NAME Module-II: Clinical Section 1

UNIT - 9
FIRST AID &
EMERGENCY MANAGEMENT
Syllabus:
Shock, poisoning, hemorrhage, external bleeding, Injuries, fracture & dislocation, thermal & chemical burns,
Frost bite, insect bite, animal bite, drowning, abscess & cellulites.

MOST REMEMBER POINTS OF THIS CHAPTER

 First aid refers to the immediate care  External suturing is done with Nylon thread
rendered in a medical emergency until (none absorbable).
advanced care is available.  Chemical name of dettol is chlorhexylenol.
 Golden points of first aid are ABC (Airway,  Most effective skin antiseptic is alcohol
Breathig, Circulation). solution of chlorhexidine
 Mouth to Mouth respiration is also known  Common site for IM inj. is deltoid muscle.
as Kiss of life.  All insect bite should be managed with cold
 Universal antidote – Activated charcoal compress but in spider bite with hot
(dose: 25 – 100gm) compress.
 Most common poisoning in Nepal is  Appropriate position for the client with
organophosphorous. shock: Supine with leg elevated.
 Most common poisoning in children is  Ringer lactate is the choice of treatment in
kerosene. serve dehydration.
 If corrosive poison then, vomiting should not  Most common type of shock first aider may
be done and management should be done by encounter is caused by hypovolemic shock.
giving milk and water.  In hypovolemic shock hypotension with
 If patient in unconscious, keep in lateral tachycardia occur.
position to prevent aspiration pneumonia.  The most commonest type of shock is
 Spiral fracture is best maintained by hypovolemic shock.
continuously traction  Shock related to toxins is septic shock.
 Most common fracture in child is greenstick  Shock related to IgE is anaphylactic shock.
fracture.  Out of four vital organs: Heart, liver brain
 Most common site in child supra condylar and kidney; only kidney can tolerate hypoxia
fracture. up to 1 hour without permanent damage.
 Most common fracture in adult is collie's  Fracture-Loss of continuation of bone tissue
fracture or lower end of radius. is called fracture
 Most common fracture in old is femur  Normal body Temperature 37.5ºC (98.6ºF).
fracture (mostly in female)  Most Reliable Temperature -Rectal temp.).
 Figure of 8 bandage is used in clavicle and  Venous bleeding is dark red.
palm fracture.
 Communicated fracture is common in old
 Communicated fracture commonly seen in
age.
old age.
 POP bandage (Plaster Of Paris) used in
 Most commonly used bandage is roller
Fracture part immobilization.
bandage.
 Pneumonia after Poisoning is called
 Suturing should be done within 6 hours.
Aspiration pneumonia.
 0.5 cm gaping should be in suturing.
 nternal suturing is done with catgut
 Zinc phosphate poisoning is organo
(absorbable thread). phosphorus poisoning.
 Gallows traction is used in femur fracture.
 2 Health Assistant Loksewa Module-II

FIRST AID  Nasopharyngeal airway

 First aid is the immediate & temporary care  Intubations (oropharyngeal airway)
given to an injured or ill person before
treatment provided by medical trained
personnel or by a health care institution.
 Keep the patient immobilized in neutral
Principle position if cervical spine fracture.
 Reach the accident site as soon as possible,  Use cervical collar and avoid head tilt & chain
rule out source or cause of injury. lift in spine fracture.
 Keep the self in safe side (personal safety is
B. Breathing or ventilation
your highest priority, followed by the safety
The second priority is the establishment of
of the victim & any bystander)
adequate ventilation.
 Do not crowd gather around victim.
Assess
 Be calm quick & methodological.
 Inspection (look): look for
 Prioritize the case that require immediate
first aid and treatment management and  Cyanosis
referral.  Penetrating injury
 Do not waste time by asking unnecessary  Use of accessory muscle
questions.  Palpation (feel) palpate for
 Prevent shock and arrange for transportation  Tracheal shift
to health care facility.
 Broken ribs
 Always inform the police about the serious
accidents.  Subcutaneous emphysema

Purpose of first aid  Auscultation (listen) auscult for

 To sustain/ preserve life of victim.  Pneumothorax: decreased breath
 To promote recovery sound on site of injured lungs.
 To prevent worsening of patient condition.  Detection of abnormal sounds in the
 To provide reassurance and comfort to the chest
causality. Manage by:
Steps of first Aid  Mouth to mouth respiration
i. Assessment of the situation:  AMBU bag ventilation
 Be calm and take full responsibilities.  O2 inhalation if available
 Ensure your safety. c. Circulation:
 Help the victim until a doctor or more Assess
qualified person arrives.  Pulse rate
ii. Assessment of victim:  BP
 Assess the victim with the help of eyes,  O2 supplies
ears, smell & touch. Manage
iii. Give immediate first aid treatment:  Stop external hemorrhage
manage the victim according to ABCDE:  Establish 2 large bore IV lines (14 G or 16
A. Airway: G if possible) (done in case of PR  BP  )
Assess,  Administration of fluid, if available.
 Can the patient talk & breath freely? d. Disability
If obstructed: Make a rapid neurological assessment, assess
 Head tilt, chin lift, Jaw thrash, finger by AVPU
sweep  A - Awake or alert
 Suction (If available)  V - Verbal response
 NAME Module-II: Clinical Section 3
 P - Painful response Cause
 U - Unresponsive  Blood loss: Massive hemorrhage due to any
e. Environmental Exposure cause
 Undress patient & look for injury  Plasma loss: Burns, Acute pancreatitis
 Avoid over crowding around patient  Fluid loss: Diarrheal vomiting, diuretics,
Nephrogenic Diabetes insipidus.
f. Refer the victim to the nearest doctor,
hospital or home as needed. Clinical features
 Pallor
SHOCK:  Restlessness
 It is a state of acute circulatory inadequacy  Sweating
leading to impaired cellular perfusion  Tachycardia with thready pulse
generalized tissue hypoxia & vital organ  Hypotension
damage.  Rapid shallow berating
 Shock is an imbalance between oxygen  Low urinary output or anuria
delivery & oxygen demand, this results in cell
dysfunction and ultimately cell death &
Treatment:
multiple organ failure.  First goal is to restore intravascular volume
as early as possible.
Clinical feature
 Ensure an adequate airway with 100% O2.
Symptoms Signs
 Keep the patient recumbent and elevate the
 Dizziness  Cold & clammy skin foot of the bed.
 Sweating Nausea  Fast & weak pulse  Monitor vitals BP, PR, RR, T urinary output.
 Fainting  Hypotension  Establish the IV line and give fluid.
 Pallor  Loss of consciousness  0.9% NaCl or ringer's lactate is the fluid of
 Thirst  Anuria choice.
Types:  Arrange blood for transfusion in case of large
1. Hypovolemic shock amounts of blood is loosed & patient is
2. Cardiogenic shock anemic.
3. Obstructive shock  Before blood available infuse 5% albumin
haemacel or dextran.
4. Distributive shock
5. Dissociative shock
Perfusion is normal but impaired Hypovolemic Shock
dissociation of O2 from Hb.  Most priority goal of hypovolemic shock
 Co poisoning management is restore intravascular volume
 Methemoglobinemia as early as possible.
Hypovolemic shock  0.9% NaCl or Ringer's lactate is the fluid of
choice.
 Shock due to decrease circulatory plasma
 Most common type of shock first aider may
volume.
encounter is caused by hypovolemic shock.
Decreased intravascular volume
  In hypovolemic shock hypotension with
Decreased preload tachycardia occur.
  The most commonest type of shock is
 Stroke volume hypovolemic shock.
 Cardiogenic shook
 CO (Cardiac output)
 Intravascular volume is normal or increased

but cardiac output is decreased due to
Hypovolemic shock
impaired myocardial contractility.
 4 Health Assistant Loksewa Module-II
Cause Treatment:
 AMI, myocarditis, cardiomyopathy,  1° goal is treatment of infection & removal of
dysrhythmias septic focus.
 Trauma/ surgery  Culture of blood & urine.
 Drug intoxication  Broad spectrum antibiotic administration.
Treatment:  I/V fluid administration.
 1° goal is to improve myocardial Neurogenic Shock
contractility.
 Neurogenic shook is shock caused by the
 Bed rest, propped up position O2 inhalation. sudden loss of the autonomic nervous
 Avoid excessive IV fluid. system signals to the smooth muscle in
 Monitor urine output & input charting vessels walls.
 Isotropic agents e.g. Dobutamine/ dopamine.  Bradycardia with hypotension is the
features of neurogenic shock
Treatment
 Highest mortality is seen in Cardiogenic  Self limiting lasts for only 5-10 minutes if it is
shock. (70-90%) causes by sudden pain, strong emotion etc.
 Excess fluid administration is  Keep in recumbent position with head down
contraindicated in Cardiogenic shock. position.
 Analgesic & sedative for pain.
Obstructive shock:
 IV atropine 1 ampoule (0.6 mg) IV slowly for
Intravascular volume & myocardial contractility
bradycardia.
normal but cardiac output is decreased due to left
ventricular outflow obstruction. Anaphylactic shock
 Cardiac tamponade  Anaphylactic shock a hypersensitivity
 Massive pulmonary thromboembolism reaction occurring in response to previous
sensitization to an antigen.
 Tension pneumothorax.
 It is life threatening, can occur within
Distributive shock:
seconds/ minutes of exposure to allergens.
Cardiac output is characteristically high but Causes
unevenly distributed leading inadequate perfusion
 Drugs: penicillin, Inj. of Cephalosporins.
to certain vascular beds.
 Inj of Tetanus Toxoid antiserum, anti-venom.
Types:
 Bee or wasp stings.
 Septic shock
 Injection of iodine containing contrast media
 Neurogenic shock: spinal injury, spinal
for IVU.
anesthesia.
Treatment
 Anaphylactic shock
 Bed rest, propped up position O2 inhalation &
 Endocrine shock: hypo/hyperthyroidism,
ventilation, endotracheal intubation if
acute adrenal insufficiency.
required.
Septic shock (Endo-toxic shock)  Adrenaline
 It is due to toxin released by bacteria, toxins  Hydrocortisone (steroid)
cause dilatation of arterioles and capillaries.  Chlorpheniramine (histaminic)
 Usually by gram negative septicemia.  If significant wheezing salbutamol
 Main symptoms are fever followed by chills nebulization, Aminophylline may be used.
& hypotension.
 NAME Module-II: Clinical Section 5
ii. 2nd degree burn
Superficial
 Shock is life threatening, due to poor tissue  Involves epidermis & papillary dermis.
perfusion and impaired cellular metabolism.  Epidermis blistered & layer lost, dermis
Oxygen and nutrient are not delivered to cell pink & moist
of the body.
 Most painful
 Shock related to toxins is septic shock.
 Pinprick sensation- normal
 Shock related to IgE is anaphylactic shock.
 Heals within 1 week without residual
 Shock resulting form anxious/ painful scorning.
stimulus or spinal cord trauma is neurogenic Deep
shock.
 Involves epidermis, papillary dermis &
 Out of four vital organs: Heart, liver brain deeper parts of reticular dermis.
and kidney; only kidney can tolerate hypoxia
up to 1 hour without permanent damage.  Pinprick sensation is decreased.
 Heals in ≥ 3 week with hypertrophic
 In hypovolemic shock and Cardiogenic shock
scarring.
stroke volume is reduced.
iii. 3rd degree burn:
 Distributive shock includes septic shock,
anaphylactic shock and neurogenic shock.  Involves epidermis, entire dermis,
subcutaneous tissue and skin
 DO NOT elevate legs if the causality has an
appendages.
unsplinted broken leg, head injury or
abdominal injury.  Painless, Hard, lethargy skin, thrombosed
vessels.
 In all type of shock skin is cold except septic
shock in which temperature is increase.  Pin prick reaction absent
 In all type of shock tachycardia with  Heals by contracture/ skin gift.
hypotension but in neurogenic shock iv. 4th degree burn:
bradycardia with hypotension.  Involves underlying tissues, muscle bone
 In all shock patient kept in low head etc.
position expect cardiovascular shock kept  Insensitive to pin prick,
in half sitting position.  Skin grafting is needed.

BURN AND SCALD Assessment of burn:

 Assessment of extent of burn in terms of
 Coagulative destruction of the surface layer
body surface area (BSA) a calculated by Rule
of the body is called burn/ scalds. of Nine or (Rule of Wallance)
 This destruction is caused by dry heat is  Area of 1 palm is taken as 1% BSA.
called burns & by moist heat is called scalds.
Classification
 Depending upon depth of skin involved burn
is classified into 4 types:
i. 1° burn (Superficial burn):
 Involves only epidermis, red painful with
no blisters.
 Heals within (48- 72 hour) 1 week
without residual scarring.
 Overexposure of sun can cause 1° degree
burn in which red skin occur (erythema)
[PSC of HA 2072]
Figs: Percentage of burns in Adults; Children
 6 Health Assistant Loksewa Module-II

Parts In Adult In In hemodynamically normal. Boluses are

(% of Children Infant reserved for unstable patients.
BSA) (% BSA) 3. What fluids? Use RL or NS. However, ORS is
Head & neck (1×9) 9 18 20 also very effective and will reduce costs if the
person can drink (who has no burns inside
Front of trunk (2×9) 18 18 20
the mouth). Use a NG tube if necessary
Back of trunk (2×9) 18 18 20 4. Give pain relief: paracetamol 1g TDS, avoid
(trunk includes chest & NSAIDs.
abdomen) 5. Strict I/O charting: target urine output of
Upper limbs (2×9) 18 18 20 30ml/hour or more.
Front of lower limb 18 13.5 10 Procedure in BHCS Facility
(2×9)  Wash burn area with soap and water for 20
Back of lower limb 18 13.5 10 minutes (presenting within 24 hours of
(2×9) burn). Use plenty of cold water to cool the
Perineum(1×1) 1 1 - wound if the person has come to the health
facility within 1 hour after a burn
Total 100% 100%
 Do not burst blisters on the first day or if
Note: It is head and lower limb percentage referral is needed. Burst blisters and remove
which differ in adults and children. the dead skin over blisters with a sterile
 Lund and Browder Formula applies in blade after the second day.
children which states that % BSA is as states  Give Inj TT 0.5ml IM stat
above in the table and each year 1% is
 Apply Silver Sulphadiazine (SSD) cream on
reduced from head and neck and added to
the burnt area.
lower limb.
 Clean healing wounds should not be dressed
Management daily. The wound should be dressed every
1. Work out if the patient needs extra fluids. In four or five days with non-stick Vaseline
general, adults with more than 20% burns gauze. If the dressing gets wet, it should be
and children with more than 10% burns changed immediately.
need extra fluids.
 All slough or dead tissue must be removed if
2. How much fluid? possible.
 Adult patients with deep-partial and full-  Give antibiotics if there are signs of wound
thickness burns involving more than 20 infection: cloxacillin or amoxicillin.
percent of the total body surface area
Food calculation in burn:Modified parkland
(TBSA) should receive initial fluid
formula:
resuscitation of 2 ml of lactated
ringers/kg/%TBSA.  The amount of fluid volume in ml in 1st 24
hour.
 Paediatric burn patients: fluid
 Body weight (in Kg) × % Of burnt surface
resuscitation is calculated based on 3
area × 4ml =Fluid in ml.
ml/kg/%TBSA
Amount:
 Electric Burns: 4 ml/kg/%TBSA
 ½ fluid is given in 1st 8 hours.
 Half of the fluid is given over the course
 ¼ fluid is given in 2nd 8 hours
of eight hours and the remaining half is
provided over a span of 16 hours.  Remaining ¼ fluid is given in 3rd 8 hours.
 The rate of fluid administration should be NOTE:
titrated to effect using a target urine  The most ideal fluid is RL. in burn and
output of 0.5 ml/kg/hr in adults or 1 remember only 2nd, 3rd and 4th degree burns
ml/kg/hr in children who are are to be considered while calculating BSA
 NAME Module-II: Clinical Section 7
and maximum fluid that can be given in 4  Infection in burn patients are commonly due
ml/kg  50% BSA even if the BSA exceeds to streptococci.
50%.  RL is the best fluid for burn patient to
Referral: resuscitate fluid.
 Children with more than 10% of body  Parkland's formula is used to calculate fluid
surface area burnt in burn.
 Adults with more than 20% of body surface
area burnt POISONING
 Those who have burns of the airway  Poisoning is a condition caused by
 Full-thickness burns if the wound is over a introduction to harmful substances or
joint or it is large. chemical into the body either by injection,
inhalation or ingestion.
 Electrical burn
 A poison or toxin is a substance when, if
 Burn by swallowing acid or alkali.
taken into the body in sufficient quantity, can
 During referral: advise extra fluids, may cause temporary or permanent damage.
need IV fluids also. Make them drink plenty
of ORS on the way to the hospital.
Route
i. Ingestion (by swallowing)
Q. A 40 year male presents to you with burns
ii. Absorption (through the skin)
involving head, face and trunk constitutes
how much percentage: iii. Inhalation (breathing it)
a. 45% b. 55% iv. Injection (injected into the body)
c. 60% d. 65% Cause of poisoning:
Ans: (a) 1. Accidental poisoning:
When the poison ingested without knowing
about it. E.g. Children may swallow their
parent medicines, most frequent between the
 Scald is type of injury caused by moist heat.
ages of 1-5 years.
 The most common form of burn is thermal
burn. (scald) 2. Suicidal poisoning:
 Entry & exit wound is feature of electrical When a person ingests any harmful
burn. substance intentionally with the purpose to
 Electrical burn is most dangerous. commit suicide.
 Alkali burn is danger then acid because it 3. Homicidal poisoning:
can penetrate and cause damage to deep It may be administered intentionally for
layers. killing enemies
 Spidery pattern of burn seen in lightening Common types of poisons:
injury.  Organophosphate poisoning eg. Metacid.
 Burn to children under 5 and also the elderly (Most Common in Nepal)
must take care by a medical professional.  Zinc phosphate poisoning
 In children with burns over 10% TBSA &  Alcohol poisoning
adults with burns over 15% TBSA. Consider  Dhatura poisoning
the need for intravenous fluid resuscitation.  Kerosene poisoning
 Erythematic burn is generally caused by sun  Paracetamol poisoning
burn. [PSC of HA 2072]  Diazepam poisoning
 Superficial second degree burn is most
Organophosphorous poisoning:
painful.
 Most common types of poisoning in Nepal.
 8 Health Assistant Loksewa Module-II
 Common organophosphorous compounds vomiting in such cases but give milk of magnesia,
include malathion, parathion, methyl sodium bicarbonate in water for acidic poisoning
parathion (Metacid). and lemon juice, vinegar for alkali.
 OP compounds are used as pesticides in Give activated charcoal for both type because it
agriculture as for eradication of vectors of prevents absorption of poisonous substance.
malaria & filiariasis.
Diagnostic features:
 History of intake.  Mix the charcoal with water and make victim
 Typical smell from mouth swallow. The charcoal prevents absorption of
 Constricted pupil (miosis) poisonous substance.
 Excessive salivation  Activated charcoal is universal antidote.
 Abdominal pain associated with diarrhea &  All poisoning case are medico-legal cases
vomiting. (police case)
 Frequent micturation  Toxicology: study of poison
 Slow pulse  Constricted pupil, diarrhea, vomiting,
 Difficulty in breathing salivation, urination, lacrimation are factures
 Muscle cramps/ fasciculation's of OP poisoning.
 Confusion coma  In poisoning 1mg/kg body wt. activated
Treatment charcoal is given within one hour of poison
ingestion.
 Clear excessive secretion from the mouth by
suction.  Kerosene poisoning is the most common type
of poisoning in children.
 Do gastric lavage in a conscious patient
repeatedly till washing becomes clear.  Organo-phosphorous poisoning is the most
common poisoning.
 Maintain an intravenous line.
 Inj. atropine (0.6 mg/ml) 3 to 6ml is given  Self poisoning is common in adult.
intramuscularly or intravenously- repot  Unconsciousness victim kept in left lateral
every 15 minutes till sign of atropine toxicity position to prevent aspiration.
(dry mouth, tachycardia ≥ 120 bpm, papillary  Slow pulse in –OP, mushroom
dilation) appear.  Rapid pulse-Dhatura, over atropinization
 Pralidoxime  Low blood pressure-Diazepam,
 Change the contaminated cloths and chlorpromazine, OP.
belongings.  Delirium hallucinations-OP, Dhatura,
 If possible use N.G. tube for unconscious alcohol, Aspirin.
patient.  Blurred vision: Dhatura, OP, alcohol etc.
In case of general poisoning:  Contracted pupil-OP, morphine, pethidine,
 Maintain A.B.C (airways, breathing &  Dilated pupil: Dhatura, atropine,
circulation) barbiturates.
 Gastrointestinal decontamination
 Gastric lavage HEMORRHAGE:
 Treat with activated charcoal.  Hemorrhage is defined as escape of blood
from the vascular compartment to the
Note:
exterior (outside the body, in the tissue,
If victim had taken corrosive poisoning, Gastric within a cavity)
lavage is not recommended, and not appropriate
way to manage by vomiting, so do not induce
 NAME Module-II: Clinical Section 9
Classification  Diathermy electro coagulation
A. According to nature of vessels:  LASER
a. Arterial: Bright red, more pressure rapid  Grafting
& profuse blood loss spurts like jet.
2. Restoration of blood volume:
b. Venous: dark red in colour
 By transfusing normal saline, ringer
 Less pressure, easiest to control then
Arterial bleeding. lactate, dextran, haemacele.
c. Capillary:  By blood transfusion.
 Red in colour  Restoration of the blood volume is
 Continuous flow carried out based on the following
guideline.
 Easiest to control
B. According to duration: Up to 10% of No replacement
i. Primary hemorrhage: It occurs during blood loss
accident, surgery operation or injury. At 10% blood loss Normal so line, Ringer lactate
ii. Reactionary hemorrhage: occur within At 10-15% of ½ Crystalline solution & ½
24 hours of injury or operation e.g. After blood loss colloidal solution
tonsillectomy after thyroidectomy.
> 15% blood loss Replace by whole blood.
iii. Secondary hemorrhage: occur after 7
3. Other measures
days of injury or operations mostly due to
infection. 1. Rest
2. Sedation by inj. morphine
Symptoms & Signs:
3. Treat the cause
 H/O injury or operation
4. Prevention of hematoma formation by
 Restlessness or giddiness
suction
 Subnormal temperature
5. Urine output measurement.
 Lowering of BP
 Perspiration
 Increasing pallor
 Thrust  More than 50% blood loss cause heart failure
& death.
 Air hunger
 Capillaries bleeding are most common.
 Scanty urine  Distal end of wounded extremities (fingers &
 Rising PR which becomes weak in volume toes) should be checked periodically for
hence called thread. adequate circulation.
 Tinnitus-tingling in the ear.  Most common effective field method to
control bleeding is direct pressure.
Management:  Initial fluid resuscitation for trauma patient
1. Control of bleeding in hemorrhagic shock is 2L of normal saline.
1. Position: elevation of the limb.  Reactionary Hemorrhage: occur within 24
hours of surgery (But usually 4-6 hours)
2. Pressure and packing
 Digital pressure Q. Reactionary hemorrhage occurs after ......
hours:
 Ribbon bandage a. 24 hours b. 48 hours
 Ligature c. Within 24 hours d. After 7 days
 Diathermy electro coagulation Ans: (c)
 10 Health Assistant Loksewa Module-II

FRACTURE (#) Clinical feature [@ PULSE]

 Fracture defined as structural break in the 1. P – pain all the site of fracture
normal continuity of bone cartilage epiphysis 2. U- unusual shape & deformity
& epiphyseal plate. 3. L-loss of function, difficulty of movement,
Classification loss of mobility or abnormal movement &
A. Etiological classification: function
1. Traumatic fracture: due to sudden injury 4. S- swelling, tenderness, shock
2. Pathological fracture: in weak bone due 5. E- Extra movement, crepitus sound on
to presence of any pathological condition fracture site.
3. Stress fracture: due to repeated minor Investigation
trauma at the same site. A. Specific investigation (for diagnosis)
B. Clinical classification (According to i. X-ray of affected area (AP and lateral
communication with exterior) view)
1. Simple or closed fracture: the fracture ii. CT scan
which is not communicated with external B. Investigation for G/A:
air (No risk of infection or Osteomyelitis)
i. Blood for HB% TC, DC, platelets, ESR.
2. Compound or open fracture: the
fracture which is communicated with ii. Chest x-ray PA view
external air through the would of skin iii. ECG (for patient > 35 years)
and soft tissue. iv. Blood urea, serum, creatinine
c. Radiological (according to the v. blood grouping & Rh typing
configuration of the fracture/ according
to direction of force) Q. The most important aspect of
management of compound fracture is:
1. Transverse fracture: by angulation
a. Wound debridement
force.
b. Internal fixation
2. Oblique fracture: by twisting force
c. Accurate reduction
3. Spiral fracture: by twisting force d. Nerve pair
4. Communicated fracture: more than two Ans(a)
fragments by angulation force (rushing Q. Major cause of death in fracture of femur
force or direct force. is due to:
5. Greenstick fracture: The fracture is a. Infection b. Delayed healing
incomplete, the periosteal lining of the c. Hemorrhage d. Gangrene
bone is in fact seen only amongst Ans: (c)
children.
First aid treatment (@ RICED)
6. Wedge fracture: in vertebral body by
vertical force.  R- Rest (make the patient comfortable)
7. Depressed fracture: direct violence eg.  I- Immobilize the fracture part with suitable
Skull bone. splint to reduce the movement at the fracture
part.
 C- Cold compression to reduce the swelling
 E- Evaluation of patient condition, conscious
level
 D- Diagnose soft tissue injury
Complication of fracture
A. Immediate
Local General/ remote
i. Skin laceration i. Shock
Fig: Different type of fracture
 NAME Module-II: Clinical Section 11
Local General/ remote Subluxation:
ii. Bleeding ii. Multiple organ  A joint is subluxated when it's articular
iii. Injury to muscles system failure surfaces are partially displaced but retain
tendons, vessels, some contact one with the other.
nerves, soft tissues &
viscera You must know
B. Early  Anterior shoulder joint dislocation is the
1. Skin-infection, necrosis & gangrene common in adult.
2. Acute compartmental syndrome  Elbow dislocation is the most common
3. Gas gangrene dislocation in children. In adults, it is second
4. Tetanus most common dislocation.
5. Pulmonary embolism Symptoms & signs:
6. Fat embolism  History of injury or accident.
7. Crush syndrome
 Pain to stretching of joints, pressure over the
8. Delirium tremens
nerves.
C. Late
 Loss of function & mobility of joints.
i. malunion, non-union, delayed union & a
vascular necrosis.  Bony ends may be detected in the abnormal
ii. growth retardation-from epiphyseal plate position.
injury.  X-ray of AP Lateral views will show at the
iii. post traumatic osteoporosis bones in a normal position.
iv. Re-fracture Treatment:
v. chronic osteomyelitis.  Reduction of dislocation by using I.V.
vi. joint stiffness injection of 10 mg of diazepam.
vii. accidental neurosis  Old dislocation/Recurrent dislocation will
Key concept on fracture need operative correction of the joint.
 Figure of 8 bandage is used in clavicle Strain:
fracture. [PSC HA 2072]  Strain is injury to tendon (muscle to bone
 If it is an open fracture and the bone is injury)
protruding from the skin do not attempt to  Sprains: ligament injury or bone to bone
push the bone under the skin. injury
 The most important focus in fracture Sign & symptoms:
management is to effectively treat any
 Pain in the area of injury.
associated external bleeding and to perform
immobilization.  Lack of or limited movement.
 Greenstick fracture is commonest fracture  Inability to bear weight
in children.  Swelling
 Distal radius fracture is most common  Tenderness
fracture in children  Bruising
 Supracondylar fracture of humerus is
commonest fracture of children between Treatment: (RICED approach)
ages of 5-10 years. i. R – Rest: Stop the activity
ii. I -Ice for to 20 min to decrease swelling
DISLOCATION: iii. C- compression to reduce swelling
Dislocation: iv. E-elevation the affected part above the heart
 Dislocation means disruption of joint with level.
total loss of contact between two articular
v. D-Diagnosis soft tissue injuries
surfaces.
 12 Health Assistant Loksewa Module-II

FROST BITE  Gangrene at last stage, which requires

operation or amputation of the part.
 Frostbite is damage caused by extreme cold
to skin/ tissues.
First Aid management
 Gradual warming of the part is very
 At extreme cold (–4°C to 10°C or below), important (do not heat the part direct)
blood vessel constrict to preserve body  Do not rub the area, do not burst blisters, do
temperature, when this state persists tissue not heat the part with fire or hot water
injury occurs. bottles.
 Frost bite usually affects tissues which are  Treat hypothermia first if present.
distant from the heart.  The gangrenous part blisters, should be
 Mostly affected organ are: carefully protected.
 Tip of the nose  Remove constricting clothing items that
could impair circulation.
 Pinna of ear, finger, neck, check etc.
Types
There are two types of frost bite:  Deep frostbite is a very serious injury and
a. Superficial frostbite:- only the skin and top requires immediate first aid and subsequent
level of tissue are affected and a full recovery medical treatment to avoid or minimize loss
is likely after the skin and tissue has turned of body parts.
back into water after being frozen.  Frost bite is severe form of hypothermia,
b. Deep frostbite: If deeper tissue becomes includes all layers of skin and it appear
frozen & blood vessel are affected damage white.
from frost bite is more likely to be  Deep frost bite can include freezing of muscle
permanent. and/or bone, it is very difficult to rewarm the
Risk factor: appendage without some damage occurring.
 Diabetes patient  Gangrene is seen in Fourth-degree frost bite.
 Any kind of trauma in cold weather  Don't walk on frostbitten feet or toes if
 Peripheral neuropathy possible. This further damages the tissues.
 Use of Beta blockers Do not rub area that is frostbitten or rub
snow on it.
 Age elderly & newborn
 Don't use direct health, such as stove, heat
Clinical features: lamp, fireplace or heating pad because these
 History of exposure to extreme cold for can cause burns before you fell them on your
house and days. numb skin.
 The affected part may be cold, painful and  Chilblains is superficial tissue injury, occurs
stiff. after prolonged intermittent exposure to
 Feeling of blanching and numbness may be temperature above freezing and high
present in early stage. humidity with high winds.
 Skin discolorations: paleness followed by  Preventing exposure to cold is best
numbness. treatment of Chilblains.
 Loose skin.  Trench foot (Immersion foot) is caused by
 Tingling/ burning sensation: pin and needle prolonged immersion of the feet in cool, wet
sensation. conditions.
 Delay or no capillary refilling.  Warning signs of hypothermia include
 Blistering. increased shivering, slurred speech,
In severe cases impaired judgment, and poor muscle
 Hardening & stiffing of the skin. coordination.
 Loss of sensation and loss of movement of  Gradual warming of the part is very
the part may be present. important (Do not heat the part)
 NAME Module-II: Clinical Section 13
Different form of Hyperthermia:  Redness & swelling
 Heat exhaustation: It is caused when the  Sting may be visible at bitten area
body loses too much water and salt due to  Dizziness
long term exposure to extreme heat. If the  Children especially may have sign of
body temperature does not cool down, it may shock, sweating, nausea, difficulty in
also lead to heat stroke, which may be life breathing (Anaphylactic shock)
threatening.  Sometimes a person complains of
 Heat stroke: It occurs when the body cannot vomiting and can become unconscious.
cool itself any longer. Sweating stops and the  Slow pulse rate
internal temperature of the body becomes Treatment:
too high.  Cold compress
 Heat Syncope: It occurs with orthostatic  Tie with a cold above the bite gently
hypotension resulting from volume  Inj. Xylocaine locally to relieve pain
depletion, peripheral vasodilatation  Symptomatic treatment
(Physiologic response to heat production)  Refer to hospital
and venous pooling. prolonged; standing
2. Spider bite:
after significant exertion and rapid change in
 Spider are generally found in the gaps of
body position after exertion, such as from
wood, hollow, places, corners of the
sitting to standing, may lead to heat syncope.
house and dark places.
 Heat Cramps: These are acute, painful and
 Very few spiders are poisonous.
involuntary muscle contraction that occur
during or after intense exercise sessions in Signs & Symptoms:
the heat. Muscle involved are usually the calf,  Redness, severe pain and local swelling
quadriceps, and abdominal muscle. Heat  After the adsorption of the poison from
cramps are associated with fluid deficiencies bitten area, the affected person suffers
from stomach cramps & muscle become
(Dehydration), electrolyte imbalances and
hard.
neuromuscular fatigue.
 Face hands and legs look swollen.
BITES  Breathlessness and condition of shock
can arise.
 Bite means injury resulting from a cut with
First Aid
the teeth or sting. Bite may be either by
 Hot compression (only in Spider bite Hot
insects or animals.
Compression done)
Types of Bite:  Inj. Lignocaine at the bite of bite.
1. Insect Bite:  Antihistamine
2. Dog bite, scorpion, wasp, hornets, bees,  Symptomatic treatment.
spider etc. C. Bees and wasps Stings:
3. Snake bite. Most harmful among the insects are the bees
1. Insect Bite: Scorpion & wasps.
Generally scorpion can be seen in the moist Symptoms
dark places and in rainy season. Scorpion  Histaminic reactions
bite rarely leads to a serious condition but  Local pain & swelling
there is severe burning, intorable increasing  Respiratory inhibition because throat
pain in the bitten area. swelling & low blood pressure because of
Symptoms: contraction of the air pipe occur.
 Severe in tolerable pain & swelling at the
 The patient can be unconsciousness.
site of bite.
 14 Health Assistant Loksewa Module-II
Treatment Symptoms and signs
 Take out the sting with forces.  History of snake bite
 Do not squeeze poison sac.  Presence of two fang mark on the site of bite
 Wash the site with soap & water in case of poisonous.
 Cold compress by applying alcohol, spirit  Pain and burning sensation at the site of bite.
or ice.  Severe pain abdomen & vomiting
 Apply calamine lotion for itching.  Pain and burning sensation at the site of bite.
 Use antihistamine in case of allergic  Severe pain abdomen & vomiting
reaction.  Heaviness &/ or drooping of eyelids (ptosis)
 May be diplopia (doubling) &/ or Blurring of
vision.
 Bee and wasps does not bite but stings.  Paraesthesia (numbness) around the mouth
 Bee of venom is acidic and venom of wasp is  May be haematuria (red urine)
alkaline.  May be bleeding from nose & gums.
 Mosquito bites reactions are due to allergens  Difficulty in breathing (dyspnoea)
present in the toxins.
 Vertigo & excessive salivation
 Bee sting in mouth and throat may cause
 Inability to move eyelids
asphyxia.
 Scorpion stings are painful but usually not
dangerous.
 Reassure the causality and keep hip calm is  Muscular & respiratory paralysis causes
also most important. death in kraits & cobra bites.
 Do not squeeze the sac attached to the  In viper bites there is bleeding from the site,
stinger because it may inject more venom. hematuria, hematemesis, hemoptysis etc.
 Inset bite may cause anaphylactic shock. (Bleeding disorder)
 Cold compress is given in all type of bite
Management:
except spider bite where Hot compression is
given. Steps for the snakebite management:
STPES Features
SNAKE BITE 1 First aid treatment and transport to the
 Snake bite occur when a snake bites the skin hospital
 They are medical emergencies if snake is 2 Rapid clinical assessment and
venomous. resuscitation
 When poisonous snake bite, it releases its 3 Antivenom treatment
venom. 4 Supportive treatment
 Snakes have fangs at front of their mouth
5 Treatment of the bitten part
with the help of which it injects venom from
i. First aid:
its parotid glands.
 Reassurance the patient, keep calm &
Type of venom (@ See My HeVy NeCK) complete rest (First step): The victim
Venom type Species may be very frightened and anxious.
Reassure victim that most of the
Neuro toxics venom Coba, kraits
suspected snakebite are caused by
Hemotoxic Vipers nonvenomous snakes.
Myotoxics Sea snakes  Immobilization: Immobilization the
bitten limb with a splint or sling. Any
 NAME Module-II: Clinical Section 15
cloth or bandage may be used for this, as  Pit and fangs are present
done for fracture limb. Any form of  Tail is mostly pointed
movement causing muscle contraction  Features o non-poisonous snake:
like walking, undressing will increase
 Rounded head.
absorption and spread of venom by
 Dual row of scales after anal plate.
squeezing veins and lymphatics.
 Round pupil.
 Locate fang marks, clean with soap &
running water.  No fangs, but teeth present.
 Remove rings, jewelries, tight fittings and
 Tail is mostly pointed.
clothing and avoiding any interference  Reassurance of patient is most important
with the bite wound to prevent infection, first aid management mostly in non-
increase absorption of venom and venomous snake bite.
increase local bleeding.  Instruct to the patient to lay down flat on the
 Apply splint (Not tourniquet) ground; kept the bitten body part below
heart level (DO NOT lift the bitten part above
 Try to keep bite site at the level of below
the chest.
heart.
 DO NOT apply tourniquet or constriction
 Refer patent to hospital.
band, it can cut off blood flow to the limb,
ii. Hospital measures: causing more damage than the snakebite.
 A large bore IV cannula should be  DO NOT wash the bite site with soap and
inserted on an affected limb. water or any other solution to remove venom
 Monitoring of BP, coagulation profile, from the bite site. Action of washing
cardiopulmonary, renal & neurological increases the flow of venom into the system
profile. by stimulating the lymphatic system.
 Treatment of complications  DO NOT make cuts or incisions on or near
iii. Antivenom treatment: the bitten area. Viper bites can cause
uncontrollable bleeding.
 Antivenom should be given if snake is
 DO NOT attempt to suck venom out with
poisonous complications of snake bite
your mouth. It is ineffective and does not
 Acute tonal failure
remove venom. You could have an ulcer or
 Respiratory paralysis wound in your mouth, allowing venom to get
 Bleeding diathesis into your bloodstream.
 DO not attempt to capture, handle or kill a
venomous snake. More people are bitten
during these activities than in any other
 Rabies is caused by virus and is the form of situation.
encephalitis.  Do not go to traditional healers or quacks.
 Dogs bite are responsible in >96% of cases.  DO NOT give the victim drink, alcohol or
 Kraits and Russell's viper much more toxic other drugs. This can cause complication in
than that of Cobra. the successful treatment of the bite.
 Russell's viper can produce neurotoxic  If bite cannot be positively identified as
symptoms too. poisonous or non-poisonous, treat as a
 Features of Poisonous snake includes: poisonous bite.
 Triangle shaped head.  Healthy, Angered, & Hungry snake has more
Venom.
 Single row of scales after anal plate.
 Elliptical pupil
 16 Health Assistant Loksewa Module-II

DROWNING  Keep in recovery position (in no spinal injury

 Drowning is a condition when the victim and pulse & breathing is present)
inhales or ingests water through his/her  Remove water by pushing abdomen.
respiratory and alimentary tract.  Wet cloths should be removed and passive
 There is chance of death if drowning is 2-5 external rearming.
minutes and death is sure if more than 5  Monitor vitals.
minutes.  Shift victim to hospital.
 Drowning is the third most common cause of Complication
accidental death. Immediate:
 Commonly seen in under 14 years age group,  Pulmonary edema
males, & alcoholics.  Hypoxic encephalopathy
Types:  Respiratory & metabolic acidosis
i. Dry drowning: no water into the lungs Other Complications
(laryngospasm)  Aspiration pneumonia
ii. Wet drowning: It occur when inhaled water  Acute lung injury
interferes with respiration & cause  Acute respiratory distress syndrome
respiratory system to collapse.  Empyema
Wet drowning can be fresh water or sea water
Most common cause of drowning by age:
 Infants/ young children:  Near-drowning is defined as survival for
 Domestic baths longer than 24 hours after suffocation by
 Garden pools immersion.
 Adolescents:  Drowning is the process of experiencing
 Swimming pools respiratory impairment from submersion/
 Rivers, Sea immersion in liquid.
 Adults:  There is chance of death if drowning is 2-5
 Water spots, boating minutes and death is sure if more than 5
 Occupational fishing minutes.
 Older people  Drowning is the third leading cause of
 Domestic baths unintentional death worldwide.
[Ref. Davidson's Principle & Practice  Droning is most common in males, alcoholics
Medicine/22nd] and under age of 5 years.
Symptoms & Sign  No breathing, No pulse, cold calm skin,
 Abdominal distension Cyanosis, congested conjunctiva froth and
 Bluish skin of the face, especially around the mud in mouth is feature of drowning.
lips.  Washer man's hands and feet, if drowning for
 Cold skin & pale appearance more than 12 hours.
 Lips and fingernails may be cyanosed.  Ensure your own safety is the first step in
 Cough with pink, frothy sputum first aid management of drowning.
 Restlessness  Pulmonary edema, hypoxic encephalopathy,
 Snoring or gurgling breathing Respiratory and metabolic acidosis is the
 The victim may be confused, immediate complication of drowning.
unconsciousness.
CELLULITES
 Frothing at the mouth & nostrils.
First aid treatment: Spreading inflammation of subcutaneous tissue or of
 Ensure your own safety first. facial planes due to streptococcus is called cellulites.
 Remove the victim from water as early as Causative agents:
possible.  Streptococcus pyogenes [Most Common]
 Check airway for foreign materials. Predisposing Factor:
 If not breathing, give artificial breathing.  The elderly and these with weakened
 If no pulse, perform CPR. immune systems.
 DM
 NAME Module-II: Clinical Section 17
 Immuno compromised conditions  Swelling
 Malnutrition  Fever
 Alcoholics  Loss of appetite
Clinical features:  Insomnia
Symptoms: Sign
1. Pain which is constant in nature, but may be  Calor (heat): Due to local rise in
throbbing when an abscess is formed. temperature following increased circulation
2. Fever, malaise, lassitude, loss of appetite.  Ruber (redness): Due to vasodilatation &
Signs: hyperaemia.
1. Patient is toxic  Dolar (pain): Due to irritation on nerve ending.
2. It is firm initially later may become soft.  Tumor (swelling): Due to increase
3. Fluctuation test may be +ve (when abscess is permeability of vessels & accumulation of fluid.
formed)  Loss of function due to pain.
Investigations  Fluctuation test positive.
i. Blood-Neutrophilic, Leucocytosis  Regional lymph node enlarged and tender
ii. Culture & Sensitivity Treatment:
Treatment:  Rest on elevated position
1. Conservative management:  Hot compression
 Bed rest  Analgesic & antipyretics
 Elevation of the affected part to reduce  Antibiotic cloxacillin 500 mg ×6 hourly × 5-7
oedema. days.
 Antibiotics-inj penicillin, 6 lak. IV 6  I&D
hourly for 10-14 days. Complications:
2. Operative treatment:  Spontaneous rupture.
When abscess formed –incision & drainage of  Hemorrhage
pus with debridement of the dead tissue.  Haematoma formation
Complications  Sinus formation
 Septicaemia  Antibioma (Antibioma is antibiotic induce
 Pyemia swelling in abscess without incision &
ABSCESS drainage)
 A localized collection of pus lined by Cold abscess
granulation tissue is called abscess.  A cold abscess is an abscess that commonly
Types of Abscess seen in tuberculosis.
i. Pyogenic abscess  It develops slowly so that there is little
ii. Pyaemic abscess inflammation or no signs of inflammation.
iii. Cold abscess due to TB MOST COMMON IN FIRST AID
Causative agents Sprain Ankle, knee, wrist joint
 Staphylococcus aureus Poisoning in children Kerosene poisoning
 Streptococci Bandage Roller bandage
 Escherichia coli Shock Hypovolemic shock
Route of entry: Site of epistaxis Little's area.
 Direct: wound, pin prick and local focus of Shock after Hypovolemic shock
infection Sterilization method Autoclaving.
 Blood stream or lymphatic Pulse taken site Radial artery
BP taken site Brachial artery
Clinical features
Fracture in adult Colle's fracture
Symptoms
Fracture in child Greenstick fracture
 Pain (throbbing in nature)
 18 Health Assistant Loksewa Module-II

Past Question Of Public Service Commission

1. What may be given to the poison victim 9 The most common poisoning in Nepal is
for both corrosive and non- corrosive [PSC of HA 2071]
poisoning? [PSC of HA 2074] a. Kerosene b. Organophosphorus
a. Steroids b. Paracetamol c. Paracetamol d. Carbon monoxide
c. Activated Charcoal d. Plain water
10. The percentage burn is calculated by
2. Maintain the time that brain will expire [PSC of HA 2071]
without oxygen: [PSC of HA 2074] a. Rule of 5 b. Rule of 9
a. 5 minutes b. 3 minutes c. Rule of 20 d. Rule of 50
c. 4 minuses d. 2 minutes
11. How OFTEN do you give breaths to adult
3. Hemorrhage that occurs after 24 hours of on mouth to mouth breathing?
operation or injuries is called : [PSC of HA 2071]
[PSC of HA 2073] a. Once every second
a. Primary hemorrhage b. Once every 3 second
b. Secondary hemorrhage c. Once every 9 second
c. Reactionary hemorrhage d. Once every 5 second
d. Concealed hemorrhage
12. Rupture of ligament is called …….
4. Which bandage is used in clavicle [PSC of HA 2071]
fracture? [PSC of HA 2072 ] a. Strain b. Sprain
a. Figure '8' typed c. Dislocation d. Subluxation
b. Head and foot bandage
c. Roller 13. If you feel fainting, you will:
d. Triangular [PSC of HA 2070-01-15]
a. Run away towards hospital
5. Erythematic burn is normally caused by:
b. Take cold or hot water
[PSC of HA 2072 ]
a. fire burn b. water burn c. Lie down on the floor or sit with your head
between you knee
c. sun burn d. acid burn
d. Take medicine
6. Which is the commonest area of anterior
epistaxis? [PSC of HA 2072 ] 14. Vasovagal syndrome is associated with one
of the following shock. [PSC of HA 2070-01-15]
a. Little's area
a. Cardiogenic shock
b. Wood drugts area b. Neurogenic shock
c. Posterior – superior part c. Anaphylactic shock
d. Anterior superior part d. Hypovolemic shock
7. Persistence of microorganism or their 15. Following are the types of bleeding
toxin in the blood caused…[PSC of HA 2071] except: [PSC of HA 2070-01-15]
a. Hypovolemic shock a. Arterial b. Venous
b. Anaphylactic shock c. Bony d. Capillary
c. Septic shock
16. You encountered a victim with fracture
d. Bacterial shock
leg & bleeding from fracture site. What do
8. One pint of blood is equal to[PSC of HA you do before transporting to the nearest
2071] hospital? [PSC of HA 2070-2-17]
a. 450 ml b. 480 ml a. Apply splint
c. 750 ml d. 600 ml b. Clear the wound
c. Apply pressure bandage
d. All of the above
1. [c] 2. [c] 3. [b] 4. [a] 5. [c] 6. [a] 7. [c] 8. [b] 9. [b] 10. [b] 11. [d] 12. [b]
13. [c] 14. [b] 15. [c] 16. [d]
 NAME Module-II: Clinical Section 19
17. After dog bite, the dog should be observed c. To prevent worsening of patient
for: [PSC of HA 2070-2-17] d. To cure the patient
a. 5–10 days b. 10–14 days 21. All the following are done as emergency
c. 15–20 days d. 20–30 days management for fracture and injury
except: [PSC of HA 2067]
18. All snake bites should be managed by a. Open I/V line
except: [PSC of HA 2070-2-17] b. Use antibiotics
a. Cleaning the wound b. Observation c. Stop bleeding
c. Inj. Tetanus toxoid d. Plastering d. Assess airway & breathing
19. Which is not principle of management of 22. First aid treatment for infected wound is:
fracture? [PSC of HA 2070-04-26] [PSC of HA 2067]
a. Wash fracture part a. Use antibiotics b. Through washing
b. Detailed examination of body c. Stop bleeding d. Suturing
c. Maintenance of breathing of victim 23. Which among the following is not the sign
d. Maintenance of airway of victim of shock? [PSC of HA 2067]
20. The objective of first aid includes all a. Nausea & vomiting
except: [PSC of HA 2065] b. Cold skin & weak pulse
a. To preserve life c. Moist & clammy skin
b. To promote recovery d. Low blood pressure
17. [b] 18. [d] 19. [b] 20. [d] 21. [b] 22. [b] 23. [a]