Operational Medicine 2001
United States Naval Hospital Corpsman 3 & 2 Training Manual
NAVEDTRA 10669-C June 1989

Hospital Corpsman 3 & 2: June 1989

Chapter 4: First Aid and Emergency Procedures

General Considerations

For a Navy Corpsman, first aid and emergency procedures are the professional care of the sick and injured before definitive medical attention can be obtained. Appropriate care may range from an encouraging word to a dramatic struggle to draw a person back from the brink of death. At all times, however, it must be remembered that first aid measures are temporary expedients whose purpose is to save life, to prevent further injury, and to preserve resistance and vitality. These measures are not meant to replace proper medical diagnosis and treatment procedures. A corpsman who understands this point, who knows the limits of the professional care a corpsman can offer, and who is motivated to keep abreast of new first aid equipment and procedures will be able to provide the competent care that will make the differences between life or death, temporary or permanent injury, and rapid recovery or long-term disability.

General First Aid Rules

There are a few general first aid rules that you should follow in any emergency:

1. Take a moment to get organized. On your way to an accident scene, use a few seconds to remember the basic rules of first aid. Remain calm as you take charge of the situation, and act quickly but efficiently. Decide as soon as possible what has to be done and which one of the patient's injuries needs attention first.

2. Unless contraindicated, make your preliminary examination in the position and place you find the victim. Moving the victim before this check could gravely endanger life, especially if the back or ribs are broken. Of course, if the situation is such that you or the victim is in danger, you must weigh this threat against the potential damage caused by premature transportation. If you decide to move the victim, do it quickly and gently to a safe location where proper first aid can be administered.

3. In a multivictim situation, limit your preliminary survey to observing for airway patency, breathing, and circulation-the immediate life-threatening conditions. Remember, irreversible brain damage can occur within 4 to 6 minutes if breathing has stopped. Bleeding from a severed artery can lethally drain the body in even less time. If both are present and you are alone, quickly handle the major hemorrhage first, and then work to get oxygen back into the system. Shock may allow the rescuer a few minutes of grace but is no less deadly in the long run.

4. Examine the victim for fractures, especially in the skull, neck, spine, and rib areas. If any are present, prematurely moving the patient can easily lead to increased lung damage, permanent injury, or death. Fractures of the innominate bone or extremities, though not as immediately life-threatening, may pierce vital tissue or blood vessels if mishandled.

5. Remove enough clothing to get a clear idea of the extent of the injury. Rip along the seams, if possible, or cut. Removal of clothing in the normal way may aggravate hidden injuries. Respect the victim's modesty as you proceed, and do not allow the victim to become chilled.

6. Keep the victim reassured and comfortable. If possible, do not allow the victim to see the wounds. The victim can endure pain and discomfort better if confident in your abilities. This is important because under normal conditions the corpsman will not have strong pain relief medications right at hand.

7. Avoid touching open wounds or burns with your fingers or unsterile objects, unless clean compresses and bandages are not available and it is imperative to stop severe bleeding.

8. Unless contraindicated, position the unconscious or semiconscious victim on his or her side or back, with the head turned to the side to minimize choking or the aspirating of vomitus. Never give an unonscious person any substance by mouth.

9. Always carry a litter patient feet first so that the rear bearer can constantly observe the victim for respiratory or circulatory distress.

Assessing the Patient's Conditions

The following procedures for assessing a patient's condition under various circumstances are based upon Department of Transportation recommendations. These are general guidelines that can be modified to suit the situation.

Determining the Problem

If the patient can communicate, determine if the problem is medical or trauma related.

If medical, follow the sequence below.

1. Evaluate diagnostic and vital signs.

2. Develop the patient's history.

3. Examine for the medical problems.

4. Examine for a trauma-related problem.

If trauma-related, follow the sequence below.

1. Evaluate diagnostic and vital signs.

2. Examine the injury.

3. Develop the patient's history.

4. Examine for a medical related problem.

If the patient cannot communicate, follow the sequence below.

1. Evaluate diagnostic and vital signs.

2. Develop the patient's history, then determine if the problem is medical or trauma related.

3. If medical, examine first for the medical problem then for a trauma related problem.

4. If trauma related, examine first for the trauma related problem then for a medical problem.

Evaluating the Diagnostic and Vital Signs

Sequence of taking vital signs

• If the patient with a traumatic injury is communicative, assess the injury site after taking vital signs.

• If the patient with a medical problem is communicative, take vital signs after the preliminary assessment and in conjunction with the medical history, if possible.

• If the patient is noncommunicative, take vital signs immediately after the primary assessment.

Essential diagnostic and vital signs

Mental status

1. Consciousness-avoid descriptive words like "stupor" or "semi-conscious"; be specific.

2. Reaction to stimulus-describe

3. Orientation

4. Responsiveness

Respirations

1. Tracheal deviation

2. Rate-tachypnea

3. Depth

   1. Hyperpnea

   2. Hypopnea

4. Dyspnea

5. Breathing sounds

6. Flaring of anterior nares on inspiration

7. Retraction of suprasternal notch on inspiration

8. Retraction of intercostal spaces

Pulse

1. Rate

2. Rhythm

3. Strength

Blood pressure

Examining for Trauma-Related Problems

Assess each of the following

Head

1. Inspect for

   1. Obvious hemorrhage

   2. Ecchymosis, erythema, or contusions

   3. Scalp lesions

2. Gently palpate for

   1. Lumps

   2. Depressions

   3. Pain on compression of skull (Do not compress if patient is noncommunicative!)

Eyes

1. Inspect for

   1. Laceration to lid or globe

   2. Foreign matter in eye

   3. Unequal pupils (anisocoria)

   4. Eye movements

   5. Pupillary reaction

2. Palpate for

   1. Swelling in orbital or periorbital area

   2. Failure to sense touch in supra-orbital and infraorbital areas if patient is communicative

Ear-inspect for

1. Discharge from external auditory canal

2. Ecchymosis over mastoid (Battle's sign)

3. Lacerations

4. Bleeding

Nose-inspect for

1. Rhinorrhea

2. Patent nostrils

3. Bleeding

4. Flaring of anterior nares on inspiration

Mouth

1. Inspect for

   1. Potential airway obstruction

   2. Edema or hemotoma

   3. Bleeding

   4. Teeth or dentures lodged in pharynx

   5. Misalignment of teeth

   6. Pain when biting teeth together

2. Palpate for fractures

   1. Zygomatic bones

   2. Mandible

   3. Maxilla

Neck

1. Inspect for

   1. Retraction at suprasternal notch on inspiration

   2. Deviation of trachea from midline

2. Auscultate for air sounds in trachea

Skin-inspect for

1. Jaundice

2. Cyanosis

3. Diaphoresis

4. Temperature

5. Moistness

6. Pallor

Thorax Inspect for

1. Respiration

   1. Rate-tachypnea

   2. Depth

      1. Hyperpnea

      2. Hypopnea

   3. Retraction of intercostal spaces

2. Chest elevation symmetry-flail chest

3. Lacerations, puncture, or ecchymosis

Palpate (unless there is a suspected spinal injury)

1. Vertebrae and ribs for symmetry and tenderness

2. Anterior to posterior compression of thorax

3. Lateral-to-lateral compression of thorax

4. Compression of clavicle

5. Cranial to chordal compression

6. Pressure of costochondral junction

7. Compression on costovertebral angles

Auscultate for lung and heart sounds

1. Lung sounds

   1. Absent or unequal breath

   2. Characteristics

      1. Rales

      2. Rhonchi

      3. Wheezes

      4. Stridor

2. Heart sounds

Percussion

1. Fluid in thorax

2. Pneumothorax or collapsed lung

Abdomen

1. Inspect for

   1. Lacerations, ecchymosis, burns, etc.

   2. Hematoma

   3. Flexion of hips to relieve pain

2. Auscultate bowel sounds  

3. Palpate firmly for

   1. Distended abdomen

   2. Guarding

   3. Local tenderness

   4. Rebound pain

Extremities

1. Inspect for

   1. Abnormal angulation or bone ends protruding

   2. Presence of extremity pulse

      1. Dorsalis pedis

      2. Radial

   3. Nail bed color (cyanosis)

   4. Impaired sensation

   5. Inability to move joint

   6. Lacerations or ecchymosis

   7. Needle marks or bites

1. Palpate for abnormal reaction

Central nervous system

1. Inspect for

   1. Mental state

      1. Consciousness

      2. Orientation

      3. Response to verbal stimulus and pain

   2. Gross deformities

   3. Lacerations

   4. Decerebrate posturing

   5. Decorticate posturing

2. Palpate for

   1. Tenderness

   2. Deformities

Examining for Medical Problems

Assess each of the following areas

1. Neck

   1. Inspect for jugular vein distention

   2. Auscultate trachea for adequate airflow

2. Thorax and lungs

   1. Inspect for evidence of pain while breathing or moving

   2. Auscultation

      1. Rales

      2. Rhonchi

      3. Wheezes

      4. Stridor

   3. Palpate to determine symmetry of breathing

   4. Percuss for

      1. Hemothorax

      2. Pneumothorax

3. Thorax and heart-auscultate for abnormal heart sounds

4. Abdomen

   1. Inspect for

      1. Flexion of hips to relieve pain

      2. Normal contour during breathing

      3. Distention

   2. Auscultate for bowel sounds

   3. Palpate for

      1. Distention

      2. Guarding

      3. Local tenderness

      4. Rebound pain

5. CNS

   1. Inspect for

      1. Mental state

      2. Pupil reaction

      3. Eye movements

      4. Muscle tone

      5. Paralysis

   2. Palpate for

      1. Loss of feeling

      2. Absent reflexes

      3. Muscle tone

      4. Paralysis

Developing the Medical History

The patient's history is an important information source that will directly influence both the treatment offered by the corpsman at the accident scene and the care given in the hospital. The history is acquired at the accident scene and the care given in the hospital. The history is acquired by observing for clues and careful questioning of the patient, family, and bystanders. A history is divided into three parts: the history of the immediate situation, the patient's medical history, and the family medical history. (The family history is usually not relevant in the field with a trauma patient.)

A history of the present illness is a directed history, striking a balance between allowing the patient to ramble and leading the patient. The purpose is to discover why you were called. In general, the following information must be gathered:

• Gross problem identification

  1. Chief complaint

  2. How does the patient feel?

• Location of the problem

  1. Pain

  2. Other symptoms (e.g., dizziness or shortness of breath)

• Quality of symptom(s)

  1. How does it feel?

  2. What does it resemble?

• Quantity of symptom(s)

  1. Pain intensity

  2. Effect on normal functioning

• Chronology of symptom(s)

  1. Time of onset

  2. Duration

  3. Frequency

• Cause of trauma

  1. What happened?

  2. Any contributing physical cause?

  3. How did injury take place (e.g., patient's head hit corner of table during fall)?

• Scenario of first medical symptoms

  1. Where did first symptoms occur?

  2. What was the patient doing?

• Aggravating and alleviating movements

• Associated complaints

  1. Other symptoms

  2. Affected normal body functions

The following are components of a complete history of a patient's medical problems:

• General health before the current problem

• Name of family physician or location of health records

• Current medications and treatments

• Recent injuries

• Allergies

• Family medical history

  1. General health of family members

  2. Recent family illnesses

First Aid Equipment and Supplies

In a first aid situation, the corpsman must always be ready to improvise. In the majority of emergency situations, standard medical supplies and equipment will not be immediately available or they may run out. Later sections of this chapter will discuss how material can be used as substitutes.

When medical supplies and equipment are available, they will probably be found in an ambulance or in the field medical Unit One bag.

Navy ambulances are stocked in accordance with NAVMEDCOMINST 6700.9. Table 4-1 lists equipment currently required. Table 4-2 lists the contents of an emergency bag that a corpsman might find in an ambulance. Table 4-3 lists the contents of the Unit One bag.

Unique operational requirements or command decisions may modify the make-up of any of the lists. It is up to the corpsman to be familiar with the emergency medical equipment at the command, since the call may come at a moment's notice to use any of these items to help save or sustain a life.

A final general first aid consideration is triage. Triage is a French word meaning "picking, sorting, or choice" and is used to mean the evaluation and classification of casualties for the purpose of establishing priorities for treatment and evacuation. In the military, there are two basic types of triage: combat and noncombat. In each case, sorting decisions may vary, depending upon the situation. The person in charge is responsible for the balancing of human lives against the realities of the tactical situation, the level of medical stock on hand, and the realistic capabilities of personnel. Triage is an ongoing process and decisions are made at every stage in the movement of the casualty.

The following discussion refers primarily to the battalion aid station (BAS), where helicopter or rapid land evacuation is not readily available, or to the shipboard battle-dressing station. Immediately upon arrival, sort the casualties into groups in the order listed below:

Class I. Those whose injuries require minor professional treatment that can be done on an outpatient or ambulatory basis. These personnel can be returned to duty in a short period of time.

Class II. Those whose injuries require immediate lifesustaining measures or are of a moderate nature. Initially, they require a minimum amount of time, personnel, and supplies.

Class III. Those for whom definitive treatment can be delayed without jeopardy to life or loss of limb.

Class IV. The hopelessly wounded who would require extensive treatment beyond the immediate medical capabilities. Treatment of these casualties would be to the detriment of others.

In a civilian or non-tactical situation, sorting of casualties is somewhat, but not significantly, different from a combat situation. There are three basic classes of injuries and the order of treatment is different.

Priority I. These casualties require immediate life sustaining action.

Priority II. These casualties generally have injuries where treatment can be delayed for a short time.

Priority III. These casualties generally have minor injuries or they have obviously mortal wounds where survival is not expected.

As mentioned before, triage is an ongoing process; depending on the treatment rendered, the mount of time elapsed, and the constitution of the casualty, you may have to reassign priorities. What appears to be a minor wound on initial evaluation may develop into a profound shock, or a casualty that requires immediate treatment may be stabilized and down-graded to a delayed status.

During the Vietnam war, the techniques of helicopter medical evacuation (MEDEVAC) were so improved that most casualties could be evacuated to a major medical facility within minutes of their injury. This considerably lightened the load of the hospital corpsman in the field, since provision for long-term care before the evacuation was not normally required. However, rapid aeromedical response did not relieve the corpsman of the responsibility for giving the best emergency care within the field limitations in order to stabilize the victim before the helicopter arrived. Triage was seldom a problem since most of the injured could be evacuated quickly.

New developments in warfare, along with changes in the probable theaters of deployment, indicate that the helicopter evacuation system may no longer be viable in a front-line environment. If this becomes the case, longer ground chains of evacuation to the BAS or division clearing station may be required. This will increase the need for the life stabilizing activities before each step in the chain and in transit. Evacuation triage will normally be for personnel in the Class II and Class III treatment categories, based on the tactical situation and the nature of the injuries. Class IV casualties may have to receive their treatment at the BAS level and Class I personnel would be treated on the line.

Remember, triage is based on the concept of saving the maximum number of personnel possible. In some cases, a casualty has the potential to survive, but the treatment necessary requires a great deal of time and supplies. As difficult as it may be, you may have to forsake this patient in order to save others that have a greater potential for survival.

Basic life support is the emergency techniques for recognizing and treating failures of the respiratory system and heart function. The primary emphasis is placed on maintaining an open AIRWAY to counter upper airway obstruction; restoring BREATHING to counter respiratory arrest; and restoring CIRCULATION to counter cardiac arrest. These are the ABC's of basic life support.

The assurance of breathing takes precedence over all other emergency care measures. The reason for this is simple: If a person cannot breathe, he or she cannot survive.

Many factors can cause the patient's airway to become fully or partially obstructed. In the adult, a very common cause of obstruction is improperly chewed food that becomes lodged in the airway; the so-called "cafe coronary." Children have a disturbing tendency to swallow foreign objects during play. Another cause occurs during unconsciousness, when the tongue may fall back and block the pharynx (fig. 4-1). Normally, the heart will continue to beat until oxygen deficiency becomes acute. Periodic checks of the carotid artery must be made to ensure that circulation is being maintained.

Partial Airway Obstruction

The signs of partial airway obstruction include unusual breath sounds, skin discoloration (cyanosis), or changes in breathing pattern. The conscious patient will usually make clutching motions toward the neck, even when the obstruction does not prevent speech. For the conscious patient with an apparent partial obstruction, encourage him or her to cough. NOTE: In cases where the patient has an apparent partial obstruction but cannot cough, begin to treat the patient as if this were a complete obstruction. This also applies to patients who are cyanotic.

Complete Airway Obstruction

The conscious patient will attempt to speak but will be unable to do so, nor will he or she be able to cough. Usually, the patient will display the universal distress signal for choking by clutching at the neck. The unconscious patient with a complete airway obstruction exhibits none of the usual signs of breathing: rise and fall of the chest and air exchange through the nose and/or mouth. A complete blockage is also indicated if a perfectly executed attempt to perform artificial ventilation fails to instill air into the lungs.

Opening the Airway

Many problems of airway obstruction, particularly those caused by the tongue, can be corrected simply by repositioning the head and neck. If repositioning does not alleviate the problem, more aggressive measures must be taken. NOTE: Before going further, it is imperative that corpsmen remember to check all victims for possible spinal injuries before any repositioning is attempted. If there is no time to immobilize these injuries and the airway cannot be opened with the victim in the present position, then great care must be taken when repositioning. The head, neck, and back must be moved as a single unit. To do this, adhere to the following steps (see figure 4-2).

• 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.  

• Move the victim's closest arm along the floor until it reaches straight out past the head.  

• Support the back of the victim's head with one hand while you reach over with the other hand to grab the far shoulder.  

• Pull the far shoulder toward you while at the same time keeping the head and neck in a natural straight line with the back. The head resting on the extended arm will help you in this critical task.

Head Tilt

The head tilt technique of opening the airway is a simple repositioning of the head. With the patient lying down, place one of your hands on his or her forehead and apply gentle, firm, backward pressure using the palm of your hand. With your other hand under the victim's neck, lift the neck (fig. 4-3). This will lift the patient's tongue away from the back of the throat and provide an adequate airway. NOTE: This technique is not recommended for patients with suspected neck or spinal injuries.

Jaw thrust

A second technique for opening the airway is the jaw thrust. This technique is accomplished by kneeling by the top of the victim's head and placing your fingers behind the angles of the lower jaw (fig. 4-4A), or hooking your fingers under the jaw (fig. 4-4B), then bringing the jaw forward. Separate the lips with your thumbs to allow breathing through the mouth as well as the nose. This technique is to be used if a neck injury is suspected.

Either the head tilt or the jaw thrust will offer some relief for most forms of airway obstruction. They also prepare the airway for artificial ventilation. If the airway is still seriously obstructed, it may be necessary to try to remove the obstruction by using the abdominal thrust or chest thrust methods indicated for opening a completely blocked airway.

Abdominal Thrusts

The abdominal thrust makes use of the air reserve in the lungs. It is also highly effective in removing water from the lungs of near drowning victims.

Abdominal Thrust Standing Technique - Stand behind the victim and wrap your arms around the victim's waist, as illustrated in figure 4-5. Make a fist with one hand and place it thumbside against the abdomen along the midline and slightly above the navel. Grasp the fist with the other hand (see figure 4-6). Give four quick upward thrusts to the victim. The obstruction should pop out like a champagne cork.

Abdominal Thrust Reclining Technique - Position yourself for the thrust by straddling the victim at the hips. Place the heels of your hands one on top of the other, along the midline, slightly above the navel, and give four quick upward thrusts into the abdomen, as illustrated in figure 4-7. Note that the victim must be lying face up.

If unsuccessful, repeat the four abdominal thrusts until the obstruction is dislodged.

Chest Thrusts

For obese or pregnant victims, the chest thrust methods are recommended for removing airway obstructions since manual pressure in the abdomen area of these people would either be ineffective or cause internal damage.

Chest Thrust Standing Technique - Bring your arms under the arms of the victim, and encircle the lower chest, as shown in figure 4-8. Grasp your wrists, keeping the thumbside close to the victim's chest. Keep your fist on the middle of the sternum, not the lower part. Press the chest with sharp, backward thrusts.

Chest Thrust Reclining Technique - Kneel at either side, and place your hands on the chest in exactly the same manner as for external chest compression (fig. 4-9). Give four quick downward thrusts with the arms.

If unsuccessful, repeat the four chest thrusts until the obstruction is dislodged.

Breathing

The second aspect of basic life support is to restore breathing in cases of respiratory arrest. Failure of the breathing mechanism may be caused by various factors. They include complete airway obstruction, insufficient oxygen in the air, the inability of the blood to carry oxygen (carbon monoxide poisoning), paralysis of the breathing center of the brain, and external compression of the body. Breathing failure is usually, but not always, immediately accompanied by cardiac arrest. Periodic checks of the carotid pulse must be made, and you must be prepared to start cardiopulmonary resuscitation (CPR).

The signs of respiratory arrest are an absence of respiratory effort, a lack of detectable air movement through the nose or mouth, unconsciousness, and a cyanotic discoloration of the lips and nail beds.

Artificial Ventilation

The purpose of artificial ventilation is to provide a method of air exchange until natural breathing is re-established. Artificial ventilation should be given only when natural breathing has been suspended; it must not be given to a person who is breathing naturally. Do not assume that a person's breathing has stopped merely because the person is unconscious or has been rescued from water, from poisonous gas, or from contact with an electric wire. Remember: DO NOT GIVE ARTIFICIAL VENTILATION TO A PERSON WHO IS BREATHING NATURALLY. If the victim does not begin spontaneous breathing after using the head tilt or jaw thrust techniques to open the airway, attempt to use artificial ventilation immediately. If ventilation is inadequate, use the thrust techniques to clear the airway, followed by another attempt at artificial ventilation.

Mouth-to-Mouth

To perform mouth-to-mouth ventilation, place one hand under the victim's neck and place the heel of the other hand on the forehead, using the thumb and index finger to pinch the nostrils shut. Tilt the head back to open the airway. If there is no spontaneous breathing, start artificial ventilation with two ventilations, allowing the lungs to deflate. If the victim still does not respond, then you must fully inflate the lungs at the rate of 12 VENTILATIONS PER MINUTE OR ONE BREATH EVERY 5 SECONDS. See figure 4-10 for the proper position. Periodically, check the pupils for reaction to light; constriction is a sign of adequate oxygenation. For infants, seal both the mouth and nose with your mouth. Blow puffs from your cheeks to prevent lung damage. Mouth-to-mouth ventilation can be administered with the jaw thrust.

Mouth-to-Nose

Mouth-to-nose ventilation is effective when the victim has extensive facial or dental injuries; this permits an effective air seal.

To administer this method, place the heel of one hand on the victim's forehead and use the other hand to lift the jaw. After sealing the victim's lips, start artificial ventilation with two breaths, allowing the lungs to deflate. If the victim does not respond, then you must fully inflate the lungs at the rate of 12 ventilations per minute or one breath every 5 seconds until the victim can breathe spontaneously.

The back-pressure arm-lift method is a less effective technique used when other methods are not feasible, such as on a battlefield where gas masks must be worn. Place the victim in the prone position, face to one side, and neck hyperextended with the hands under the head. Quickly clear the mouth of any foreign matter. Kneel at the victim's head and place your hands on the back so that the heels of your hands lie just below a line between the armpits, with thumbs touching and fingers extending downward and outward (fig. 4-11). Rock forward, keeping your arms straight and exert pressure almost directly downward on the victim's back, forcing air out of the lungs. Then rock backward, releasing the pressure and grasping the arm just above the elbows. Continue to rock backward, pulling the arms upward and inward (toward the head) until resistance and tension in the shoulders are noted. This expands the chest, causing active intake of air (inspiration). Rock forward and release the victim's arms. This causes passive exiting of air (expiration). Repeat the cycle of press, release, lift, and release 12 times a minute until the victim can breathe spontaneously.

Mask-to-Mask

Certain types of gas masks for use in a contaminated environment, such as on a battlefield after a chemical or biological warfare attack, are equipped to allow a corpsman to give a victim artificial ventilation without either the corpsman or the patient being exposed to the unhealthy atmosphere. This is carried out by a coupling on the face of each mask. When they are joined, an airway is formed, allowing ventilation to proceed.

Gastric Distention

Sometimes during artificial ventilation, air is forced into the stomach instead of into the lungs. The stomach becomes distended (bulges), indicating that the airway is blocked or partially blocked, or that ventilations are too forceful. This problem is more commonly seen in children but can occur with any patient. A slight bulge is of little worry, but a major distention can cause two serious problems. First is a reduced lung volume; the distended stomach forces the diaphragm up. Second, there is a strong possibility of vomiting.

The best way to avoid gastric distention is to properly position the head and neck and/or limit the volume of ventilations delivered.

NOTE: THE AMERICAN HEART ASSOCIATION (AHA) STATES THAT NO ATTEMPT SHOULD BE MADE TO FORCE AIR FROM THE STOMACH UNLESS SUCTION EQUIPMENT IS ON HAND FOR IMMEDIATE USE.

If suction equipment is ready and the patient has a marked distention, you can turn the patient on his or her side facing away from you. With the flat of your hand, apply gentle pressure between the navel and the rib cage. Be prepared to use suction should vomiting occur.

Supportive Equipment

As a corpsman, you should become familiar with various pieces of supportive equipment that may be available to help you to maintain an open airway and to restore breathing in emergency situation. They include artificial airways, the bag-valve-mask system, the mouth-to-mask system with the oxygen-inlet valve, and suction.

Use of Oxygen (O₂)

In an emergency first aid situation, the corpsman will probably have a size E, 650-liter cylinder available. This is fitted with a yoke-style pressure reducing regulator, with gauges to show tank pressure and flow rate (adjustable from 0 to 15 liters per minute). A humidifier can be attached to the flowmeter nipple to help prevent tissue drying caused by the water vapor free oxygen. An oxygen line can be connected from the flowmeter nipple or humidifier to a number of oxygen delivery devices that will be discussed later.

When available, oxygen should be administered, as described below, to cardiac arrest patients and to self-ventilating patients who are unable to inhale enough oxygen to prevent hypoxia (oxygen deficiency). Hypoxia is characterized by tachycardia, nervousness, irritability, and finally cyanosis. It develops in a wide range of situations from poisoning to shock, crushing chest injuries, cerebrospinal accidents, and heart attack.

Oxygen must never by used near open flames since it supports burning. The cylinders must be handled carefully since they are potentially lethal missiles if punctured or broken.

Artificial Airways

The oropharyngeal and nasopharyngeal airways are primarily used to keep the tongue from occluding the airway.

Oropharyngeal Airway - This airway can be used only on unconscious victims because a conscious person will gag on it. They come in various sizes for different age groups (it is important to choose the correct size for the victim), and they are shaped to rest on the contour of the tongue and extend from the lips to the pharynx.

One method of insertion is to depress the tongue with a tongue blade and slide the airway in. Another method is to insert the airway upside down into the victim's mouth; then rotate it 180 degrees as it slides into the pharynx (fig. 4-12).

Nasopharyngeal Airway - This airway may be used on conscious victims since it is better tolerated because it generally does not stimulate the gag reflex. Since they are made of flexible material, they are designed to be lubricated and then gently passed up the nostril and down into the pharynx. If the airway meets an obstruction in one nostril, withdraw it and try to pass it up the other nostril.

Bag-Valve-Mask System

The bag-valve-mask system (fig. 4-13) is designed to help ventilate an unconscious victim for long periods, while delivering high concentrations of oxygen. This system can be useful in extended CPR attempts because when using external cardiac compressions, the cardiac output is cut to 25 to 30 percent of the normal capacity and artificial ventilation does not supply enough oxygen through the circulatory system to maintain life for a long period.

Various types of bag-valve-mask systems that come in both adult and pediatric sizes are in use in the Navy. Essentially, they consist of a self-filling ventilation bag, an oxygen reservoir, plastic face masks of various sizes, and tubing for connection to an oxygen supply.

The bag-valve-mask system is difficult to use if the corpsman has not had a great deal of practice with it. It must not be used by inexperienced persons. The system can be hard to clean and reassemble properly, the bagging hand can tire easily, and an airtight seal at the face is hard to maintain, especially if a single rescuer must also keep the airway open. In addition, the amount of air delivered to the victim is limited to the volume that the hand can displace from the bag (approximately 1 liter per compression).

Technique - Hook the bag up to an oxygen supply and adjust the flow from 10 to 15 liters per minute depending on the desired concentration (15 liters per minute will deliver an oxygen concentration of 90 percent). After hyperextending the neck to open airway or inserting an oropharyngeal airway, place the mask over the face and hold it firmly in position with the index finger and thumb, while the remaining fingers keep the jaw tilted upward (fig. 4-14). The other hand is used to compress the bag once every 5 seconds. Observe the chest and abdomen for expansion. If none is observed, the face mask seal may not be airtight, the airway may be blocked, or some component of the bag-valve-mask system may be malfunctioning.

Mouth-to-Mask System

A pocket mask designed for mouth-to-mask ventilation, with an oxygen-inlet flow valve, can be used to give oxygen enriched artificial ventilation. Although this system cannot achieve oxygen concentrations as high as the bag-valve-mask system, it has the advantages of providing greater air volume (up to 4 liters per breath), and being far easier to use since both hands can be used to maintain the airway and keep the mask firmly in place (fig. 4-15).

Technique - Standing behind the head of the victim, open the airway by tilting the head backward. Place the mask over the victim's face (for adults, the apex goes over the bridge of the nose; for infants, the apex fits over the chin, with the base resting on the bridge of the nose). Form an airtight seal for the mask and keep the airway open by pressing down on the mask with both thumbs while using the other fingers to lift the jaw up and back. The corpsman then ventilates into the open chimney of the mask.

Oxygen can be added by hooking the valve up to an oxygen supply. Since the oxygen flow will be diluted by the rescuer's breath in artificial ventilation, the flow rate will have to be adjusted to increase oxygen concentration. At 5 liters per minute, the oxygen concentration will be approximately 50 percent. At 15 liters per minute, this will increase to 55 percent.

The mask has an elastic strap so it can be used on conscious self-ventilating patients to increase oxygen concentration.

Esophageal Obturator Airway (EOA)

An EOA is a semi-flexible large-bore tube approximately 30 cm in length, with 19 holes in the shaft and an inflatable cuff. A soft face mask is attached to one end and the other end is closed. The airway was designed for personnel who are not authorized to place endotracheal tubes. One of the distinct advantages is that it can be inserted blindly through the mouth without having to visualize the larynx. It is also helpful in the prevention of gastric regurgitation. The disadvantages are that the tracheo-bronchial tree cannot be adequately suctioned and there is the possibility of esophageal rupture when the cuff is inflated too fully.

The following steps are to be followed when inserting the EOA:

1. Hyperventilate the patient.

2. Position the head in a neutral position or slightly flexed. DO NOT hyperextend the neck.

3. Lift the jaw as in figure 4-16A.

4. Insert the tube until the mask is flush with the face as in figure 4-16B.

5. Ventilate through the tube and auscultate both lung fields. The EOA is sometimes inserted into the trachea; this is of little worry if recognized and corrected immediately.

6. Inflate the cuff (about 35cc of air). Overinflation can possibly rupture the esophagus or may compress the trachea causing an obstruction.

7. Ventilate and auscultate again to ensure proper placement.

Cricothyroidotomy

A cricothyroidotomy, often known as an emergency tracheotomy, consists of incising the cricothyroid membrane, which lies just beneath the skin between the thyroid cartilage and the cricoid cartilage. The cricothyroid membrane can be located easily in most cases. Hyperextend the neck so that the thyroid notch (Adam's apple) becomes prominent anteriorly. Identify the position of the thyroid notch with the index finger. This finger descends in the midline to the prominence of the cricoid cartilage. The depression of the cricothyroid membrane is identified above the superior margin of the cricoid cartilage (fig. 4-17). A small lateral incision is made at the base of the thyroid cartilage to expose the cricothyroid membrane. This membrane is then excised, taking care not to go too deeply, and a small bore airline is then inserted into the trachea.

An alternate method is to use a 12 to 16 gauge intercatheter. Locate the cricothyroid membrane as above and insert the needle into the trachea. Immediately upon penetrating the cricothyroid membrane, thread the plastic catheter into the trachea and remove the needle. The catheter can then be connected to an oxygen line for translaryngeal oxygen jet insufflation.

A cricothyroidotomy should not be attempted except as a last resort when other methods of opening the airway are unsuccessful.

Suctioning Devices

In a first aid setting, the hospital corpsman may have access to portable or fixed suctioning devices equipped with flexible tubing, semirigid tips, suction catheters, and nonbreakable collection bottles. The suction pressure should be tested regularly and the equipment kept clean.

Technique - After testing the apparatus, attach a catheter or tip, and open the victim's mouth. Carefully insert the end into the pharynx. Apply suction, but for no more than 15 seconds. Suction may be repeated after a few breaths.

Circulation

Cardiac arrest is the complete stoppage of heart function. If the victim is to live, action must be taken immediately to restore heart function. The symptoms include absence of carotid pulse, lack of heartbeat, dilated pupils, and absence of breathing.

A rescuer knowing how to administer cardiopulmonary resuscitation (CPR) greatly increases the chances of a victim's survival. CPR consists of external heart compression and artificial ventilation. This compression is performed on the outside of the chest, and the lungs are ventilated by the mouthto-mouth or mouth-to-nose techniques. To be effective, CPR must be started within 4 minutes of the onset of cardiac arrest. The victim should be supine on a firm surface.

CPR should not be attempted by a rescuer who has not been properly trained. If improperly done, CPR can cause serious damage. It must never be practiced on a healthy individual for training purposes; use a training aid instead. To learn this technique, see your medical education department or an American Heart Association or American Red Cross certified corpsman, nurse, or physician.

One Rescuer Technique

The rescuer must not assume that an arrest has occurred solely because the victim is lying on the floor and appears to be unconscious. First, try to arouse the victim by gently shaking the shoulders and trying to obtain a response; (loudly ask: "Are you O.K.?"). If there is no response, place the victim supine on a firm surface. Kneel at a right angle to the victim, and open the airway using the head tilt or jaw thrust methods described previously. Attempt to ventilate. If unsuccessful, resposition the head and again attempt to ventilate. If still unsuccessful, deliver four abdominal or chest thrusts to open the airway. Repeat the thrust sequence until the obstruction is removed.

Once the airway has been opened, check for the carotid pulse. The carotid artery is most easily found by locating the larynx at the front of the neck and then sliding two fingers down the side of the neck toward you. The carotid pulse is felt in the groove between the larynx and the sternocleidomastoid muscle. If the pulse is present, ventilate as necessary. If the pulse is absent, locate the sternum and begin closed cardiac massage.

To locate the sternum, use the middle and index fingers of your lower hand to locate the lower margin of the victim's rib cage on the side closest to you (fig. 4-18A). The fingers are then moved up along the edge of the rib cage to the notch where the ribs meet the sternum in the center of the lower chest (fig. 4-18B). The middle finger is placed on the notch and the index finger is placed next to it. The heel of the other hand is placed along the midline of the sternum next to the index finger (fig. 4-18C). Remember to keep the heel of your hand off the xiphoid tip of the sternum. A fracture in this area can damage the liver, causing hemorrhage and death.

Place the heel of one hand directly on the sternum and the heel of the other on top of the first (fig. 4-18D). Interlock your fingers or extend them straight out and KEEP THEM OFF THE VICTIM'S CHEST!

Lean or rock forward with the elbows locked and apply vertical pressure to depress the sternum (adult) 1 1/2 to 2 inches. Then release the pressure, keeping the hands in place on the chest.

You will feel less fatigue if you use the proper technique and a more effective compression will result. Ineffective compression occurs when the elbows are not locked, the rescuer is not directly over the sternum, or the hands are improperly placed on the sternum.

When one rescuer performs CPR, as shown in figure 4-19, the ratio of compressions to ventilation is 15 to 2, and it is performed at a rate of 80 compressions per minute to maintain 60 full compression each minute. Vocalize: "one and, two and, three and, . . ." until you reach 15. After 15 compressions, you must give the victim 2 ventilation. Continue for four full cycles. Quickly check for the carotid pulse and spontaneous breathing. If there are still no signs of recovery, continue CPR. If a periodic check reveals a return of pulse and respiration, discontinue CPR, but closely monitor the victim and be prepared to start CPR again if required.

Before learning the next technique, review the steps to take for a cardiac arrest involving one rescuer.

1. Determine whether the victim is conscious.  

2. Check vital signs.  

3. Ventilate two times (it may be necessary to remove an airway obstruction at this time).  

4. Again check vital signs; if there are none, begin the compression-ventilation rate of 15 to 2 for four complete cycles.  

5. Check pulse, breathing, and pupils; if there is no change, continue the compression-ventilation rate of 15 to 2 until the victim is responsive, you are properly relieved, or you can no longer continue.

Two Rescuer Technique

If there are two people trained in CPR on the scene, one must perform compression while the other performs ventilation (fig. 4-20). The ratio for the two person CPR is 5 compressions to 1 ventilation, at a rate of 80 compressions per minute. One rescuer is positioned at the chest area and the other beside the victim's head. The rescuers should be on opposite sides of the victim to ease position changes when one rescuer gets tired. Changes should be made on cue without interrupting the rhythm.

To help avoid confusion, one rescuer must be designated the leader. The leader must make the preliminary checks of the victim's vital signs and perform the initial 2 ventilations. The second rescuer will get ready for compression and perform the compressions.

When CPR is started, give the compression in a constant, methodical rhythm. The rescuer giving the compressions counts them out loud (one one thousand, two one thousand, three one thousand, four one thousand, five one thousand). As the fifth compression is released, the other rescuer ventilates the victim. Allow a short pause to ventilate the victim.

CPR for Children and Infants

Closed chest cardiac massage for children is similar to that for adults. The primary difference is that the heel of only one hand is used to depress the middle of the sternum from 3/4 to 1 1/2 inches. The other hand can be used to maintain a head tilt that helps ventilation. For infants, only two fingers are used to depress the middle of the sternum from 1/2 to 3/4 of an inch. For both infants and children, the compression rate increases from 80 to 100 compressions per minute.

The head-tilt or jaw thrust methods of ensuring an open airway will cause the upper back of an infant or small child to arch upward. Additional support for the back is provided by a folded towel, sheet, or blanket.

Soft Tissue Injuries

The most common injuries seen by the corpsman in a first aid setting are soft tissue injuries with the accompanying hemorrhage, shock, and danger of infection. Any injury that causes a break in the skin, underlying soft tissue structures, or body membranes is known as a WOUND. This section will discuss the classification of wounds, the general and specific treatment of soft tissue injuries, the use of dressings and bandages in treating wounds, and the special problems that arise because of the location of wounds.

Classification of Wounds

Wounds may be classified according to their general condition, size, location, the manner in which the skin or tissue is broken, and the agent that caused the wound. It is usually necessary for you to consider these factors to determine what first aid treatment is appropriate for the wound.

General Condition of the Wound

If the wound is fresh, first aid treatment consists mainly of stopping the flow of blood, treating for shock, and reducing the risk of infection. If the wound is already infected, first aid consists of keeping the victim quiet, elevating the injured part, and applying a warm wet dressing. If the wound contains foreign objects, first aid treatment may consist of removing the objects if they are not deeply embedded. DO NOT remove objects embedded in the eyes or the skull, and do not remove impaled objects. Impaled objects must be stabilized with bulky dressing before transport.

Size of the Wound

In general, since large wounds are more serious than small ones, they usually involve more severe bleeding, more damage to the underlying organs or tissues, and a greater degree of shock. However, small wounds are sometimes more dangerous than large ones; they may become infected more readily due to neglect. The depth of the wound is also important because it may lead to a complete perforation of an organ or the body, with the additional complication of entrance and exit wounds.

Location of the Wound

Since a wound may involve serious damage to the deeper structures, as well as to the skin and the tissue immediately below it, the location of the wound is important. For example, a knife wound to the chest may puncture a lung and cause interference with breathing. The same type of wound in the abdomen may result in a dangerous infection in the abdominal cavity, or it might puncture the intestines, liver, kidneys, or other vital organs. A knife wound to the head may cause brain damage, but the same wound in a less vital spot such as an arm or leg might be less important.

Types of Wounds

When you consider the manner in which the skin or tissue is broken, there are six general kinds of wounds: abrasions, incisions, lacerations, punctures, avulsions, and amputations. Many wounds, of course, are combinations of two or more of these basic types.

Abrasions - Abrasions are made when the skin is rubbed or scraped off. Rope burns, floor burns, and skinned knees or elbows are common examples of abrasions. This kind of wound can become infected quite easily because dirt and germs are usually embedded in the tissues.

Incisions - Incisions, commonly called CUTS, are wounds made by sharp cutting instruments such as knives, razors, and broken glass. Incisions tend to bleed freely because the blood vessels are cut cleanly and without ragged edges. There is little damage to the surrounding tissues. Of all classes of wounds, incisions are the least likely to become infected, since the free flow of blood washes out many of the microorganisms (germs) that cause infection.

Lacerations - These wounds are torn, rather than cut. They have ragged, irregular edges and masses of torn tissue underneath. These wounds are usually made by blunt, rather than sharp, objects. A wound made by a dull knife, for instance, is more likely to be a laceration than an incision. Bomb fragments often cause laceration. Many of the wounds caused by accidents with machinery are lacerations; they are often complicated by crushing of the tissues as well. Lacerations are frequently contaminated with dirt, grease, or other material that is ground into the tissue; they are therefore very likely to become infected.

Punctures - Punctures are caused by objects that penetrate into the tissues while leaving a small surface opening. Wounds made by nails, needles, wire, and bullets are usually punctures. As a rule, small puncture wounds do not bleed freely; however, large puncture wounds may cause severe internal bleeding. The possibility of infection is great in all puncture wounds, especially if the penetrating object has tetanus bacteria on it. To prevent anaerobic infections, primary closures are not made in the case of puncture wounds.

Avulsions - An avulsion is the tearing away of tissue from a body part. Bleeding is usually heavy. In certain situations, the torn tissue may be surgically reattached. It can be saved for medical evaluation by wrapping it in a sterile dressing and placing it in a cool container, and rushing it, along with the victim, to a medical facility. Do not allow the avulsed portion to freeze and do not immerse it in water or saline.

Amputations - A traumatic amputation is the nonsurgical removal of the limb from the body. Bleeding is heavy and requires a tourniquet, which will be discussed later, to stop the flow. Shock is certain to develop in these cases. As with avulsed tissue, wrap the limb in sterile dressings, place it in a cool container, and transport it to the hospital with the victim. Do not allow the limb to be in direct contact with ice, and do not immerse it in water or saline. The limb can often be successfully reattached.

Causes of the Wound

Although it is not always necessary to know what agent or object has caused the wound, it is helpful. Knowing what has caused the wound may give you some idea of the probable size of the ound, its general nature, the extent to which it is likely to become contaminated with foreign matter, and what special dangers must be guarded against. Of special concern in a wartime setting is the velocity of wound causing missiles (bullets or shrapnel). A low velocity missile damages only the tissues it comes into contact with. On the other hand, a high velocity missile can do enormous damage by forcing the tissues and body parts away from the track of the missile with a velocity only slightly less than that of the missile itself. These tissues, especially bone, may become damage-causing missiles themselves, thus accentuating the destructive effects of the missile.

Having classified the wound into one or more of the general categories listed, the corpsman will have a good idea of the nature and extent of the injury, along with any special complications. This information will aid in the treatment of the victim.

Management of Open Soft Tissue Injury

There are three basic rules to be followed in the treatment of practically all open soft tissue injuries: to control hemorrhage, to treat the victim for shock, and to do whatever you can to prevent infection. These will be discussed, along with the proper application of first aid materials and other specific first aid techniques. Hemorrhage

Hemorrhage is the escape of blood from the vessels of the circulatory system. The average adult body contains about 6 liters of blood. Five hundred milliliters of blood, the amount given by blood donors, can usually be lost without any harmful effect. The loss of 1 liter of blood usually causes shock, but shock may develop if small amounts of blood are lost rapidly, since the circulatory system does not have enough time to compensate adequately. The degree of shock progressively increases as greater amounts of blood escape. Young children, sick people, or the elderly may be especially susceptible to the loss of even small amounts of blood since their internal systems are in such delicate balance.

Capillary blood is usually brick red in color. If capillaries are cut, the blood oozes out slowly. Blood from the veins is dark red. Venous bleeding is characterized by a steady, even flow. If an artery near the surface is cut, the blood, which is bright red in color, will gush out in spurts that are synchronized with the heartbeats. If the severed artery is deeply buried, however, the bleeding will appear to be a steady stream.

In actual practice, you might find it difficult to decide whether bleeding is venous or arterial, but the distinction is not usually important. The important thing to know is that all bleeding must be controlled as quickly as possible.

External hemorrhage is of greatest importance to the corpsman because it is the most frequently encountered and the easiest to control. It is characterized by a break in the skin and visible bleeding. Internal hemorrhage, which will be discussed later, is far more difficult to recognize and to control.

Control of Hemorrhage

The best way to control external bleeding is by applying a compress to the wound and exerting pressure directly to the wound. If direct pressure does not stop the bleeding, pressure can also be applied at an appropriate pressure point. At times, elevation of an extremity is also helpful in controlling hemorrhage. The use of splints in conjunction with direct pressure can be beneficial. In those rare cases where bleeding cannot be con- trolled by any of these methods, you must use a tourniquet.

If bleeding does not stop after a short period, try placing another compress or dressing over the first and securing it firmly in place. If bleeding still will not stop, try applying direct pressure with your hand over the compress or dressing.

Remember that in cases of severe hemorrhage, do not worry too much about finding appropriate materials or about the dangers of infection. The basic problem is to stop rapid exsanguination. If no material is available, simply thrust your hand into the wound. In most situations, direct pressure is the first and best method to use in the control of hemorrhage.

Pressure Points

Bleeding can often be temporarily controlled by applying hand pressure to the appropriate pressure point. A pressure point is a place where the main artery to the injured part lies near the skin surface and over a bone. Apply pressure at this point with the fingers (digital pressure) or with the heel of the hand; no first aid materials are required. The object of the pressure is to compress the artery against the bone, thus shutting off the flow of blood from the heart to the wound.

There are 11 principal points on each side of the body where hand or finger pressure can be used to stop hemorrhage. These points are shown in figure 4-21. If bleeding occurs on the face below the level of the eyes, apply pressure to the point on the mandible. This is shown in figure 4-21A. To find this pressure point, start at the angle of the jaw and run your finger forward along the lower edge of the mandible until you feel a small notch. The pressure point is in this notch.

If bleeding is in the shoulder or in the upper part of the arm, apply pressure with the fingers behind the clavicle. You can press down against the first rib or forward against the clavicle-either kind of pressure will stop the bleeding. This pressure point is shown in figure 4-21B.

Bleeding between the middle of the upper arm and the elbow should be controlled by applying digital pressure in the inner (body) side of the arm, about halfway between the shoulder and the elbow. This compresses the artery against the bone of the arm. The application of pressure at this point is shown in figure 4-21C. Bleeding from the hand can be controlled by pressure at the wrist, as shown in figure 4-21D. If it is possible to hold the arm up in the air, the bleeding will be relatively easy to stop.

Figure 4-21E shows how to apply digital pressure in the middle of the groin to control bleeding from the thigh. The artery at this point lies over a bone and quite close to the surface, so pressure with your fingers may be sufficient to stop the bleeding.

Figure 4-21F shows the proper position for controlling bleeding from the foot. As in the case of bleeding from the hand, elevation is helpful in controlling the bleeding.

If bleeding is in the region of the temple or the scalp, use your finger to compress the main artery to the temple against the skull bone at the pressure point just in front of the ear. Figure 4-21G shows the proper position.

If the neck is bleeding, apply pressure below the wound, just in front of the prominent neck muscle. Press inward and slightly backward, compressing the main artery of that side of the neck against the bones of the spinal column. The application of pressure at this point is shown in figure 4-21H. Do not apply pressure at this point unless it is absolutely essential, since there is a great danger of pressing on the windpipe and thus choking the victim.

Bleeding from the lower arm can be controlled by applying pressure at the elbow, as shown in figure 4-21I.

As mentioned before, bleeding in the upper part of the thigh can sometimes be controlled by applying digital pressure in the middle of the groin, as shown in figure 4-21E. Sometimes, however, it is more effective to use the pressure point of the upper thigh, as shown in figure 4-21J. If you use this point, apply pressure with the closed fist of one hand and use the other hand to give additional pressure. The artery at this point is deeply buried in some of the heaviest muscle of the body, so a great deal of pressure must be exerted to compress the artery against the bone.

Bleeding between the knee and the foot may be controlled by firm pressure at the knee. If pressure at the side of the knee does not stop the bleeding, hold the front of the knee with one hand and thrust your fist hard against the artery behind the knee, as shown in figure 4-21K. If necessary, you can place a folded compress or bandage behind the knee, bend the leg back, and hold it in place by a firm bandage. This is a most effective way of controlling bleeding, but it is so uncomfortable for the victim that it should be used only as a last resort.

You should memorize these pressure points so that you will know immediately which point to use for controlling hemorrhage from a particular part of the body. Remember, the correct pressure point is that which is (1) NEAREST THE WOUND, and (2) BETWEEN THE WOUND AND THE MAIN PART OF THE BODY.

It is very tiring to apply digital pressure, and it can seldom be maintained for more than 15 minutes. Pressure points are recommended for use while direct pressure is being applied to a serious wound by a second rescuer, or after a compress, bandage, or dressing has been applied to the wound, since it will slow the flow of blood to the area, thus giving the direct pressure technique a better chance to stop the hemorrhage. It is also recommended as a stopgap measure until a pressure dressing or a tourniquet can be applied.

Elevation

The elevation of an extremity, where appropriate, can be an effective aid in hemorrhage control when used in conjunction with other methods of control, especially direct pressure. This is because the amount of blood entering the extremity is decreased by the uphill gravitational effect. Do not elevate an extremity until it is certain that no bones have been broken or until broken bones are properly splinted.

Splints

Another effective method of hemorrhage control in cases of bone fractures is splinting. The immobilization of sharp bone ends reduces further tissue trauma and allows lacerated blood vessels to clot. In addition, the gentle pressure exerted by the splint helps the clotting process by giving additional support to compresses or dressings already in place over open fracture sites.

Later in this chapter we will go into the subject of splinting in greater detail.

Tourniquet

A tourniquet is a constricting band that is used to cut off the supply of blood to an injured limb. Use a tourniquet only if the control of hemorrhage by other means proves to be difficult or impossible. A tourniquet must always be applied ABOVE the wound, i.e., towards the trunk, and it must be applied as close to the wound as practical.

Basically, a tourniquet consists of a pad, a band, and a device for tightening the band so that the blood vessels will be compressed. It is best to use a pad, compress, or similar pressure object, if one is available. It goes under the band. It must be placed directly over the artery or it will actually decrease the pressure on the artery and thus allow a greater flow of blood. If a tourniquet placed over a pressure object does not stop the bleeding, there is a good chance that the pressure object is in the wrong place. If this occurs, shift the object around until the tourniquet, when tightened, will control the bleeding. Any long flat material may be used as the band. It is important that the band be flat: belts, stockings, flat strips of rubber, or neckerchiefs maybe used; but rope, wire, string, or very narrow pieces of cloth should not be used because they cut into the flesh. A short stick may be used to twist the band, tightening the tourniquet. Figure 4-22 shows how to apply a tourniquet.

To be effective, a tourniquet must be tight enough to stop the arterial blood flow to the limb, so be sure to draw the tourniquet tight enough to stop the bleeding. However, do not make it any tighter than necessary.

After you have brought the bleeding under control with the tourniquet, apply a sterile compress or dressing to the wound and fasten it in position with a bandage.

Here are the points to remember about using a tourniquet:

• Don't use a tourniquet unless you can't control the bleeding by any other means.

• Don't use a tourniquet for bleeding from the head, face, neck, or trunk. Use it only on the limbs.  

• Always apply a tourniquet ABOVE THE WOUND and as close to the wound as possible. As a general rule, do not place a tourniquet below the knee or elbow except for complete amputations. In certain distal areas of the extremities, nerves lie close to the skin and may be damaged by the compression. Furthermore, rarely does one encounter bleeding distal to the knee or elbow that requires a tourniquet. 

• Be sure you draw the tourniquet tight enough to stop the bleeding, but don't make it any tighter than necessary. The pulse beyond the tourniquet should disappear.  

• Don't loosen a tourniquet after it has been applied. Transport the victim to a medical facility that can offer proper care.  

• Don't cover a tourniquet with a dressing. If it is necessary to cover the injured person in some way, MAKE SURE that all the other people concerned with the case know about the tourniquet. Using crayon, skin pencil, or blood, mark a large "T" on the victim's forehead or on a medical tag attached to the wrist.

Management of Soft Tissue Injury

Internal soft tissue injuries may result from deep wounds, blunt trauma, blast exposure, crushing accidents, bone fracture, poison, or sickness. They may range in seriousness from a simple contusion to life-threatening hemorrhage and shock.

Visible indications of internal soft tissue injury include the following:

1. Hematemesis - vomiting bright red blood.

2. Hemoptysis - coughing up bright red blood.

3. Melena - excretion of tarry black stools.

4. Hematochezia - excretion of bright red blood from the rectum.

5. Hematuria - pass blood in the urine.

6. Nonmenstrual vaginal bleeding.

7. Epistaxis - nosebleed.

8. Pooling of the blood near the skin surface.

More often than not, however, there will be no visible signs of injury, and the corpsman will have to infer the probability of internal soft tissue injury from other symptoms that include:

1. Pale, moist, clammy skin.

2. Subnormal temperature.

3. Rapid, feeble pulse.

4. Falling blood pressure.

5. Dilated, slowly reacting pupils with impaired vision.

6. Tinnitus.

7. Syncope.

8. Dehydration and thirst.

9. Yawning and air hunger.

10. Anxiety, with a feeling of impending doom.

There is little that a corpsman can do to correct internal soft tissue injuries since they are almost always surgical problems. The hospital corpsman's goal must be to obtain the greatest benefit from the victim's remaining blood supply. The following should be done:

1. Treat for shock.

2. Keep the victim warm and at rest.

3. Replace lost fluids with a suitable blood volume expander (refer to the "Intravenous Therapy" section of the Nursing Procedures Manual; DO NOT give the victim anything to drink until the extent of the injury is known for certain.

4. Give oxygen, if available.

5. Splint injured extremities.

6. Apply cold compresses to identifiable injured areas.

7. Transport the victim to a medical treatment facility as soon as possible.

Dressings and Bandages

A dressing is a pad or bolster of folded linen that is placed in direct contact with the wound. It should be large enough to cover the entire area of the wound and to extend at least 1 inch in every direction beyond the edges. If the dressing is not large enough, the edges of the wound are almost certain to become contaminated.

In most situations, a corpsman will have sterile, prepackaged dressings available. However, emergencies will sometimes arise when they will be impossible to obtain, or the supplies will run out. In such a situation, use the cleanest cloth available. A freshly laundered handkerchief, towel, or shirt may be used. Unfold these material carefully so that you do not touch the part that goes next to the skin. Always be ready to improvise, but never put materials directly in contact with wounds that are likely to stick to the wound, leave lint, or be difficult to remove.

Bandages are strips or rolls of gauze or other materials that are used for wrapping or binding any part of the body and to hold compresses in place. The types of bandages that are most commonly used are the roller bandage and the triangular bandage that can be used to make the Barton bandage and the cravat bandage.

Roller Bandage

The roller bandage, shown in figure 4-23, consists of a long strip of material (usually gauze, muslin, or elastic) that is wound into a cylindrical shape. Roller bandages come in various widths and lengths. Most of the roller bandages in the first aid kits have been sterilized, so pieces may be cut off and used as compresses in direct contact with wounds. If you use a piece of roller bandage in this manner, you must be careful not to touch it with your hands or with any other unsterile object.

A piece of roller bandage may be used to make a four-tailed bandage. This is done by splitting the cloth from each end, leaving as large a center area as necessary. Figure 4-24A shows a bandage of this kind. The four-tailed bandage is often used to hold a compress on the chin, as shown in figure 4-24B, or on the nose, as shown in figure 4-24C. It is good for bandaging any protruding part of the body, because the center portion of the bandage forms a smoothly fitting pocket when the tails are crossed over.

In applying a roller bandage, hold the roll in the right hand so that the loose end is on the bottom; the outside surface of the loose or initial end is next applied to and held on the body part by the left hand. The roll is then passed around the body part by the right hand, which controls the tension and application of the bandage. Two or three of the initial turns of a roller bandage should overlie each other to secure the bandage and to keep it in place (see figure 4-25).

In applying the turns of the bandage, it is often necessary to transfer the roll from one hand to the other. Bandages should be applied evenly, firmly, but not too tightly. Excessive pressure may cause interference with the circulation and may lead to disastrous consequences. In bandaging an extremity, it is advisable to leave the fingers or toes exposed so the circulation of these parts may be readily observed. It is likewise safer to apply a large number of turns of a bandage, rather than to depend upon a few turns applied too firmly to secure a compress.

In applying a wet bandage, or one that may become wet, you must allow for shrinkage. The turns of a bandage should completely cover the skin, as any uncovered areas of skin may become pinched between the turns, with resulting discomfort.

In bandaging any extremity, it is advisable to include the whole member (arm or leg, excepting the fingers or toes) so that uniform pressure may be maintained throughout. It is also desirable in bandaging a limb that the part is placed in the position it will occupy when the dressing is finally completed, as variations in the flexion and extension of the part will cause changes in the pressure of certain parts of the bandage.

The initial turns of a bandage on an extremity (including spica bandages of the hip and shoulder) should be applied securely, and when possible, around the part of the limb that has the smallest circumference. Thus, in bandaging the arm or hand, the initial turns usually are applied around the wrist, and in bandaging the leg or foot, the initial turns are applied immediately above the ankle.

The final turns of a competed bandage usually are secured in the same manner as the initial turns, by employing two or more overlying circular turns. As both edges of the final circular turns are exposed, they should be folded under to present a neat, cufflike appearance. The terminal end of the completed bandage is turned under and secured to the final turns by either a safety pin or adhesive tape. When these are not available, the end of the bandage may be split lengthwise for several inches, and the two resulting tails may be secured around the part by tying.

Roller Bandage for Elbow - A spica or figure-of-eight type of bandage is used around the elbow joint to retain a compress in the elbow region and to allow a certain amount of movement. Flex the elbow slightly, if you can do so without causing further pain or injury, or anchor a 2- or 3-inch bandage above the elbow and encircle the forearm below the elbow with a circular turn. Continue the bandage upward across the hollow of the elbow to the starting point. Make another circular turn around the upper arm, carry it downward, repeating the figure- of-eight procedure, and gradually ascend the arm. Overlap each previous turn about two-thirds of the width of the bandage. Secure the bandage with two circular turns above the elbow and tie. To secure a dressing on the tip of the elbow, reverse the procedure and cross the bandage in the back (fig. 4-26).

Roller Bandage for Hand and Wrist - For the hand and wrist, a figure-of- eight bandage is ideal. Anchor the dressing, whether it is on the hand or wrist, with several turns of a 2- or 3-inch bandage. If on the hand, anchor the dressing with several turns and continue the bandage diagonally upward and around the wrist and back over the palm. Make as many turns as necessary to secure the compress properly (fig. 4-27).

Roller Bandage for Ankle and Foot - The figure-of-eight bandage is also used for dressings of the ankle, as well as for supporting a sprain. While keeping the foot at a right angle, start a 3-inch bandage around the instep for several turns to anchor it. Carry the bandage upward over the instep and around behind the ankle, forward and again across the instep and down under the arch, thus completing one figure- of-eight. Continue the figure-of-eight turns, overlapping one-third to one-half its width, with an occasional turn around the ankle, until the compress is secured or until adequate support is obtained (fig. 4-28).

Roller Bandage for Heel - The heel is one of the most difficult parts of the body to bandage. Place the free end of the bandage on the outer part of the ankle and bring the bandage under the foot and up. Then carry the bandage over the instep, around the heel, and back over the instep to the starting point. Overlap the lower border of the first loop around the heel and repeat the turn, overlapping the upper border of the loop around the heel. Continue this procedure until the desired number of turns is obtained, and secure with several turns around the lower leg (fig. 4-29).

Roller Bandage for Arm and Leg - The spiral reverse bandage must be used to cover wounds of the forearms and lower extremities; only such bandages can keep the dressing flat and even. Make two or three circular turns around the lower and smaller part of the limb to anchor the bandage and start upward, going around making the reverse laps on each turning, overlapping about one-third to one-half the width of the previous turn. Continue as long as each turn lies flat. Continue the spiral and secure the end when completed (fig. 4-30).

Barton Bandage

With the initial end of the roller bandage applied to the head, just behind the right mastoid process, the bandage