This section only covers what to do medically in an immediate life threatening situation. The main objective is to keep the patient alive until advanced medical care can be given.
Everyone should take a Wilderness First Responder course or, at the very least, a Basic First Aid course. Under no circumstances should this information replace a live first aid course conducted by a professional and qualified first aid instructor.
If possible, the first thing to do in all situations that require immediate first aid is to call emergency medical services. Know what the emergency services number is in whatever country you visit.
Something to think about:
The idea of first aid is to keep the patient alive until advanced medical care can be administered. In a survival situation, advanced care may not be available. Nursing a patient takes valuable time and resources. If there is no possibility of advanced medical care, you may only be delaying an inevitable death, and in the process may be taking away resources from other survivors. Is it worth risking everybody? This is a choice you may have to make.
This section will explain what to do when you first come across someone in need of first aid. It will allow you to determine urgent problems in the body’s critical systems, i.e., circulatory, nervous and respiratory.
Stop and fix problems as you find them. Some may be obvious, others will need further investigation.
Although this is presented in a “do this, then this” form, it is unlikely that you can follow it smoothly in a medical emergency. You have to be flexible.
Whoever is the most qualified ‘medic’ on the scene is the one in charge; if someone comes along that is more qualified, that new person takes charge.
When you come across any situation, it is important to not rush in. To ensure the safety of you and everyone around, you must first assess the entire situation. Ensure the surroundings are safe for you, your rescue partners, the public, and then the patient(s), in that order.
Next you will try to determine what may have caused the situation and if there may be spinal damage. Knowing the cause will help you to determine likely injuries, predict further complications and help you avoid getting injured by the same thing.
Finally, assess the number of patients, the need of additional rescuers and what resources you have or need.
This may seem overwhelming, but your brain is awesome. With some practice, and depending on the complexity of the situation, all this information can be gathered within seconds.
Approach the victim and check his mental status using AVPU.
Gently shake the individual and ask loudly “Hello, can you hear me? Are you okay?”
Alert: patient is alert.
Verbal: patient responds to verbal stimulus.
Pain: patient responds to pain stimulus.
Unresponsive: patient is unresponsive.
Anything below “Alert” may be the result of other critical system injuries, or could also give rise to them. Assess with the secondary exam after critical first aid has been completed; Must Read – Secondary Exam.
If you need to and are able, put on gloves and call for help.
Use the emergency roll to get the patient on his/her back and check his/her critical systems at the same time.
Vice lock the patients spine.
Ø Support the head and spinal column.
Ø Grasp the jaw and the back of the head and squeeze the center line of the torso between your forearms.
Roll the patient onto his/her back.
For larger patients, use the heel of your foot to nudge his/her pelvis into rolling along with the upper body.
Move to the back of the patient.
Hover your closer hand over the mouth to check for breath.
At the same time, with your other hand, check the radial pulse which is located just below the wrist at the base of the thumb.
Note: do not use your thumb to check pulse, as the thumb has a light pulse of its own.
Also check/treat severe bleeding; Must Read – Critical First Aid – Circulation.
Check if air is moving in and out.
If the patient is breathing, air is moving.
If you didn’t notice it during the emergency role, put your ear close to the patients face so that you are looking down the torso.
Place your hand on the abdomen and look, listen and feel for signs of breathing.
If the airway is not open, use the chin lift:
Lift up the chin gently with one hand while pushing down on the forehead with the other to tilt the head back.
If you suspect a neck injury, open the airway using the chin-lift without tilting the head back.
If the airway remains blocked, tilt the head slowly and gently until the airway is open.
With infants (under 1 year old), be careful not to tilt the head back too far or it may block the breathing passage instead of opening it.
If the airway is still not open, check for a blockage:
If there is one, sweep your finger in his/her mouth to remove it. Be careful of teeth.
If there is any fluid, e.g., blood, water and vomit, use gravity to help drain it.
Support the patient’s head and neck with one hand and reach around to the center of his/her back with the other.
Roll the patient onto your thighs and clear the airway using the finger sweep if needed.
If the airway is being blocked due to swelling, e.g., trauma, burns, anaphylaxis treat the cause (if possible).
Next, give 2 rescue breaths:
Transmission of infection between rescuer and patient is extremely rare. As far as we know, HIV or AIDS has never been transmitted via rescue breathing. If you are worried, a barrier can be improvised by slitting a small hole in some sort of material, e.g., glove, plastic bag.
Pinch the person’s nose shut using your thumb and forefinger.
Your hand stays on the patient’s forehead, maintaining the head tilt.
Your other hand also remains lifting up under his/her chin.
Inhale normally first (not deeply), and then form a tight seal between yours and the patient’s mouths.
With your mouth tightly sealed on the patient’s, slowly breathe into him/her for one second.
If the patient’s chest does not rise it means the air is not going in.
Do two of these breaths.
If the patient’s chest does not rise after the first breath you will need to do the head tilt again before attempting the second breath.
For small children: the breath into the child lasts for 1.5 seconds, and chest compressions are performed with these two rescue breaths; Must Read - Immediate First Aid - Critical First Aid – Circulation – Chest Compressions.
Be careful with your force of breathe. Only use enough to make the chest rise.
For infants: cover the nose and mouth with your mouth.
The breath into the infant lasts for 1.5 seconds.
Be careful with your force of breathe. Only use enough to make the chest rise.
If the rescue breaths do not go in, there is still a blockage - use abdominal compressions:
Straddle the patient at the legs.
Place a fist between the breastbone and belly button.
Thrust upwards up to five times to dislodge the obstruction.
Attempt the rescue breaths again.
Do 5 more abdominal compressions if needed, then 2 more rescue breaths.
Repeat the 5 abdominal compressions and 2 rescue breaths until your breaths go in.
If breathing is not adequate, treat the underlying cause (if possible).
Position: put the patient in a position of comfort
Reassurance: reassure the patient.
Oxygen: provide 100% oxygen if available.
Positive Pressure Ventilation is artificial respiration by mechanical means. The non-mechanical equivalent is rescue breathing. Use one breath every 6 to 8 seconds, which is about 8 to 10 breaths a minute; Must Read - Immediate First Aid - Critical First Aid – Airway – Rescue Breathing.
If there is no pulse, you will do CPR instead of just rescue breathing; Must Read - Immediate First Aid - Critical First Aid – Circulation - Cardiopulmonary Resuscitation.
If you didn’t check pulse with an emergency role, do so now. Lightly press the pads of your index and middle fingers on either the radial or carotid pulse. Do not use your thumb to check pulse since your thumb has a light pulse of its own.
The carotid pulse is located on the neck in the hollow between the windpipe and the large muscle.
If there is no pulse, start CPR (Cardiopulmonary resuscitation).
Don’t waste time. If you are unsure about whether the heart is beating and you can’t find a pulse within a few seconds, just start CPR.
CPR is the combination of chest compressions and rescue breathing.
During CPR, consider three things: airway, breathing and circulation.
Open the airway with the chin lift; Must Read - Immediate First Aid - Critical First Aid – Airway – Chin Lift.
Give two rescue breaths; Must Read - Immediate First Aid - Critical First Aid – Airway – Rescue Breathing.
Give 30 chest compressions at the rate of 100 compressions per minute.
Kneel at the patient’s side, near his or her chest.
Place the heel of your hand on the breastbone (sternum) between the nipples at the bottom of the ribcage, i.e., where there is a little notch.
Place your other hand on top of the one that is in position.
Lock your fingers together pulling them up slightly so they are off the chest wall.
Bring your shoulders directly over the person’s sternum.
A chest compression is two parts: compression (pushing down) and relaxation (releasing the chest back up).
Compression and relaxation should go for an equal length of time.
With your hands in position, press downward, keeping your arms straight.
Push down to about a third of the chest depth, then relax to let it return to the normal position.
Push hard and fast.
A cracking sound may be due to the ribs or cartilage cracking; don’t worry about it (for now), just keep doing the compressions.
Do 30 compressions for every 2 breaths at an overall rate of about 100 compressions per minute.
For an infant: encircle your hands around the chest and use just your thumbs to compress the chest.
For children aged 1 to 8: compress at about the nipple line.
If there are two rescuers: the person pumping the chest stops while the other gives rescue breaths.
If the victim starts to vomit: turn the patient’s head to the side and try to sweep out or wipe off the vomit, then continue with CPR.
When not to do CPR:
If advanced medical care is not readily available (e.g., more than 1 to 2 hours away), you need to make a decision whether to even start CPR or not.
To make a tough decision a little easier, you can follow these points as a standard. Do not start CPR if one or more of the following:
Ø The patient’s core temperature is below 32 °C (90 °F).
Ø The patient has been underwater without air for more than 1 hour.
Ø The patient has an obvious lethal injury, e.g., massive hemorrhaging (severe bleeding must be blocked before giving compressions).
Also, any time that you do start CPR, you need to decide for how long you will continue. If advanced help is likely, continuing until it arrives is reasonable. If you are unsure whether help will arrive, for how long should you continue? 1 hour? 2 hours? These are decisions you have to make depending on the situation.
If CPR is not needed, check perfusion:
Perfusion is the flow of fluid, e.g., blood, through a certain area of the body. Signs of inadequate perfusion include cold/clammy skin, low mental status, slow capillary refill, weak pulse in extremities, e.g., radial pulse.
If there is inadequate perfusion, treat the cause (if possible) and use PROP; Must Read - Immediate First Aid - Critical First Aid - Breathing – PROP.
Testing Capillary Refill
Apply pressure to the skin and then wait to see how long it takes for blood to flow back into the site. A slow capillary refill means a slow return of blood which indicates decreased perfusion. Returning from white to pink in less than 2 seconds is normal. 3 or more seconds and something is probably wrong.
Good places to check capillary refill for general whole body perfusion are the fingers and/or toes.
Apply well-aimed, direct pressure to the wound.
Elevate the wounded area above his/her heart (if possible).
Wait ten minutes then check if bleeding has stopped.
If it is spurting, stick your finger down on the wound and hold it there.
If the patient continues to bleed after some time of well-aimed, direct pressure, use pressure point constriction at an arterial pressure point between the injury and the heart; the closer to the bleeding site the better.
Do not perform pressure point constriction for more than 10 minutes as it can result in necrosis (death of body tissue). Be extra careful of the carotid artery, as it hinders oxygen to the brain.
If the patient is still bleeding, consider carefully whether to apply a tourniquet.
Note: this is a last resort. Only use a tourniquet if there is severe, uncontrolled bleeding that will cause loss of life and no other option is available and/or working.
Long-term use of a tourniquet may cause loss of limb.
To apply an improvised tourniquet:
Find a length of strong, pliable cloth, preferably no less than 5cm wide (2 inches), e.g., backpack strap, clothing, long sock.
Apply it on the limb, preferably with padding underneath, e.g., rolled up clothing. It should be placed between the wound and the heart, approximately 5 to 10 cm (approximately 2 to 4 inches) from the wound.
If possible, wrap it around the limb several times, keeping the material as flat as possible.
Tie a simple overhand knot.
Place a torsion device, e.g., a strong stick on top of the knot, then secure it in place with two overhand knots.
Twist the torsion device just enough to stop arterial bleeding (bright red bleeding). Continued dark bleeding for a short while is normal in cases of amputation; Diagnoses and Treatments – Musculoskeletal System – Amputation.
Once tightened, secure the torsion device in place, e.g., loop the ends of the tourniquet over the ends of the stick and tie them together under the limb.
Note what time you applied it.
Do not cover it.
After 20 minutes of applying the tourniquet, ensure a pressure dressing is in place and bleeding has stopped.
Very slowly, loosen the tourniquet to restore circulation.
Leave the loosened tourniquet in position in case the bleeding resumes.
If transferring the patient to other caregivers, e.g., paramedics, write down the time at which you applied the tourniquet and the letters TK on the patient’s forehead.
The nervous system includes the brain and spine.
Checking mental status is the first things you should do after you assess the situation; Must Read – Immediate First Aid - Critical First Aid – Assess the Situation.
If you suspect a spine injury, or are unsure, do not move the patient unless absolutely necessary; Must Read - Secondary Exam - Physical Exam - Spinal Assessment.
Protect and stabilize the spine; Must Read - Secondary Exam - Physical Exam - Spinal Stabilization.
After critical systems have been assessed and all critical problems have been treated (including the ones below), move onto the secondary exam; Must Read - Secondary Exam.
Anaphylaxis is a life threatening allergic reaction.
A history of mild allergic reaction does not mean you will never have a severe allergic reaction to the same thing. Often, the first time someone is exposed to an allergen, very little happens, but the second (or third etc.) time there is a major reaction.
Symptoms usually show within minutes of exposure. The faster you treat it the better. Recurrent reactions can occur within 24 hours of the original episode. Treat these in the same way as the initial reaction.
Possible causes of anaphylaxis
Drugs: more common ones are anesthetics, antibiotics like penicillin, dyes injected during x-rays, heart and blood pressure medicines and NSAIDs.
Exercise: often after eating.
Foods: nuts, fruit, seafood etc.
Insect stings: bees, wasps etc.
Latex: rubber gloves, condoms etc.
There are also many unknown causes.
Abdominal Pain.
Decreased mental state.
Diarrhea.
Dizziness.
Hives.
Itching.
Nausea.
Respiratory problems.
Shock (Rapid heart rate, low blood pressure etc.).
Skin-redness.
Swelling of the mouth and face.
Paresthesias (tingling).
Vomiting.
Weakness.
Diphenhydramine, e.g., Benadryl: 1 mg/kg of body weight, maximum of 50 mg, every 4 to 6 hours. Chewing the pill will make it work faster.
Rescue Breathing or CPR as needed.
Administer epinephrine if:
There is an obvious major reaction, e.g., difficulty breathing, unconsciousness.
A reaction worsens over a few minutes.
Dosage of epinephrine: 0.01 ml/kg of body weight, maximum of 0.3 ml. Injections can be repeated every 5 minutes if needed.
Administer diphenhydramine as soon as able.
Consider a corticosteroid, e.g., prednisone
Dosage of prednisone: 1 mg/kg of body weight, maximum of 60 mg, once a day.
Observe for at least 24 hours in case of secondary reaction.
If in doubt, administer the epinephrine.
The easiest way to do this is with a commercial injector, e.g., EpiPen. Patients that have a history of anaphylaxis will probably carry these with them. It is a good idea to have one in your first aid kit just in case, and they are usually allowed on planes.
These injectors have clear instructions written on them. Exact usage varies but basically you remove the cap, hold it firmly in your fist and press it firmly into the patient’s thigh.
There is no need to stab the patient with it. That will just cause unnecessary bruising and pain.
Do not put your finger or thumb on the top of the device just in case you inject yourself.
Epinephrine can also be given with a normal syringe.
A heart attack occurs when the heart is unable to get oxygen due to a blockage of blood flow. Aging people that do not keep in good health are most likely to suffer heart attacks.
Symptoms vary from person to person and from case to case, i.e., you may not get the same symptoms as a previous heart attack.
Chest pain, tightness or pressure.
Heartburn.
Indigestion.
Nausea.
Pain radiating to the jaw and right arm.
Shortness of breath.
Sweating.
Vomiting.
Weakness, dizziness and light headedness.
Seek advanced medical care as soon as symptoms of heart attack are suspected. If in doubt, seek treatment.
Aspirin: chew in event of heart attack.
Nitroglycerin: a patient with a history of heart attack may have this prescribed. Use as directed.
Oxygen.
Rest.
Pressure Immobilization Technique
The pressure immobilization technique is used for only the most life threatening venomous bites and stings. The idea is to slow the venom’s movement into the circulatory system. This buys time until advanced medical care can be given.
The patient must be kept as still as possible, especially the site of the wound. Do not elevate the wound.
In general, only use for:
Australian snakes, all species.
Blue-ringed octopus.
Conus.
Funnel-web spiders.
Applying the Pressure Immobilization Technique
Ideally, use an elastic roller bandage.
Bandage upwards from the lower portion of the bitten or stung limb, and continue up as high as possible.
Each wrap should overlap the last.
Ensure the bandage does not impair perfusion; Must Read – Critical First Aid – Circulation – Perfusion.
Mark the location of the bite on the bandage.
Immobilize the limb; Diagnoses and Treatments – Musculoskeletal System – Immobilization.
Check perfusion frequently as continued swelling may impair it.
Note: do not bandage bites/stings to the head or torso. Keep patient still and seek medical care ASAP.
Assume any penetrating wound to the chest is a sucking chest wound.
Symptoms of a Sucking Chest Wound
Bloody froth.
Patient gasping for breath.
Sucking sound.
Treatment for a Sucking Chest Wound
Seal the wound with airtight material, taping only three sides so air can escape but not enter.
If no airtight material is available, use your hand.
Monitor the patients breathing and check the dressing regularly.
You can aid breathing by lifting the untapped side of the dressing as the patient exhales.
