Tier Requirements/ Medicare Tier 4 Comprehensive - 2008 ANALGESICS NSAIDs diclofenac sodium delayed-rel Tier COX-2 Inhibitors Gout Narcotic Analgesics Narcotic Analgesics, CII morphine sulfate immediate release Tier Tier Requirements/ Non-narcotic Analgesics ANESTHETICS Local Anesthetics ANTI-INFECTIVES Antibacterials
Unit i: course overview and introductionFrom COMMUNITY EMERGENCY RESPONSE TEAM MANUAL
TREATING LIFE-THREATENING CONDITIONS In emergency medicine, airway obstruction, bleeding, and shock are “killers” because without treatment they will lead to death. The first priority of medical operations is to attend to those potential kil ers by: Check airway/breathing. At an arm’s distance, make contact with the victim and speak loudly. If the victim does not respond: Check breathing rate. Abnormally rapid respiration (above 30 per minute) indicates shock. Maintain the airway and treat for shock and tag “I.” If below 30 per minute, then move to Step 2.
If the victim is not breathing after two attempts to open airway, then tag “DEAD.” Take immediate action to control severe bleeding. Check circulation using the blanch test (for capillary refill) or a radial pulse test.
Press on an area of skin until normal skin color is gone. Time how long it takes for normal color to return. Treat for shock if normal color takes longer than 2 seconds to return, and tag “I.” Note if the pulse is abnormal (rapid, thready, weak, etc.) If absent, tag “I” and treat for bleeding and shock.
Step 3 Check mental status. Inability to respond indicates that immediate treatment for shock is necessary. Treat for shock and tag “I.” Classification
Skin Layers Affected
Reddened, dry skin Pain Swelling (possible) Wet appearance Pain Swelling (possible) Remove the victim from the burning source. Put out any flames and remove smoldering clothing unless it is stuck to the skin.
Cool skin or clothing, if they are stil hot, by immersing them in cool water for not more than 1 minute or covering with clean compresses that have been soaked in cool water and wrung out. Cooling sources include water from the bathroom or kitchen; garden hose; and soaked towels, sheets, or other cloths. Treat al victims of full thickness burns for shock.
Infants, young children, and older persons, and persons with severe burns, are more susceptible to hypothermia. Therefore, rescuers should use caution when applying cool dressings on such persons. A rule of thumb is do not cool more than 15% of the body surface area (the size of one arm) at once, to reduce the chances of hypothermia.
Cover loosely with dry, sterile dressings to keep air out, reduce pain, and prevent Wrap fingers and toes loosely and individual y when treating severe burns to the Loosen clothing near the affected area. Remove jewelry if necessary, taking care to document what was removed, when, and to whom it was given. Elevate burned extremities higher than the heart.
Do not use ice. Ice causes vessel constriction.
Do not apply antiseptics, ointments, or other remedies.
Do not remove shreds of tissue, break blisters, or remove adhered particles of clothing. (Cut burned-in clothing around the burn.) When treating a burn victim, DO:
Cool skin or clothing if they are still hot.
Cover loosely with dry, sterile dressings to keep air out, reduce pain, and prevent Elevate burned extremities higher than the heart.
When treating a burn victim:
Do NOT use ice. Ice causes vessel constriction.
Do NOT apply antiseptics, ointments, or other remedies.
Do NOT remove shreds of tissue, break blisters, or remove adhered particles of
clothing. (Cut burned-in clothing around the burn.) Infants, young children, and older persons, and persons with severe burns, are more susceptible to hypothermia. Therefore, rescuers should use caution when applying cool dressings on such persons. A rule of thumb is do not cool more than 15% of the body surface area (the size of one arm) at once, to prevent hypothermia.
GENERAL GUIDELINES FOR TREATING CHEMICAL AND INHALATION BURNS
Chemical and inhalation burns vary from traditional heat-related burns in their origin and treatment. Keep in mind that suspicion of either chemical or inhalation burns elevates GUIDELINES FOR TREATING CHEMICAL BURNS
Unlike more traditional burns, chemical burns do not result from extreme heat, and Chemical burns are not always obvious. You should consider chemical burns as a possibility if the victim’s skin is burning and there is no sign of a fire. If chemical burns 1. Protect yourself from contact with the substance. Use your protective gear — 2. Ensure that any affected clothing or jewelry is removed. 3. If the irritant is dry, gently brush away as much as possible. Always brush away from the eyes and away from the victim and you. 4. Use lots of cool running water to flush the chemical from the skin for 15 minutes. The running water will dilute the chemical fast enough to prevent the injury from 5. Apply cool, wet compress to relieve pain.
6. Cover the wound very loosely with a dry, sterile or clean cloth so that the cloth will GUIDELINES FOR TREATING INHALATION BURNS
Remember that 60 to 80% of fire fatalities are the result of smoke inhalation. Whenever fire and/or smoke is present, CERT members should assess victims for signs and symptoms of smoke inhalation. These are indicators that an inhalation burn is present: Sudden loss of consciousness Evidence of respiratory distress or upper airway obstruction The patient may not present these signs and symptoms until hours (sometimes up to a full 24 hours) after the injury occurred, and such symptoms may be overlooked when Smoke inhalation is the number one fire-related cause of death. If CERT members have reason to suspect smoke inhalation, be sure the airway is maintained, and alert a medical professional as soon as possible. WOUND CARE
Treatment for controlling bleeding was covered in Unit 3. The focus of this section is on cleaning and bandaging, which will help to prevent secondary infection.
CLEANING AND BANDAGING WOUNDS
Wounds should be cleaned by irrigating with clean, room temperature water. NEVER use hydrogen peroxide to irrigate the wound.
You should not scrub the wound. A bulb syringe is useful for irrigating wounds. In a disaster, a turkey baster may also be useful.
When the wound is thoroughly cleaned, you will need to apply a dressing and bandage to help keep it clean and control bleeding.
There is a difference between a dressing and a bandage: A dressing is applied directly to the wound. Whenever possible, a dressing A bandage holds the dressing in place.
If a wound is still bleeding, the bandage should place enough pressure on the wound to help control bleeding without interfering with circulation.
You should follow these rules: If there is active bleeding (i.e., if the dressing is soaked with blood), redress over the existing dressing and maintain pressure and elevation to control bleeding.
In the absence of active bleeding, remove the dressings, flush the wound, and then check for signs of infection at least every 4 to 6 hours.
Signs of possible infection include: Swelling around the wound site If necessary and based on reassessment and signs of infection, change the treatment priority (e.g., from Delayed to Immediate).
The main treatments for an amputation (the traumatic severing of a limb or other body When the severed body part can be located, CERT members should: • Save tissue parts, wrapped in clean material and placed in a plastic bag, if available. Label them with the date, time, and victim’s name.
• Keep the tissue parts cool, but NOT in direct contact with ice • Keep the severed part with the victim Sometimes, you may also encounter some victims who have foreign objects lodged in their bodies — usually as the result of flying debris during the disaster.
When a foreign object is impaled in a patient’s body, you should: Immobilize the affected body part ot attempt to move or remove the object, unless it is obstructing the airway Try to control bleeding at the entrance wound without placing undue pressure on the Clean and dress the wound making sure to stabilize the impaled object. Wrap bulky dressings around the object to keep it from moving.
TREATING FRACTURES, DISLOCATIONS, SPRAINS, AND STRAINS
The objective when treating a suspected fracture, sprain, or strain is to immobilize the injury and the joints immediately above and below the injury site.
Because it is difficult to distinguish among fractures, sprains, or strains, if uncertain of
the type of injury, CERT members should treat the injury as a fracture.
A fracture is a complete break, a chip, or a crack in a bone. There are several types of fractures.
• A closed fracture is a broken bone with no associated wound. First aid treatment for closed fractures may require only splinting.
• An open fracture is a broken bone with some kind of wound that allows contaminants to enter into or around the fracture site.
TREATING AN OPEN FRACTURE
Open fractures are more dangerous than closed fractures because they pose a significant risk of severe bleeding and infection. Therefore, they are a higher priority and need to be checked more frequently. When treating an open fracture: Do not draw the exposed bone ends back into the tissue.
You should: Cover the wound with a sterile dressing Splint the fracture without disturbing the wound Place a moist 4 by 4-inch dressing over the bone end to keep it from drying out If the limb is angled, then there is a displaced fracture. Displaced fractures may be described by the degree of displacement of the bone fragments. Nondisplaced fractures are difficult to identify, with the main signs being pain and swelling. You should treat a suspected fracture as a fracture until professional treatment is available.
TREATING FRACTURES, DISLOCATIONS, SPRAINS AND STRAINS (CONTINUED)
Dislocations are another common injury in emergencies.
A dislocation is an injury to the ligaments around a joint that is so severe that it permits a separation of the bone from its normal position in a joint.
The signs of a dislocation are similar to those of a fracture, and a suspected dislocation If dislocation is suspected, be sure to assess PMS (Pulse, Movement, Sensation) in the affected limb before and after splinting/immobilization. If PMS is compromised, the patient’s treatment priority is elevated to “I.” You should not try to relocate a suspected dislocation. You should immobilize the joint
until professional medical help is available.
SPRAINS AND STRAINS
A sprain involves a stretching or tearing of ligaments at a joint and is usually caused by stretching or extending the joint beyond its normal limits.
A sprain is considered a partial dislocation, although the bone either remains in place or is able to fal back into place after the injury.
The most common signs of a sprain are: Tenderness at the site of the injury Restricted use or loss of useThe signs of a sprain are similar to those of a nondisplaced fracture. Therefore, you should not try to treat the injury other than by immobilization and elevation.
A strain involves a stretching and/or tearing of muscles or tendons. Strains most often involve the muscles in the neck, back, thigh, or calf.
In some cases, strains may be difficult to distinguish from sprains or fractures. Whether an injury is a strain, sprain, or fracture, treat the injury as if it is a fracture.
Splinting is the most common procedure for immobilizing an injury.
Cardboard is the material typically used for makeshift splints but a variety of materials ft materials . Towels, blankets, or pillows, tied with bandaging materials or soft igid materials . A board, metal strip, folded magazine or newspaper, or other rigid Anatomical splints may also be created by securing a fractured bone to an adjacent unfractured bone. Anatomical splints are usually reserved for fingers and toes, but, in an emergency, legs may also be splinted together.
Soft materials should be used to fil the gap between the splinting material and the body part.
With this type of injury, there will be swelling. Remove restrictive clothing, shoes, and jewelry when necessary to prevent these items from acting as unintended tourniquets.
Splinting Using a Towel
Splinting using a towel, in which the towel is rolled up and wrapped around the
limb, then tied in place. Pillow splint
Pillow splint, in which the pil ow is wrapped around the limb and tied.
Anatomical splint in which the injured leg is tied at intervals to the non-injured
leg, using a blanket as padding between the legs.
Bleeding from the nose can have several causes. Bleeding from the nose can be Nontrauma-related conditions such as sinus infections, high blood pressure, and A large blood loss from a nosebleed can lead to shock. Actual blood loss may not be evident because the victim will swallow some amount of blood. Those who have swallowed large amounts of blood may become nauseated and vomit.
These are methods for controlling nasal bleeding: Pinch the nostrils together Put pressure on the upper lip just under the nose While treating for nosebleeds, you should: Have the victim sit with the head slightly forward so that blood trickling down the throat will not be breathed into the lungs. Do not put the head back.
Ensure that the victim’s airway remains open Keep the victim quiet. Anxiety will increase blood flow.
TREATING COLD-RELATED INJURIES
ypothermia , which is a condition that occurs when the body’s temperature drops rostbite , which occurs when extreme cold shuts down blood flow to extremities, HYPOTHERMIA
Hypothermia may be caused by exposure to cold air or water or by inadequate food combined with inadequate clothing and/or heat, especially in older people.
The primary signs and symptoms of hypothermia are: A body temperature of 95° F (37° C) or lower In later stages, hypothermia will be accompanied by: Slurred speech ListlessnessBecause hypothermia can set in within only a few minutes, you should treat victims who have been rescued from cold air or water environments.
2. Wrap the victim in a blanket or sleeping bag and cover the head and neck.
3. Protect the victim against the weather.
4. Provide warm, sweet drinks and food to conscious victims. Do not offer alcohol.
5. Do not attempt to use massage to warm affected body parts.
6. Place an unconscious victim in the recovery position: Place the victim’s arm that is nearest to you at a right angle against the ground, with Move the victim’s other arm across his or her chest and neck, with the back of the victim’s hand resting against his or her cheek.
Grab a hold of the knee furthest from you and pul it up until the knee is bent and the Pul the knee toward you and over the victim’s body while holding the victim’s hand Position the victim’s leg at a right angle against the floor so that the victim is lying on If the victim is conscious, place him or her in a warm bath.
Do not to allow the victim to walk around even when he or she appears to be fully recovered. If the victim must be moved outdoors, cover the victim’s head and face.
A person’s blood vessels constrict in cold weather in an effort to preserve body heat. In extreme cold, the body will further constrict blood vessels in the extremities in an effort to shunt blood toward the core organs (heart, lungs, intestines, etc.). The combination of inadequate circulation and extreme temperatures will cause tissue in these extremities to freeze, and in some cases, tissue death will result. Frostbite is most common in the hands, nose, ears, and feet.
There are several key signs and symptoms of frostbite: Skin discoloration (red, white, purple, black) Burning or tingling sensation, at times not localized to the injury site A patient suffering from frostbite must be warmed slowly! Thawing the frozen extremity too rapidly can cause chilled blood to flow to the heart, shocking and potential y 1. Immerse injured area in warm (NOT hot) water, approximately 107.6° F. 2. Do NOT allow the body part to re-freeze as this will exacerbate the injury.
3. Do NOT attempt to use massage to warm body parts.
Wrap affected body parts in dry, sterile dressing. Again, it is vital this task be completed careful y. Frostbite results in the formation of ice crystals in the tissue; rubbing could potentially cause a great deal of damage! TREATING HEAT-RELATED INJURIES
There are several types of heat-related injuries that you may encounter in a disaster eat cramps are muscle spasms brought on by over-exertion in extreme heat. eat exhaustion occurs when an individual exercises or works in extreme heat, resulting in loss of body fluids through heavy sweating. Blood flow to the skin increases, causing blood flow to decrease to the vital organs. This results in a mild eat stroke is life-threatening. The victim's temperature control system shuts down, and body temperature can rise so high that brain damage and death may result.
The symptoms of heat exhaustion are: Cool, moist, pale, or flushed skin A patient suffering heat exhaustion will have a near normal body temperature. If left untreated, heat exhaustion will develop into heat stroke.
TREATING HEAT-RELATED INJURIES (CONTINUED)
Heat stroke is characterized by some or al of the following symptoms:
4. Rapid, weak pulse and rapid, shal ow breathing In a heat stroke victim, body temperature can be very high — as high as 105º F. If an individual suffering from heat stroke is not treated, death can result TREATMENT
Treatment is similar for both heat exhaustion and heat stroke. Take the victim out of the heat and place in a cool environment.
Cool the body slowly with cool, wet towels or sheets. If possible, put the victim in a Have the victim drink water, SLOWLY, at the rate of approximately half a glass of water every 15 minutes. Consuming too much water too quickly will cause nausea and vomiting in a victim of heat sickness.
If the victim is experiencing vomiting, cramping, or is losing consciousness, DO NOT administer food or drink. Alert a medical professional as soon as possible, and keep a close watch on the individual until professional help is available.
BITES AND STINGS
In a disaster environment, everything is shaken from normalcy, including insects and animals. In this time of chaos, insect bites and stings may be more common than is typical as these creatures, like people, are under additional stress.
When conducting a head-to-toe assessment, you should look for signs of insect bites and stings. The specific symptoms vary depending on the type of creature, but, general y, bites and stings will be accompanied by redness and itching, tingling or burning at the site of the injury, and often a welt on the skin at the site.
Treatment for insect bites and stings follows these steps: Remove the stinger if still present by scraping the edge of a credit card or other stiff, straight-edged object across the stinger. Do not use tweezers; these may squeeze the venom sac and increase the amount of venom released.
Wash the site thoroughly with soap and water.
Place ice (wrapped in a washcloth) on the site of the sting for 10 minutes and then off for 10 minutes. Repeat this process.
You may help the victim take his or her own allergy medicine (Benadryl, etc.), but you may NOT dispense medications.
BITES AND STINGS AND ALLERGIC REACTIONS
The greatest concern with any insect bite or sting is a severe allergic reaction, or anaphylaxis. Anaphylaxis occurs when an allergic reaction becomes so severe that the airway is compromised. If you suspect anaphylaxis: 2. Remove constrictive clothing and jewelry as the body often swells in response to 3. If possible, find and help administer a victim’s Epi-pen. Many severe allergy d. DO NOT administer medicine aside from the Epi-pen. This includes pain 5. Watch for signs of shock and treat appropriately.
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