosphorus is a chemical used in marking rounds and grenades that begins to give off heat and light when exposed to air. LIQUID CHEMICAL BURN DRY CHEMICAL Dry Chemicals - If the chemical is in a dry form (such as lime), use a clean, dry cloth to brush off loose particles of the dry chemical. Take care to avoid getting the particles on your body. After brushing off the particles, flush the area with as much water or other nonflammable liquid as possible. Liquid Chemicals - If the burn is caused by a liquid chemical, pour as much water as possible over the burned area. (This is called "flushing" the area.) Use cool water from a canteen, Lyster bag, or water trailer if it is available. If a sufficient amount of water is not available, use any nonflammable fluid to flush the area.

  23. BODY SECTION SURFACE AREA(ADULT) Head and neck9 percent Anterior trunk (chest and abdomen)18 percent Posterior trunk (back and buttocks)18 percent Upper extremities18 percent (each arm--9 percent) Lower extremities36 percent (each leg--18 percent) Genitalia and perineum1 percent TOTAL100 percent BODY SECTION SURFACE AREA (CHILD) Head and neck 18 percent Anterior trunk (chest and abdomen)18 percent Posterior trunk (back and buttocks)18 percent Upper extremities18 percent (each arm--9 percent) Lower extremities27 percent (each leg--13.5 percent) Genitalia and perineum1 percent TOTAL100 percent

  24. Treatment for Burns • Expose the Burned Area CAUTION: Do not cool the burned area with water on any burn greater than 10 percent body surface area. Over cooling of any burn can cause the patient to become rapidly hypothermic. CAUTION: Do not immerse a third degree burn. Estimating the Body Surface Area Burned • Initiate an Intravenous Infusion (IF NEEDED) • Apply Cold Soaks (IF APPROPRIATE) • Dress the Burn Wound Apply dry, sterile dressings over the burned areas. If the burned area is too large to cover with regular dressings, cover the burned area with a sterile sheet, clean linen, or the cleanest material available. • Monitor and Evaluate the Casualty Treatment for Chemical Burns Remove Chemicals from the Skin • Flush the area for at least 20 minutes. Flush longer if the chemical is an alkali, such as caustic soda. Alkalies penetrate deeper and cause more severe injuries. • Do not delay flushing in order to remove the casualty's clothing. • Remove his clothing and jewelry while flushing the area. • Do not use a hard blast of water to flush the burned area. High water pressure can increase the damage to the tissues. • Some chemicals have a delayed reaction. Flush even though the casualty does not feel pain. Do not stop flushing just because the casualty's pain goes away. Treatment for Chemicals in Eyes • Have the casualty lie down with his face up. • Turn the casualty's head slightly to one side. • Gently hold the eyelids of the casualty's lower eye open and begin flushing the eye. Pour from the inner canthus to the outer canthus. Turning the head and pouring from the inner to outer canthus help to keep contaminated water from entering the other eye. • Turn the casualty's head slightly to the other side. • Gently hold the eyelids of the casualty's lower eye (eye not just flushed) open and begin flushing that eye, pouring from the inner edge of the eye to the outer edge. • Continue to alternate flushing one eye, then the other. Continue to flush both eyes for at least 5 minutes (20 minutes if the chemical is an alkali).

  25. SHOCK • Hypovolemic Shock - Hypovolemic shock results when there is a decrease in the volume of circulating fluids in the body. Hypovolemic shock is usually caused by severe bleeding (hemorrhaging) or severe loss of body fluids (dehydration) due to heat injury, severe burns (second- and third-degree burns on 20 percent or more of the body surface area), vomiting, diarrhea, or excessive sweating. • Metabolic shock - Metabolic shock is caused by a severe fluid loss due to an illness. • Neurogenic shock -Neurogenic shock is caused by dilation of the blood vessels due to loss of nervous control over the vascular system. There is not enough blood and plasma in the circulatory system to fill the vessels even though no circulatory fluids have been lost. • Psychogenic shock - Psychogenic shock (fainting) is caused by a temporary dilation of the blood vessels which results in a decreased blood supply to the brain. • Cardiogenic shock -Cardiogenic shock is caused by a failure of the heart to pump sufficient blood. • Septic shock - Septic shock is caused by a severe infection that attacks the blood vessels and causes them to loose circulating fluid. • Respiratory shock - Respiratory shock is due to an insufficient amount of oxygen in the blood. • Anaphylactic shock - Anaphylactic shock is caused by an allergic reaction to an insect sting, food, drugs, or other substance. In anaphylactic shock, the casualty's skin may be flush, warm, itch, or break out. The face and tongue may swell and the lips turn bluish (cyanosis). The casualty may have difficulty in breathing, cough, or have pain in the chest. The blood pressure drops and pulse becomes weak, which results in faintness or coma.

  26. Treatment for Shock Reassure Casualty Maintain the Airway Control Bleeding Initiate IV Position the Casualty to Help Control Shock Loosen the Casualty's Clothing • Maintain Casualty's Body Temperature Monitor the Casualty Anaphylactic Shock Anaphylaxis is an unusual allergic reaction. It is caused by a hypersensitivity to a specific substance introduced into the body for the second or a subsequent time. When the reaction is severe, it is called anaphylactic shock. The shorter the time before symptoms appear, the greater the risk of a fatal reaction. Anaphylactic shock is always considered a serious medical emergency. Treatment - The drug of choice for emergency treatment is aqueous epinephrine, administered by injection. Epinephrine is the pharmacologic antagonist of the action of chemical mediators (such as histamines) on smooth muscle and other effector cells

  27. MUSCULOSKELETAL INJURIES Closed Fracture – (A) A closed fracture is a fracture in which the skin is not broken. A closed fracture may result in significant loss of blood due to internal bleeding (bleeding into surrounding body tissues or into a body cavity). This blood loss may result in shock. Open Fracture. (B) An open fracture is one in which the skin is broken (penetrated). The source of the penetration may have been the end of a fractured bone or (C). a foreign object, such as a bullet, which penetrated the skin and fractured the bone If an open wound is caused by a fractured bone, the bone may remain visible or it may slip back below the skin and muscle tissues

  28. Types of Fractures A fracture may be displaced (bone moved out of normal alignment) or nondisplaced (bone remains in normal alignment). A nondisplacedfracture may be difficult to identify without an x-ray • Greenstick. A greenstick fracture is an incomplete fracture in which one side of the bone is broken and the bone is bent. • Comminuted - A comminuted fracture is one in which the bone is crushed or splintered into many pieces. • Transverse - A transverse fracture is a straight crosswise fracture (break is at a right angle to the axis of the bone). • Oblique - An oblique fracture is a diagonal or slanted fracture (not at a right angle to the axis of the bone). • Spiral - A spiral fracture coils around the bone and is caused by twisting. • Impacted - An impacted fracture results when one bone is driven into another bone, resulting in one or both bones being fractured and the bones being wedged together. • Pathologic - A pathologic fracture results when a bone that has been weakened by disease breaks under a force that would not fracture a normal bone. • Epiphyseal - An epiphyseal fracture is a fracture located between the expanded end of a long bone (epiphysis) and the shaft of the bone.

  29. Signs and Symptoms of Fractures – • A fracture may be found during the primary or secondary survey of the casualty. Life-threatening injuries (lack of breathing, massive bleeding, and shock) should be treated before fractures since they immediately threaten a casualty's life. A serious fracture, however, can also be life threatening. A fracture can be identified by the following signs and symptoms. NOTE: A sign is something that can be observed by someone other than the casualty. Bleeding, bruises, and pulse rates are examples of signs. A symptom is something which the casualty senses, but which cannot be observed directly by another person. Pain is an example of a symptom. • Visible Fracture - In an open fracture, the fractured bone or bone fragments may be visible. • Deformity - The body part may appear deformed due to the displacement of the bone, the unnatural position of the casualty, or angulations where there is no joint (for example, the casualty's forearm is "bent" instead of straight). • Pain - The casualty will probably experience pain at a particular location. The pain (point tenderness) usually identifies the location of the fracture. The casualty may be able to "feel" the fractured bones. • Swelling - There may be swelling (edema) at the suspected fracture site. • Discoloration - The area around the suspected fracture site may be bruised or have hemorrhagic spots (ecchymosis). • Crepitation - The fracture bones may make a crackling sound (crepitation) if they rub together when the casualty moves. CAUTION: Do not ask the casualty to move the injured body part in order to test for crepitation. • Loss of Motion - The casualty may not be able to move the injured limb. If a spinal injury is present, paralysis may exist, especially paralysis of the legs. • Loss of Pulse - If the fractured bone is interfering with blood circulation, there may be no pulse distal to (below) the site of the fracture. • False Motion - There may be motion at a point where there is normally no motion. This movement at the fracture site is called false motion.

  30. Treating Fractures – • Fractures may be discovered either during the primary or secondary survey of the casualty. Take measures to maintain or restore breathing and heartbeat, control major bleeding, and control shock before treating a fracture. The general procedures for treating a fracture of an extremity (arm or leg) are given below. • Expose the Limb - If you suspect the casualty has a fractured limb, gently remove the casualty's clothing from the injured limb and check for signs of a fracture. Loosen any clothing that is tight or binds the casualty. DO NOT remove the casualty's boots. • Locate Site of Fracture - The site of the fracture is normally found by identifying the site of the deformity, false motion, bruise, wound, and/or point tenderness. To determine point tenderness in a conscious casualty, gently palpate the area with your fingers to determine the location of maximum discomfort. • Remove Jewelry (IF NEEDED) - If the casualty has a suspected fracture of the arm, remove any jewelry on the injured arm and put the jewelry in the casualty's pocket. If the limb swells, the jewelry may interfere with blood circulation. The jewelry may then have to be cut off to restore adequate blood circulation. • Assess Distal Neurovascular Function - Check for impairment of the nerves and/or circulatory system below the site of the suspected fracture. Some of the methods used to identify impairment are given below. • Check pulse - Palpate a pulse site below the fracture site. If no pulse or a weak pulse is found, the fracture may be putting pressure on the artery or may have damaged the artery. A weak pulse can be determined by comparing the pulse felt below the fracture with the pulse felt at the same location on the uninjured limb. A casualty with no pulse below the fracture site should be evacuated as soon as the limb is splinted. • Check capillary refill - If the fractured limb is an arm, press on the casualty's fingernail, then release. If normal color does not return within two seconds, the limb may have impaired circulation. This is also called the blanch test. • Check skin temperature - Touch the casualty's skin below the fracture. Coolness may indicate decreased or inadequate circulation. Compare the temperature of the injured limb to the temperature of the same area on the uninjured limb. • Check sensation - Ask a conscious casualty if he can feel your touch. Then lightly touch an area below the fracture. For example, if his arm is fractured, touch the tip of the index and little fingers on the injured arm. Ask the casualty if the injured limb feels numb or has a tingling sensation. • Check motor function - Ask a conscious casualty to try opening and closing the hand of an injured arm or moving the foot of an injured leg. If the attempt produces pain, have the casualty stop his efforts. • Dress Wounds - If the fracture is open, apply a field dressing or improvised dressing the wound before splinting the limb. Do not attempt to push exposed bone back beneath the skin. If the bone slips back spontaneously, make a notation of the fact on the casualty's Field Medical Card (FMC). The card is initiated after treatment is completed and accompanies the casualty to the medical treatment facility. • Immobilize Fracture - Immobilize the fracture to relieve pain and to prevent additional damage to tissues at the fracture site due to movement of the fractured bone(s). If an extremity is fractured, apply a splint using the following general rules.

  31. DISLOCATIONS, SPRAINS, AND STRAINS • Dislocations - A dislocation results when the end of a bone is moved from its normal articular position. The ligaments that hold the ends of the bones together may be torn. Other tissues surrounding the joint (the joint capsule) may also be injured. Joints frequently affected include the shoulder, elbow, fingers, hips, and ankles. • Signs and Symptoms - A dislocation results in a deformed appearance due to the bone being out of its normal position. A dislocation also causes pain and/or a feeling of pressure over the joint. The region around the joint usually swells and is tender. The casualty may not be able to move the joint (the joint is "locked"). If the end of the dislocated bone is pressing on a nerve or blood vessel, the casualty may experience numbness or paralysis distal to (below) the injury. • Treatment - Treat a dislocation as though it were a closed fracture. • Immobilize the joint in the position in which the joint was found. Do not attempt to straighten or realign the bones. • Reduce the swelling by elevating the joint and applying cold (a cold pack or ice compress, if available) to the joint for the first 24 hours after the musculoskeletal injury. After 24 hours, heat or warm soaks should be used to facilitate circulatory perfusion to the injured area. • Check for pulse, strength, and sensation distal to the injury. If there is no pulse distal to the injury, attempt to restore blood circulation by gentle manipulation. If there is still no pulse, evacuate the casualty to a medical treatment facility as quickly as possible. • Sprains - A sprain results when the ligaments connecting two bones are stretched or torn. The other tissues that surround the joint may also be damaged. A sprain usually results when a joint is suddenly twisted beyond its normal range of motion. Skiing accidents often result in sprains. Sprains are most common in the knees and ankles. A sprain can result from a partial or temporary dislocation in which the bones resume their normal position following the injury. A sprain may produce as much damage as a dislocation. • Signs and Symptoms - A sprain does not cause a deformed appearance since the bones are not out of their normal positions. A sprain causes pain (tenderness), swelling, and discoloration (bruise) at the injured joint. The casualty may be unable to move the joint due to pain. • Treatment - Treat the sprain as though it were a closed fracture. • Immobilize the joint. • Reduce swelling by elevating the joint and applying cold, if available. • Strains - A strain is a stretching or tearing of the muscle tissues around a joint. It is usually caused by excessive effort such as overstretching or overexertion. It is commonly called a "muscle pull." • Signs and Symptoms - A strain does not result in a deformed appearance. Swelling may or may not be present. Muscle spasms may be present. A strain can cause pain when the joint is moved. • Treatment - Have the casualty avoid putting weight on the injured joint. If you are unsure whether the injury is a strain or sprain, treat it as a sprain.

  32. UPPER EXTREMITY FRACTURES • Forearm (SAM SPLINT) • Unroll the SAM splint and flatten it. • Fold the SAM splint in half so it is a tall "V" shape. • Bend the edges of the splint in until the shape of the splint generally conforms to the curve and shape of the limb being splinted (A). Each half of the splint will have a "U" shape. • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the forearm is splinted. • Apply the SAM splint to the forearm. The elbow should rest in the bottom of the "V" and the sides of the "V" are on the inside and outside of the forearm. • Adjust the shape of the SAM splint to conform to the limb, if needed. • Apply at least one cravat above the fracture site and at least one cravat below the fracture site. If possible, apply two cravats above the fracture site and two cravats below the fracture site. Do not apply a cravat over the fracture site. • Tie the tails of the cravats in a non-slip knot on the outside of the splint. Tuck the ends of the tails into the cravat to prevent accidental entanglement when the casualty is moved. • Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again. If this does not restore circulation, evacuate the casualty as soon as possible. • If cravats are not available, use tape or a roller bandage to secure the SAM splint. • Position the casualty's forearm so it is across his chest with the wrist slightly higher than the elbow. • Apply a sling and a swathe to further immobilize the casualty's arm. Make the swathe wide across the injured arm. • Secure the splint using at least two cravats (B).

  33. Humerus (SAM SPLINT) • Unroll the SAM splint and flatten it. • Fold the SAM splint into an irregular (uneven) "V" shape with one side of the V about four to six inches longer than the other. • Bend the edges of the splint so the sides of the splint are U-shaped and generally conform to the shape of the limb being splinted. • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the upper arm is splinted. • Position the casualty's forearm so it is across his chest with the wrist slightly higher than the elbow. • Apply the SAM splint to the upper arm. The upper part of the forearm (where it joins the elbow) should rest in the bottom of the "V," the short side of the "V" is on the inside of the upper arm (but not pressing on the arm pit), and the long side is on the outside of the upper arm with the end extending to or past the shoulder. • Adjust the shape of the SAM splint to conform to the limb, if needed. • Secure the splint using at least two cravats. Apply at least one cravat above the fracture site and at least one cravat below the fracture site. If possible, apply two cravats above the fracture site and two cravats below the fracture site. Do not apply a cravat over the fracture site. • Tie the tails of the cravats in a non-slip knot on the outside of the splint. Tuck the ends of the tails into the cravat to prevent accidental entanglement when the casualty is moved. • Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again. If this does not restore circulation, evacuate the casualty as soon as possible. • If cravats are not available, use tape or a roller bandage to secure the SAM splint. • Apply a sling and a swathe to further immobilize the casualty's arm. If possible, apply two swathes--one above the fracture site and one below the fracture

  34. Humerus (IMPROVISED SPLINT) Wire ladder splints, SAM splints, and pneumatic splints are used to immobilize a fracture of the upper extremity. If these splints are not available, a splint can be made from improvised rigid objects and securing materials. Basswood boards, tree limbs, broken poles, boards, or rolled newspaper can be used as rigid objects. If a rigid object cannot be readily found, the casualty's chest can be used as the rigid object. Cravats, slings, and swathes are normally made from triangular bandages. If muslin bandages or other materials are not available to make triangular bandages, strips of torn cloth, belts, or similar objects can be used. Wire, shoestrings, and other very narrow materials should not be used. General procedures for applying an improvised splint to a fractured humerus are given in the following paragraphs. • Gather two rigid objects, securing materials, and padding. • Pad the rigid objects. • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the splint is applied. • Place the rigid objects on each side of the upper arm. Make sure the inside rigid object is not pressing on the axilla (armpit). • Secure the rigid objects with cravats or other securing material. • Apply at least one cravat above the fracture site and at least one cravat below the fracture site. If possible, apply two cravats above the fracture site and two cravats below the fracture site. Do not apply a cravat over the fracture site. • Tie the tails of the cravats in a non-slip knot on the outer rigid object and tuck in the tails. • Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again. If this does not restore circulation, evacuate the casualty as soon as possible. • Apply a sling and a swathe to further immobilize the casualty's arm. If possible, apply two swathes--one above the fracture site and one below the fracture site.

  35. Elbow (IMPROVISED SPLINT) • Immobilize the upper arm and forearm in the position you find them. If the elbow is bent, leave it bent. If the elbow is not bent (arm straight), do not try to bend it in order to apply a sling to the arm. • Elbow in Bent Position • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the splint is applied. • Apply a rigid object (padded, if possible) to the inside of the casualty's limb so it can immobilize the elbow. • Secure the rigid object with at least two cravats (A). • Apply at least one cravat above the fracture site (secure the upper arm to the rigid object) and at least one cravat below the fracture site (secure the forearm to the rigid object). Do not apply a cravat over the elbow. • Tie the tails of the cravats in a non-slip knot on the rigid object and tuck in the tails. • Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again. If this does not restore circulation, evacuate the casualty as soon as possible. • Apply a sling and swathe to help support the arm, but do not place the elbow and rigid object inside the sling.

  36. Elbow Not Bent • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the splint is applied. • Apply two rigid objects (padded, if possible) to the casualty's limb. The rigid objects should be long enough to immobilize the elbow and the wrist. The bottom rigid object should extend beyond the fingers of the injured hand. Make sure the inner splint does not press on the axilla. • Place a rolled cravat or similar material in the palm of the casualty's injured hand. • Secure the rigid object with at least four cravats (B). • Apply at least two cravats above the fracture site and two cravats below the fracture site. Do not apply a cravat over the elbow. • Tie the tails of the cravats in a non-slip knot on the outer rigid object and tuck in the tails. • Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again. If this does not restore circulation, evacuate the casualty as soon as possible. • Apply two swathes, one above the elbow and one • below the elbow.

  37. Forearm (IMPROVISED SPLINT) A fractured forearm can be splinted using one or two rigid objects. • Gather one or two rigid objects, securing materials, and padding. The rigid object(s) should extend from the elbow to beyond the fingers. • Pad the rigid object(s). • Check the casualty's pulse below the fracture site. If no pulse is found, evacuate the casualty as soon as possible after the splint is applied. • Place the padded rigid object under the casualty's injured forearm so the splint extends from the elbow past the fingers. If two rigid objects are used, place the second padded rigid object on top of the forearm. • Place a rolled cravat or similar material in the palm of the casualty's cupped hand and turn the hand so it will be in a natural position (palm toward casualty's body). • Secure the rigid object(s) with at least three cravats or other securing material. • Apply the first cravat between the fracture site and the elbow. • Apply the second cravat between the fracture site and the wrist. • Apply the third cravat in an "X" fashion over the hand. Leave the fingernails exposed so a blanch test (pressing on nails, then releasing to see how fast color returns to the nail beds) can be performed. • Tie the tails of the cravats in a non-slip • knot on the outer part of the rigid • object and tuck in the tails. • Check the casualty's pulse after each cravat is • applied. If the pulse can no longer be • detected, loosen the cravat and apply it again. • If this does not restore circulation, evacuate • the casualty as soon as possible. • Apply a sling and a swathe to further • immobilize the injured arm.

  38. Dislocated Shoulder A dislocation of the shoulder occurs when the head of the humerus is pushed out of its socket at the shoulder. The dislocation can be either anterior (the head pushed forward) or posterior (the head pushed backward). Most dislocations will be anterior dislocations. Shoulder dislocations are painful and the casualty (if conscious) will usually attempt to hold the arm on the injured arm to prevent movement. The shoulder will not have its normal rounded appearance. Immobilize the injured shoulder and upper arm without attempting to reduce the injury (replace the humerus in its socket). • Anterior Dislocation - If the head of the humerus is displaced toward the casualty's front, the arm will be a fixed position away from the casualty's chest. Do not try to reposition the arm as any attempt to move the arm toward the chest will produce additional pain. Immobilize the arm in the extended position. • Check the casualty's pulse below the dislocation. If no pulse is found, evacuate the casualty as soon as possible after the arm is immobilized. • Apply padding (a rolled blanket, pillow, or other material) between the upper and the chest to fill the space between them. • Flex the elbow so the casualty's wrist is slightly higher than the elbow. • Apply a sling (arm sling number two) to support the forearm. • Apply a swathe to further immobilize the arm and to secure the padding materials. • Evacuate the casualty in either a sitting position or laying on a litter. • Posterior Dislocation - If the head of the humerus is displaced toward the casualty's back: • Check the casualty's pulse below the dislocation. If no pulse is found, evacuate the casualty as soon as possible after the arm is immobilized. • Position the casualty's forearm across his midsection with his wrist slightly higher than his elbow. • Apply a sling to immobilize the arm. Use the arm sling number two method to protect the shoulder from additional pressure. • Apply a swathe to further immobilize the arm. • Evacuate the casualty, either in sitting position or lying on a litter. • Apply a Sling A sling is used to support and immobilize the forearm. It also serves to immobilize the elbow and upper arm. A sling is normally made from a triangular bandage (A). A swathe is normally applied to further immobilize the casualty's injured arm.

  39. Apply a Sling (Arm Sling Number One) to an Arm. • (A). A swathe is normally applied to further immobilize the casualty's injured arm This arm sling is used when the shoulder of the injured arm is not injured. • (B). Insert the triangular bandage between the injured arm and the casualty's chest so the arm is in the center, the apex of the sling is beyond the elbow, and the top corner of the material is over the shoulder of the injured side • Position the forearm so the hand is slightly higher than the elbow (about a 10 degree angle). • Fold the material along the base (the long side opposite the apex) back to the casualty's fingers, forming a cuff. • (C). Bring the lower portion of the material over the injured arm so the bottom corner goes over the shoulder of the uninjured side The elbow should be inside the sling. • Bring the top corner behind the casualty's neck. • (D). Tie the two corners together in a non-slip knot at the "hollow" at the neck on the uninjured side If the casualty's right arm is fractured, for example, tie the knot so it will rest in the hollow on the left side of his neck. • Secure the apex of the sling to keep the • elbow and forearm from slipping out of the • sling. • Safety pin method. Fold the apex forward • over the elbow and sling. Pin the apex to • the sling. • (E). Pig tailing (twisting) method. Twist the • apex of the sling and tuck it in at the elbow

  40. Apply a Sling (Arm Sling Number Two) to an Arm. • This arm sling is used when the shoulder of the injured arm is also injured (dislocated or fractured). NOTE: The sling goes under, not over, the injured shoulder. • (A).Insert the triangular bandage between the injured arm and the casualty's chest so the arm is in the center, the apex of the sling is beyond the elbow, and the top corner of the material is over the shoulder of the uninjured side • Position the forearm so the hand is slightly higher than the elbow (about a 10-degree angle). • Fold the material along the base (the long side opposite the apex) back to the casualty's fingers, forming a cuff. • (B). Bring the lower portion of the material over the injured forearm and under the armpit of the injured arm The elbow should be inside the sling. • Bring the top corner behind the casualty's neck. • (C).Tie the two corners together in a non-slip knot on the casualty's back between his shoulder blades • Twist the apex of the sling and tuck it in at the elbow. The corner can also be secured using a safety pin or similar device.

  41. LOWER EXTREMITY FRACTURES • SIGNS AND SYMPTOMS OF A FRACTURED OR DISLOCATED HIP The femur and the hip join together to form a "ball and socket" type joint. When the head of the femur is pulled away from the hip, a dislocation exists. When the neck or upper end of the femur is fractured, it is commonly called a "fractured hip" even though none of the pelvic bones is actually fractured. A dislocated hip and a fractured hip (upper femur) are very similar. Some of the signs and symptoms associated with these injuries are given below. • Pain - Both injuries are accompanied by considerable pain. The casualty will resist moving because of the pain. • Severe Deformity - A hip injury results in severe deformity of the affected leg and hip. There are two general categories of hip dislocations--anterior and posterior. • Impaired Sensation - The affected extremity may have tingling or other abnormal sensations (paresthesia) or the casualty may have a loss of sensation in the limb. • Impaired Circulation - Impaired circulation may result in coolness and/or cyanosis (bluish tint) of the affected limb. In some cases, the pulse distal to the injury may be lost due to pressure against the artery. • Blood Loss - Hip injuries usually result in significant blood loss, especially if a fracture is present. If there is no open wound, the internal bleeding will result in swelling. Significant internal bleeding may occur before the swelling is evident. The blood loss can result in hypovolemic shock.

  42. Anterior dislocations occur when a hip is flexed with the leg abducted and externally rotated. This force drives the femoral head out of the acetabulum, tearing ligaments, and often fracturing the femoral head and/or acetabulum. • Posterior dislocations comprise 70 to 80 percent of all hip dislocations. A large force is required to strike the flexed knee with the hip flexed, adducted, and internally rotated in order to cause a posterior dislocation.

  43. Immobilize a Fractured Hip (SPINE BOARD) A casualty with signs and symptoms of a fractured or dislocated hip should be immobilized using a long spine board. If a long spine board is not available, use a door, wide plank, or other firm surface to immobilize the injured extremity and pelvis. Use the log roll technique to place the casualty on the spine board. Some special considerations for performing the log roll and immobilizing the casualty when he has a hip injury are given below. • If the casualty is lying on his abdomen, turn him onto his back using the procedures given in paragraph 2-11. Position the assistants next to the casualty's uninjured side and have them secure holds on the injured side. In this way, the casualty will be rolled on his uninjured side, not his injured side. • When preparing to place the long spine board beneath the casualty, have the assistants kneel next to the casualty's uninjured side and have the spine board positioned on the casualty's injured side. Roll the casualty on his uninjured side, not on his injured side, and slip the board beneath the casualty. Position the casualty on the board. • Apply additional padding to the casualty to immobilize the hip and leg in a comfortable position. Secure padding materials in place. • If the hip is dislocated, apply pillows, blankets, or other material to support the leg in its abnormal position. • If the hip is fractured, place bulky support materials between the casualty's legs and strap the legs together. Position the casualty's knees in an up (flexed) position and place bulky support material beneath the knees. If there is no other major fracture of the lower extremities, support material may be placed beneath the buttocks to reduce abdominal pain. • Continue to check the pulse in the affected limb and observe for signs and symptoms of hypovolemic shock.

  44. Immobilize a Fractured Femur(IMPROVISED SPLINT) A fractured femur should be immobilized using a traction splint whenever possible. If a traction splint is not available, immobilize the casualty using an improvised splint. • Obtain Materials. You will need two rigid objects, padding, and securing materials. • Rigid objects - Tree branches, poles, boards, sticks, unloaded rifle, or similar objects can be used. The rigid objects should be straight, long enough to extend beyond the joint above the fracture site and beyond the joint below the fracture site. Preferably, one should be long enough to extend from the groin to the foot and the other should extend from above the hip to the foot. • Padding- Padding is needed to keep the rigid objects from rubbing against the skin on the injured limb. Blankets, jackets, ponchos, extra clothing, shelter halves, leafy plants, or the casualty's own clothing (trouser leg) can be used as padding. The padding helps to prevent excessive pressure that could interfere with blood circulation. • Securing materials - The rigid objects and padding can be secured with cravats made from muslin bandages or other folded material. Rigid objects can also be secured with strips of clothing, belts, pistol belts, bandoleers, or similar materials. Narrow materials such as wire and cord should not be used since they could interfere with blood circulation. • Position the Rigid Objects - Place the shorter rigid object on the inside of the injured leg and the longer one on the outside. Position them so the joint above the fracture and the joint below the fracture can be immobilized. Make sure the end of the inner rigid object is not pressing against the groin. Pressure on sensitive areas can interfere with blood circulation. • Apply Padding - Place padding between the rigid objects and the limb. Apply extra padding to bony body areas such as the knee and ankle and at sensitive areas such as the groin. • Secure the Rigid Objects and Check Circulation - Wrap the securing materials around the rigid objects so they immobilize the limb. Tie the tails of each securing cravat in a non-slip knot on the outer rigid object and away from the casualty. The securing material should be tight enough to hold the rigid objects securely in place, but not tight enough to interfere with blood circulation. (You should be able to slip one finger between the knot and the rigid object.) Check the casualty's pulse after each cravat is tied. If the cravat interferes with the casualty's circulation, loosen the cravat and apply it again.

  45. Immobilize a Fractured Femur (IMPROVISED SPLINT)

  46. Immobilize a Fractured Leg(IMPROVISED SPLINT) A fractured tibia or fibula in the lower leg can be immobilized with an improvised splint. The improvised splint used to immobilize a fractured thigh can also be used to immobilize a fractured leg. The following procedures are used to apply shorter boards to immobilize a fractured leg. The same basic procedures can also be used with other improvised splints. Figure (B) shows a tree limb splint used to immobilize a fractured leg or ankle. Figure (C) shows a blanket and poles splint used to immobilize a fractured knee (knee straight), leg, or ankle. Figure (D) shows the casualty's uninjured leg being used as the rigid object (anatomical splint) to immobilize the injured leg. A splint used for a fracture can also be used for a dislocation. • Obtain Materials - You will need two rigid objects, padding, and securing materials. The rigid objects should extend from the casualty's foot to approximately half way up his thigh. • Position the Securing Materials - Position two cravats above the fracture site, and two below the fracture site. Push the securing materials under natural body curvatures and move them up or down until they are in proper position. Do not place a cravat directly under the fracture site. • Position one cravat above the knee. • Position the second cravat between the knee and the fracture site. • Position the third cravat between the fracture site and the ankle. • Position the fourth cravat beneath the ankle. • Position the Rigid Objects - Place one rigid object on the inside of the injured leg and the other on the outside. Position them so the joint above the fracture and the joint below the fracture can be immobilized. • Apply Padding - Place padding between the rigid objects and the limb. Apply extra padding to the knee and ankle areas. • Secure the Rigid Objects and Check Circulation - Wrap the securing materials around the rigid objects so they immobilize the limb. Tie the tails of each securing cravat in a non-slip knot on the outer rigid object and away from the casualty. The securing material should be tight enough to hold the rigid objects securely in place, but not tight enough to interfere with blood circulation. (You should be able to slip one finger beneath the knot.) Check the casualty's pulse after each cravat is tied. If the cravat interferes with the casualty's circulation, loosen the cravat and apply it again.

  47. Immobilize a Fractured or Dislocated Ankle (SAM SPLINT) The universal splint, called the SAM splint, can be used as the rigid object in splinting a fractured or dislocated ankle. The SAM splint is a piece of flat aluminum about 36 inches long and about 4.5 inches wide completely covered by foam that serves as padding for the splint. The SAM splint is lightweight (less than 7 ounces). The splint is rolled up for easy storing (A) and can be reused. • Unroll the SAM splint and flatten it. • Fold the SAM splint in half so it is a tall "V" shape. • Bend the edges of the splint in until the splint generally conforms to the curve and shape of the foot and leg being splinted. Each half of the splint will have a "U" shape (B). Bending the edges also increases the rigidity of the SAM splint. • Flatten the vertex of the splint so the bottom of the casualty's foot will fit comfortably. • Check the casualty's pulse below the fracture/dislocation site. • Apply the splint around the casualty's foot and leg. Adjust the shape of the SAM splint to conform to the limb, if needed. • Secure the splint using at least three cravats (C). • Tie the tails of the cravats in a non-slip knot on the outside of the splint. Tuck the ends of the tails into the cravat to prevent accidental entanglement when the casualty is moved. Check the casualty's pulse after each cravat is applied. If the pulse can no longer be detected, loosen the cravat and apply it again.

  48. Apply an Anchor Wrap The following steps are used to apply an anchor wrap to a limb. The anchor wrap is usually used to anchor (secure) the roller bandage when beginning other wrappings. • Lay the end of the bandage on the bottom of the limb to be wrapped and at an angle so one corner (apex) of the bandage will not be covered when the bandage is brought around the limb (A). • Wrap the bandage completely around the limb twice and past the raised corner (B). • Fold the corner over the second turn of the bandage (C). • Continue wrapping the bandage around the limb a third time, bringing the bandage over and covering the turned-down corner. The bandage is now anchored.

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