Table of Contents
Unit 7. 4
Sterilization and Disinfection. 4
Learning objectives: 5
Personal hygiene. 5
Activity 5
Examples of practiced personal hygiene. 5
General 5
Hands 6
Hand washing. 7
Activity. 7
Learn proper hand washing techniques. 7
Occupational Hygiene. 9
Chemical hazards. 9
Physical hazards. 9
Biological hazards. 9
Pathogens. 9
Bacteria. 9
Viruses. 10
Fungi 10
Parasites. 11
Transmission of pathogens. 11
Chain of infection. 12
Activity 13
Nosocomial infections. 14
Activity 14
Main routes of transmission of infections. 14
Predisposition to infection. 15
Prevention. 15
Isolation 15
Hand washing and gloving. 17
Aprons 17
Universal or Standard Precautions for Control of Infection. 18
Isolation precautions in hospitals. 18
Source. 18
Host 19
Transmission. 19
Fundamentals of isolation precautions. 19
Hand washing and gloving. 19
Patient placement 19
Transport of Infected Patients. 20
Masks, respiratory protection, eye protection, face shields. 20
Gowns and protective apparel 20
Patient-care equipment and articles. 21
Linen and laundry. 21
Dishes, glasses, cups, and eating utensils. 21
Routine and terminal cleaning. 21
Asepsis. 23
Activity 23
Activity 24
Sterilisation. 25
Physical sterilisation. 25
Heat 25
Autoclaving/Steam under Pressure. 26
Filtration. 29
Chemical sterilisation. 29
Safe disposal of sharp instruments. 37
Activity. 37
Class room evaluation. 39
·
Unit 7
Sterilization and Disinfection
Learning objectives:
After completing unit 7 dispenser students will be able to:
describe and demonstrate personal hygiene and hygiene of their work environment
list rules of general safety
explain the chain of infection
explain the differences between medical asepsis, surgical asepsis, disinfection and sterilization
explain general or universal precaution techniques and isolation precaution techniques
describe nosocomial infections and their risk to clients
describe risk of contracting infection to healthcare professionals
demonstrate proper hand washing
prepare and sterilize instruments
carry out safe disposal of instruments (syringes, needles, disposable medical/surgical) equipment.
Personal hygiene
Activity
Discuss with your class their understanding of personal hygiene.
Ask students to give examples of good personal hygiene prompting them about general, hand and other types of personal hygiene.
Personal hygiene is the basic concept of cleaning, grooming and caring for our bodies. While it is an important part of people’s daily lives at home, personal hygiene is also important for workers’ health and safety in the workplace. Workers who pay attention to personal hygiene can prevent the spread of germs and disease. They can also reduce their exposures to chemicals and contaminants, and avoid developing skin allergies, other skin conditions, and chemical sensitivities.
Examples of practiced personal hygiene
General
Washing the body and hair frequently
Cutting / cleaning nails
Cutting hair
Washing clothes and cleaning home
Changing bed sheets frequently.
Hands
Some germs can stay alive on hands for up to three hours and in that time they can spread to all the things touched – including food and other people. Hands should be washed regularly throughout the day and especially at these times:
Before:
· Preparing and eating food
· Caring for patients, changing dressings, giving medicines
· Looking after babies or the elderly
· Putting in contact lenses in the eyes
Between:
· Handling raw foods (meat, fish, eggs and poultry) and touching any other food or kitchen utensils (knives, spoons etc)
After:
· Touching bare human body parts other than clean hands and clean, exposed portions of arms
· Food preparation
· Handling raw foods, particularly meat, fish, eggs and poultry
· Eating or drinking
· Going to the toilet
· Touching rubbish/waste bins
· Handling soiled equipment or utensils
· Changing nappies
· Caring for the sick, especially those with gastro-intestinal disorders (e.g. diarrhoea)
· Coughing or sneezing, using a handkerchief or disposable tissue
· Handling and stroking pets or farm animals
Others
· As mouth is the area most prone to collecting harmful bacteria and generating infections, a person’s mouth hygiene should be good. Mouth hygiene means taking care of the teeth and gums, and treating or preventing bad breath by:
o brushing teeth with toothpaste at least two times per day, if not after every meal, to minimize the amount of bacteria in the mouth which leads to tooth decay and gum disease. This also helps treat and prevent bad breath
o flossing teeth at least once a day, usually before going to bed at night. This reduces plaque in the more difficult to reach places—between teeth and at the back of the molars
o rinsing mouth with antibacterial mouthwashes (such as Listerine)
o visiting dentist at least every six months
· Avoid contact with bodily fluids, such as blood, stools, urine, and vomit
· Avoid handling foods for others if one is ill, especially with any gastrointestinal problems
· Do not sneeze or cough near foods
· Cover all cuts, burns and sores and change dressings regularly – pay extra attention to any open wounds on hands and arms
· Wear clean undergarments and clothing.
Hand washing
Since person-to-person spread can play a significant role in the spread of some gastrointestinal tract pathogens, hand hygiene is a critical element of any disease outbreak prevention and control strategy.
Activity
Learn proper hand washing techniques
Step 1
Wash hands using soap and warm, running water. Rub hands vigorously during washing for at least 20 seconds with special attention paid to the backs of the hands, wrists, between the fingers and around and under the fingernails.
Step 2
Rinse hands well while leaving the water running.
Step 3
With the water running, dry hands with a single-use towel.
Step 4
Turn off the water using a paper towel, covering washed hands to prevent re-contamination.
Adapted from the US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, Georgia.
Occupational Hygiene
"Occupational Hygiene is the discipline of anticipating, recognizing, evaluating and controlling health hazards in the working environment with the objective of protecting worker health and well-being and safeguarding the community at large.
(International Occupational Hygiene Association definition)
Occupational Hygiene deals with the assessment and control of chemical, physical or biological hazards in the workplace that could cause disease or discomfort. It manages people and programs for the preservation of health and well-being of those who enter the workplace.
Chemical hazards
Chemical hazard arises from contamination with harmful or potentially harmful chemicals. When chemicals are not properly managed, they can have harmful consequences, such as toxic fumes, fires, and explosions. This may result in death and injury to people, damage to physical property, and severe effects on the environment.
Physical hazards
Physical hazards are those substances which threaten a person’s physical safety. They may include noise (elevated sound levels), temperature extremes (too hot or too cold), illumination extremes, ionizing or non-ionizing radiation, indoor air quality and safety.
Biological hazards
A biological hazard is an organism, or substance derived from an organism, that poses a threat to human health. This can include medical waste, samples of a microorganism, virus or toxin (from a biological source) that can impact human health. It can also include substances harmful to animals. E.g. exposure to viruses causing chicken pox, hepatitis A, B and C, SARS, and dengue fever.
Pathogens
A pathogen is a living organism that causes disease. Following are different types of common pathogens that cause diseases:
Bacteria
Bacteria are one-celled organisms, spherical, spiral, or rod-shaped and appearing singly or in chains. They reproduce independently. Although the vast majority of bacteria are harmless or beneficial to humans, and usually exist on the skin, gut, or in the nose without causing any disease at all, a few bacteria cause infectious diseases. E.g. Mycobacterium tuberculosis (which cause tuberculosis), Streptococcus pneumoniae (which cause pneumonia and skin infections), and Shigella, Campylobacter and Salmonella (which cause food borne illnesses). Pathogenic bacteria also cause infections such as tetanus, diphtheria, syphilis and leprosy. Bacterial infections may be treated with antibiotics which are of many different types.
A small number of bacteria produce spores. Spores are dormant, tough, and non-reproductive structures. The primary function of spores is to ensure the survival of a bacterium through periods of environmental stress. They are, therefore, resistant to most sterilizing techniques such as extreme heat and radiation. Spores can, however, be destroyed by burning or autoclaving. Exposure to extreme heat for a long enough period will generally have some effect, though many spores can survive hours of boiling or cooking. Prolonged exposure to high energy radiation, such as x-rays and gamma rays, will also kill most spores.
Spores are commonly found in soil and water, where they may survive for long periods of time. Examples of bacteria having spores include Clostridium tetani, the pathogen which causes the disease tetanus (See Unit 5, Basic concepts of management of EPI-related diseases).
Viruses
Viruses are the smallest of all infectious agents, averaging about 100 billionths of a meter in length. Viruses are much smaller than bacteria. They cause familiar infectious diseases such as the common cold, chicken pox, measles, mumps, and influenza. They also cause severe illnesses such as AIDS, smallpox, hepatitis B and C, and HIV.
They invade living, normal cells and use those cells to multiply and produce other viruses like themselves. This eventually kills the cells, which can make the person sick.
Viral infections are hard to treat because viruses live inside body's cells and are "protected" from medicines, which usually move through the bloodstream. Antibiotics do not work for viral infections. There are a few antiviral medicines available. Vaccines can help prevent getting many viral diseases.
Fungi
Fungi are a type of plant that can infect people. Yeasts, molds, and mushrooms are all examples of fungi. Fungi live in air, in soil, on plants and in water. Some live in the human body. Only about half of all types of fungi are harmful.
Some fungi reproduce by spreading microscopic spores. These spores are often present in the air, where they can be inhaled or come into contact with the surfaces of a person's body. Consequently, fungal infections usually begin in the lungs or on the skin. Of the wide variety of fungal spores that land on the skin or are inhaled into the lungs, most do not cause infection. A person is more likely to get a fungal infection if they have a weakened immune system (e.g. if a person has AIDS), take steroids, take antibiotics for a bacterial infection, or have diabetes. Certain types of fungi (such as Candida) are normally present on body surfaces or in the intestines. Although normally harmless, these fungi sometimes cause local infections of the skin and nails.
Some common fungal infections are athlete's foot (scaling and sogginess of the skin, commonly of the web spaces between the toes), ringworm of the nails (malformed, thickened and crumbly nails), and ringworm of the scalp (hair loss with inflammation in the affected area).
Fungi can be difficult to kill; for skin and nail infections, medicine can be applied directly to the infected area. Oral antifungal medicines are also available for serious infections.
Parasites
Parasites are organisms that grow, feed, and are sheltered on or within a human body (or other organisms) without providing any benefit to their host. Many parasites do not cause disease per se. Parasitic diseases can affect practically all living organisms, from plants to mammals. Parasites could be single-cell or multi-cellular. Single-cell parasites tend to be at least 10 times larger than bacteria, or about 0.01 millimeter long. Multi cellular parasites are so large they can usually be seen with the naked eye. Tapeworms, for instance, can reach a length of 6 meters (20 feet).
Food and water are the most common sources of parasite transmission. Since we eat and drink water frequently throughout the day, our exposure to parasites is constant. Examples of parasites causing human disease are Plasmodium malariae (which causes malaria), beef tapeworm, hookworm, roundworm, and liver fluke.
Transmission of pathogens
One of the primary pathways by which food or water become contaminated is from the release of untreated sewage into a drinking water supply or onto cropland, with the result that people who eat or drink contaminated sources become infected. This is the typical mode of transmission for the infectious agents of (at least) cholera, hepatitis A, polio.
Chain of infection
Chain of infection means how infections are spread. It is a circle of six links which is used to understand the infection process. For an infection to occur and spread each of the six links of the cycle or chain must take place. Removing any link in the chain will bring about a cessation of the infectious cycle; therefore, knowing and identifying the links in the chain and performing the appropriate course of action to break a link will halt the continuous spread of the infection. In simple terms breaking a link stops the spread of the infection.
The links are: infectious agent, reservoir, portal of exit from the reservoir, mode of transmission, and portal of entry into a susceptible host as described below:
i. Infectious agent
A microbial organism (germ) with the ability to cause disease. Infectious agents are bacteria, viruses, fungi, and parasites. The greater the organism's virulence (ability to grow and multiply), invasiveness (ability to enter tissue) and pathogenicity (ability to cause disease), the greater the possibility that the organism will cause an infection.
ii. Reservoir
A place within which infectious agents can live and reproduce. For example, infectious agents live in human beings, animals, and inanimate objects such as water, table tops, and doorknobs.
iii. Portal of exit
A place of exit providing a way for an infectious agent to leave the reservoir. For example, the infectious agent may leave the reservoir through the nose or mouth when someone sneezes or coughs, or through the stools of an infected intestine.
iv. Mode of transmission
Method of transfer by which the infectious agent moves or is carried from one place to another. E.g. the hands of the health care worker may carry bacteria from one person to another.
v. Portal of entry
An opening allowing the infectious agent to enter the host. Portals include body openings (nose, mouth, anus, vagina etc.) or breaks in the skin etc. Portals also result from tubes placed in body cavities, such as urinary catheters, or from punctures produced by invasive procedures such as intravenous fluid replacement.
vi. Susceptible host
A person who cannot resist an infectious agent invading the body, multiplying, and resulting in infection. The host is susceptible to the disease, lacking immunity or physical resistance to overcome the invasion by the pathogenic microorganism.
Figure1: Model of chain of infection
Activity
This activity will be done with six students who will represent a ‘chain of infection’. Each student is to assume the role of one of the six links. All students form a circle holding each other’s hands. Each link of the circle is to explain who they are and how they help in spreading the infection.
Nosocomial infections
Nosocomial infections (or hospital-acquired infections) are infections which are a result of treatment in a hospital or other healthcare facility, but secondary to the patient's original condition. Infections are considered nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge. The most common nosocomial infections are of the urinary tract, and various pneumonias.
Activity
Discuss with your class why infection spreads so easily in hospital wards.
Discuss with your class how infection spreads in hospital wards.
Discuss how the spread of infection could be prevented.
Reasons why nosocomial infections are so common include:
· Hospitals house large numbers of people who are sick and whose immune systems (system with the ability to fight off infections) are often in a weakened state;
· People who are hospitalized are generally very sick people;
· Medical staff move from patient to patient, providing a way for germs to spread;
· Many medical procedures bypass the body's natural protective barriers;
· Routine use of antibiotics in hospitals leads to the emergence of bacteria which are resistant to the usual antibiotics.
Thorough hand washing and/or use of alcohol rubs by all medical staff before each patient contact is one of the most effective ways to combat nosocomial infections. More careful use of antibiotics is also considered vital.
Germs are transmitted in hospitals by several routes, and the same germs may be transmitted by more than one route.
Main routes of transmission of infections
There are five main routes of transmission of infections in hospital facilities and outside hospitals: contact, droplet, airborne, common vehicle, and vector borne.
i. Contact transmission, is the most important and frequent mode of transmission of nosocomial infections, is divided into two subgroups:
a. Direct-contact transmission involves a direct body surface-to-body surface contact and physical transfer of germs between a susceptible host and an infected person, such as occurs when a staff member turns a patient or gives a patient a bath or can occur between two patients.
b. Indirect-contact transmission involves contact of a susceptible host with a contaminated object, such as contaminated instruments, needles, or dressings, or contaminated hands that are not washed and gloves that are not changed between patients.
ii. Droplet transmission occurs when droplets are generated from the source person mainly during coughing, sneezing, and talking, and during the performance of certain procedures such as bronchoscopy. Transmission occurs when droplets containing germs from the infected person are propelled a short distance through the air and deposited on the host's body.
iii. Airborne transmission occurs by dissemination of droplets containing germs that remain suspended in the air for long periods of time or dust particles containing the germs. Germs carried in this manner can be dispersed widely by air and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors. Germs transmitted by airborne transmission include Mycobacterium tuberculosis and some viruses.
iv. Common vehicle transmission applies to germs transmitted by contaminated items such as food, water, medications, devices, and equipment.
v. Vector borne transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms.
Predisposition to infection
Factors predisposing a patient to nosocomial infection are:
i. People in hospitals are usually already in a poor state of health, impairing their defense against bacteria – old age or premature birth along with immunodeficiency (due to drugs, illness, or radiation) present a general risk, while some diseases can present specific risks.
ii. Invasive devices, for instance intubation tubes, catheters, surgical drains and tracheostomy tubes all bypass the body’s natural lines of defense against germs and provide an easy route for infection.
iii. A patient’s treatment itself can leave them vulnerable to infection – immune-suppression, antacid treatment, antibiotic therapy and recurrent blood transfusions.
Prevention
Isolation
Isolation precautions are designed to prevent transmission of germs by common routes in hospitals. Because agent and host factors are more difficult to control, interruption of transfer of germs is directed primarily at transmission.
Hand washing and gloving
Hand washing is the single most important measure to reduce the risks of transmitting germs from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions.
In addition to hand washing, gloves play an important role in reducing the risks of transmission of germs. Gloves are worn for three important reasons in hospitals.
· First, gloves are worn to provide a protective barrier and to prevent contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes and non-intact skin
· Second, gloves are worn to reduce the likelihood that germs present on the hands of staff will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and non-intact skin.
· Third, gloves are worn to reduce the likelihood that hands of staff contaminated with germs from a patient or a fomite can transmit these germs to another patient. In this situation, gloves must be changed between patient contacts and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing, because gloves may have small, in-apparent defects or may be torn during use, and hands can become contaminated during removal of gloves.
Aprons
Wearing an apron during patient care reduces the risk of infection. The apron should either be disposable or be used only when caring for a specific patient
Universal or Standard Precautions for Control of Infection
Universal precautions (or Standard precautions) are infection control techniques; they refer to the practice of avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields and of disposing instruments, especially scalpels and needles, in a sharps container.
Universal precautions were recommended following the AIDS outbreak in the 1980s. Every patient is treated as if they are infected and therefore precautions are taken to minimize risk. Essentially, universal precautions are good hygiene habits, such as hand washing and the use of gloves and other barriers, correct sharps handling, and aseptic techniques.
Additional precautions are used in addition to universal precautions for patients who are known or suspected to have an infectious condition e.g. tuberculosis, mumps, rubella, whooping cough.
Universal precautions should be practiced in any environment where workers are exposed to bodily fluids, such as blood, semen, vaginal secretions, cerebrospinal fluid etc. Bodily fluids that do not require such precautions include stools, nasal secretions, urine, vomitus, sweat, sputum and saliva.
Universal precautions are recommended not only for doctors, nurses and patients, but for health care support workers. Some support workers, most notably laundry and kitchen staff, may be required to come into contact with patients or bodily fluids.
Protective clothing may include but is not limited to:
Barrier gowns
Gloves
Eyewear (goggles or glasses)
Face shields
Hair nets
Shoe coverings.
Isolation precautions in hospitals
Transmission of infection within a hospital requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism.
Source
Human sources of the infecting microorganisms in hospitals may be patients, staff, or visitors. Other sources of infecting microorganisms can be the various hospital objects that have become contaminated, including equipment and medications.
Host
Resistance among persons to disease causing germs varies greatly with some persons developing clinical disease while others not. Host factors such as age, underlying diseases, treatments with antibiotics, corticosteroids, or some other drugs, irradiation, and breaks in the first line of defense mechanisms caused by such factors as surgical operations, anesthesia, and indwelling catheters may render patients more susceptible to infection.
Transmission
See the Section on nosocomial infections.
Fundamentals of isolation precautions
A variety of infection control measures are used for decreasing the risk of transmission of germs in hospitals. These are as follows:
Hand washing and gloving
See the Section on Nosocomial infections.
Patient placement
Appropriate patient placement is a significant component of isolation precautions. A private room is important to prevent direct- or indirect-contact transmission. When possible, a patient with highly transmissible germs is placed in a private room with hand washing and toilet facilities, to reduce opportunities for transmission of germs. When a private room is not available, an infected patient is placed with an appropriate roommate. Patients infected by the same microorganism usually can share a room, provided they are not infected with other potentially transmissible microorganisms and the likelihood of re-infection with the same organism is minimal.
Transport of Infected Patients
Limiting the movement and transport of patients infected with disease causing germs and ensuring that such patients leave their rooms only for essential purposes reduces opportunities for transmission of germs in hospitals. When patient transport is necessary, it is important that:
1) appropriate barriers (e.g., masks) are worn by the patient
2) staff in the area to which the patient is to be taken are notified of the patient’s arrival and of the precautions to be used to reduce the risk of transmission of infectious germs, and
3) patients are informed of ways by which they can assist in preventing the transmission of their infectious germs to others.
Masks, respiratory protection, eye protection, face shields
Various types of masks, goggles, and face shields are worn alone or in combination to provide barrier protection. A mask that covers both the nose and the mouth, and goggles or a face shield are worn by hospital personnel during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to provide protection of the mucous membranes of the eyes, nose, and mouth from contact transmission of pathogens. A surgical mask generally is worn by hospital personnel to provide protection against spread of infectious large-particle droplets that are transmitted by close contact and generally travel only short distances (up to 3 ft) from infected patients who are coughing or sneezing.
Gowns and protective apparel
Various types of gowns and protective apparel are worn to provide barrier protection and to reduce opportunities for transmission of germs in hospitals. Gowns are worn to prevent contamination of clothing and to protect the skin of staff from blood and body fluid exposures. Gowns especially treated to make them impermeable to liquids, leg coverings, boots, or shoe covers provide greater protection to the skin when splashes or large quantities of infective material are present or anticipated. Gowns are also worn by staff during the care of patients infected with certain germs to reduce the opportunity for transmission of disease causing germs from patients or items in their environment to other patients or environments; when gowns are worn for this purpose, they are removed before leaving the patient's environment and hands are washed.
Patient-care equipment and articles
Some used articles are enclosed in containers or bags to prevent inadvertent exposures to patients, staff, and visitors and to prevent contamination of the environment. Used sharps are placed in puncture-resistant containers; other articles are placed in a bag.
Contaminated, reusable critical equipment/devices or semi-critical equipment/devices are sterilized after use to reduce the risk of transmission of germs to other patients. (See the section on Sterilization)
Non-critical equipment contaminated with blood, body fluids, secretions, or excretions is cleaned and disinfected after use. Contaminated disposable (single-use) patient-care equipment is handled and transported in a manner that reduces the risk of transmission of germs and decreases environmental contamination in the hospital.
Linen and laundry
Although soiled linen may be contaminated with disease causing germs, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of germs to patients, staff, and environments.
Dishes, glasses, cups, and eating utensils
No special precautions are needed for dishes, glasses, cups, or eating utensils, disposable or reusable dishes and utensils can be used for patients on isolation precautions. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses, cups, and eating utensils.
Routine and terminal cleaning
The room, or cubicle, and bedside equipment of patients on Transmission-Based Precautions are cleaned using the same procedures used for patients on Standard Precautions, unless the infecting germ(s) and the amount of environmental contamination indicates special cleaning. In addition to thorough cleaning, adequate disinfection of bedside equipment and environmental surfaces (e.g., bedrails, bedside tables, carts, commodes, doorknobs, faucet handles) is indicated for certain germs, which can survive for prolonged periods of time. Patients admitted to hospital rooms that previously were occupied by patients infected with such germs are at increased risk of infection from contaminated environmental surfaces and bedside equipment if they have not been cleaned and disinfected adequately.
Adapted from: Guideline for Isolation Precautions in Hospitals.
Julia S. Garner, RN, MN, and the Hospital Infection Control Practices Advisory Committee. From the Public Health Service, US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, Georgia. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80, and Am J Infect Control 1996; 24:24-52.
Asepsis
One of the methods for breaking the chain of infection is asepsis. Asepsis is defined as “a condition in which infectious agents are absent or controlled”. Aseptic practices break the chain of infection by preventing the transmission of infectious agents.
There are three levels of aseptic control:
· Antisepsis or sanitation
· Disinfection
· Sterilization
Antisepsis/sanitation method of infection control includes using soap and water to wash the hands and body as well as the use of antiseptics such as alcohol, iodine and betadine to clean the skin for medical procedures, as these inhibit the growth of infectious agents. This level of asepsis may kill or inhibit some organisms but is generally not effective against viruses and spores.
Disinfection is the process of using chemical agents or boiling water to destroy or kill disease causing germs. These chemical agents are not always effective against viruses and spores. Further, disinfectants are often harsh and may irritate or damage the skin so they are mainly used on surfaces, equipment and instruments. Common disinfectants include Clorox bleach solutions, Lysol, and pinesol products.
Sterilization is the only level of asepsis that kills all microbes both pathogenic (disease causing) and nonpathogenic (non-disease causing). It is the method used by all health care facilities and includes a number of techniques as described earlier. Sterilization is mainly used on medical instruments and equipment, surgical dressings, gowns etc. See the next section for details.
Medical asepsis
Medical asepsis (or Clean Technique) maintains cleanliness to prevent the spread of germs and ensures that the environment is as free of germs as possible. Medical asepsis helps to contain infectious organisms and to maintain an environment free from contamination.
Activity
Ask students how medical asepsis could be achieved.
The techniques used to maintain medical asepsis include hand washing, gowning and wearing facial masks when appropriate, as well as separating clean from contaminated or potentially contaminated materials and providing information to patients about basic hygienic practices. Appropriate hand washing by the nurse and the patient remains the most important factor in preventing the spread of microorganisms.
The basic principles of medical asepsis are:
i. Wash hands frequently, but especially before handling foods, before eating, after using a tissue paper, after going to the toilet, before and after each patient contact, and after removing gloves
ii. Keep soiled items and equipment from touching the clothing
iii. Do not place soiled bed linen or any other items onto the floor
iv. Avoid having patient’s cough, sneeze, or breath directly on others
v. Move equipment away from you when brushing, dusting, or scrubbing articles
vi. Avoid raising dust
vii. Clean the least soiled areas first then more soiled ones
viii. Dispose of soiled or used items directly into appropriate containers
ix. Pour liquids that are to be discarded directly into the drain so as to avoid splattering in the sink and onto you
x. Avoid leaning against sinks, supplies or equipment
xi. Avoid touching your eyes, face, nose or mouth
xii. Use practices of personal grooming that help prevent spreading germs
Surgical asepsis
Surgical asepsis (or Sterile Technique) includes procedures used to eliminate all microorganisms from an object or area. Surgical asepsis requires more stringent techniques than medical asepsis. An object or area is described as being sterile or not sterile.
Activity
Ask students how surgical asepsis could be achieved.
Ask students where surgical asepsis is practiced.
The basic principles of surgical asepsis include:
i. Only a sterile object can touch another sterile object
ii. Open sterile packages so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile wrapper touching unsterile clothing
iii. Avoiding spilling any solution on a cloth or paper used as a field for a sterile set-up
iv. Hold sterile objects above the level of the waist
v. Avoid talking, coughing, sneezing, or reaching over a sterile field or object
vi. Never walk away from or turn your back on a sterile field
vii. All items brought into contact with broken skin or used to penetrate the skin in order to inject substances into the body, or to enter normally sterile body cavities, should be sterile
viii. Use dry, sterile forceps when necessary
ix. Consider the edge (outer 1 inch) of a sterile field to be contaminated
x. Consider an object contaminated if you have any doubt as to its sterility
Surgical Asepsis is used in the operating room, delivery room, during surgical procedures, catheterization, and during dressing changes.
Sterilisation
Sterilization is the complete destruction of all living organisms including bacteria, viruses, spores and fungi, achieved by various methods.
There are two types of sterilization:
a) physical sterilization
i) heat (steam; dry heat)
ii) radiation
iii) filtration
b) chemical sterilization
i) ethylene oxide
ii) ozone
iii) chlorine bleach
iv) glutaraldehyde and formaldehyde
vi) hydrogen peroxide
Physical sterilisation
Heat
A widely-used method for steam sterilization is the autoclave. Autoclaves commonly use steam heated to 121 °C or 134 °C. To achieve sterility, a holding time of at least 15 minutes is required. Additional sterilizing time is usually required for liquids and instruments packed in layers of cloth, as they may take longer to reach the required temperature. After sterilization, autoclaved liquids must be cooled slowly to avoid boiling over when the pressure is released.
To ensure the autoclaving process was able to cause sterilization, most autoclaves have meters and charts that record or display information such as temperature and pressure as a function of time. Indicator tape is often placed on packages of products prior to autoclaving. A chemical in the tape will change color when the appropriate conditions have been met. Some types of packaging have built-in indicators on them.
For effective sterilization, steam needs to penetrate the autoclave load uniformly, so an autoclave must not be overcrowded, and the lids of bottles and containers must be left ajar. During the initial heating of the chamber, residual air must be removed. Indicators should be placed in the most difficult places for the steam to reach to ensure that steam actually penetrates there.
For autoclaving, as for all disinfection or sterilization methods, cleaning is critical. Cleaning can removes a large number of organisms. Proper cleaning can be achieved by physical scrubbing. This should be done with detergent and warm water to get the best results. Cleaning instruments or utensils with organic matter, cool water must be used because warm or hot water may cause organic debris to coagulate.
Autoclaving/Steam under Pressure
Most common sterilization by moist heat requires steam under pressure at temperature range of 121-1340C usually given in an autoclave.
Sterilization by steam autoclave (saturated steam under pressure of approximately 15 psi to achieve a chamber temperature of at least 250oF for a designated time) is the preferred and most convenient method to rapidly destroy all forms of microbial life. Steam autoclaves are used to sterilize glassware, instruments, gloves, liquids in bottles, biological waste, dressings, and other materials needing such treatment. However, to do this, material to be sterilized must come into contact with live steam. Bags or containers should be left open during autoclaving or water (~200ml) should be added to sealed bags to generate steam.
Principles
Moist sterilization requires that the steam used for sterilization must be both dry and saturated. Saturated in the sense that the steam in this context is at a phase where it is holding all the water that it can, in the form of transparent vapors. It does not contain water droplets and therefore it describe as being dry; if it meets an object cooler than itself it condenses.
Moist heat sterilization i.e. Autoclaving is performed in an autoclave. The most common conditions for sterilization under pressure Include:
Process
Temperature 0c
Holding Time(Min) for Sterilization
Pressure in PSI (Pounds Per Square Inch)
Moist Heat
121
126
134
15
10
3
15
20
30
Proper autoclave treatment will inactivate all fungi, bacteria, viruses and also bacterial spores.
Figure2: Autoclaves
Figure 3: Steam Autoclave
Moist Heat Sterilization: Moist heat sterilization is the most efficient bio-cidal agent. It is used for:
• Surgical dressings
• Sheets
• Surgical and diagnostic equipment
• Containers
• Closures
• Aqueous injections
• Ophthalmic preparations
• Irrigation fluids
Dry heat can be used to sterilize items, but as the heat takes much longer to be transferred to the organism, both the time and the temperature must usually be increased, unless forced ventilation of the hot air is used. The standard setting for a hot air oven is at least two hours at 160 °C (320 °F). A rapid method heats air to 190 °C (374 °F) for 6 minutes for unwrapped objects and 12 minutes for wrapped objects. Dry heat has the advantage that it can be used on powders and other heat-stable items that are adversely affected by steam (for instance, it does not cause rusting of steel objects).
Radiation
Methods exist to sterilize using radiation such as electron beams, X-rays, gamma rays, or subatomic particles.
Gamma rays are very penetrating and are commonly used for sterilization of disposable medical equipment, such as syringes, needles, cannulas and IV sets. Gamma radiation requires bulky shielding for the safety of the operators; they also require storage of a radioisotope, which continuously emits gamma rays (it cannot be turned off, and therefore always presents a hazard in the area of the facility).
Electron beam processing is also commonly used for medical device sterilization. Electron beams use an on-off technology and provide a much higher dosing rate than gamma or x-rays. Due to the higher dose rate, less exposure time is needed. A limitation is that electron beams are less penetrating than either gamma or x-rays.
X-rays are less penetrating than gamma rays and tend to require longer exposure times, but require less shielding, and are generated by an X-ray machine that can be turned off for servicing and when not in use.
Ultraviolet (UV) light irradiation is useful only for sterilization of surfaces and some transparent objects.
Subatomic particles may be more or less penetrating, and may be generated by a radioisotope or a device, depending upon the type of particle.
Filtration
Clear liquids that would be damaged by heat, irradiation or chemical sterilization can be sterilized by mechanical filtration. This method is commonly used for sensitive pharmaceuticals. A filter with pore size 0.2 µm will effectively remove bacteria. If viruses must also be removed, a much smaller pore size is needed. Solutions filter slowly through membranes.
Chemical sterilisation
Chemicals are also used for sterilization. Although heating provides the most reliable way to rid objects of all transmissible agents, it is not always appropriate, because it will damage heat-sensitive materials such as biological materials, fiber optics, electronics, and many plastics.
Ethylene oxide (EO or EtO) gas is the most common sterilization method, used for over 70% of total sterilizations, and for 50% of all disposable medical devices; it is commonly used to sterilize objects sensitive to temperatures greater than 60 °C such as plastics, optics and electrics. Ethylene oxide treatment is generally carried out between 30 °C and 60 °C for at least three hours. It is used to process sensitive instruments which cannot be adequately sterilized by other methods. It can kill all known viruses, bacteria and fungi, including bacterial spores and is satisfactory for most medical materials, even with repeated use. However it is highly flammable, and requires a longer time to sterilize than any heat treatment.
Ozone is used in industrial settings to sterilize water and air, as well as a disinfectant for surfaces. It has the benefit of being able to oxidize most organic matter. On the other hand, it is a toxic and unstable gas that must be produced on-site, so it is not practical to use in many settings.
Chlorine bleach is another accepted liquid sterilizing agent. Household bleach consists of 5.25% sodium hypochlorite. It is usually diluted to 1/10 immediately before use; however to kill Mycobacterium tuberculosis (organism that causes tuberculosis) it should be diluted only 1/5. Bleach will kill many organisms immediately, but for full sterilization it should be allowed to react for 20 minutes. It is highly corrosive and may corrode even stainless steel surgical instruments.
Glutaraldehyde and formaldehyde solutions (also used as fixatives) are accepted liquid sterilizing agents, provided that the immersion time is sufficiently long. To kill all organisms can take up to 12 hours with glutaraldehyde and even longer with formaldehyde.
Hydrogen peroxide is another chemical sterilizing agent. It is relatively non-toxic once diluted to low concentrations and leaves no residue.
The following table gives the 4 levels of Processing/Reprocessing for already used medical equipment/devices for re-use. This is called the reprocessing of used medical equipment/devices.
The four levels are:
· Cleaning
· Low level disinfection
· High level disinfection
· Sterilization
Activity
Brainstorm what types of equipment/devices would need which of the four levels of Processing/Reprocessing.
Table: Reprocessing Decision Chart
Level of
Processing/Reprocessing
Classification of
Equipment/ Device
Examples of Equipment/Devices
Products to Use**
1. Cleaning
Physical removal of soil, dust or foreign material. Chemical, thermal or mechanical aids may be used.
Cleaning usually involves soap and water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization may take place.
All reusable
equipment/devices
· Oxygen tanks and cylinders
• Quarternary ammonium
compounds (QUATs)
• Enzymatic cleaners
• Soap and water
• Detergents
• 0.5% Accelerated
hydrogen peroxide
2. Low level disinfection
Level of disinfection required when processing non-critical
Equipment/devices or some environmental surfaces.
Low level disinfectants kill most bacteria and some fungi as well as viruses. Low level disinfectants do not kill mycobacteria or bacterial spores.
Non-critical equipment/devices
(Medical equipment/device that either touches only intact skin but not mucous membranes [inner lining of the eyes, nose, and mouth] or does not directly touch the patient. Reprocessing of non-critical equipment/devices involves cleaning and may also require low level disinfection)
• Environmental surfaces touched by staff during procedures (e.g. dialysis machines)
• Bedpans, urinals, commodes
• Stethoscopes
• Blood pressure cuffs
• Glucose meters
• Electronic thermometers
• ECG machines/leads/
• Ultrasound
equipment/probes that come into contact with intact skin only
• Bladder scanners
• Baby scales
• Environmental surfaces (e.g. IV poles, wheelchairs, beds, call bells)
• 3% Hydrogen peroxide
(10 minutes)
• 60-95% Alcohol (10
minutes)
• Hypochlorite (1000 ppm)
• 0.5% Accelerated
hydrogen peroxide (5
minutes)
• Quarternary ammonium
compounds
• Iodophors
• Phenolics ** (should not be used in nurseries)
3. High level disinfection
The level of disinfection required when processing semi-critical equipment/devices.
High level disinfection processes destroy bacteria, mycobacteria,
Fungi and viruses, but not necessarily bacterial spores.
Semi-critical equipment/devices
(Medical equipment/device that comes in contact with non-intact skin or mucous membranes but ordinarily does not penetrate them.)
• Flexible endoscopes that do not enter sterile cavities or tissues
• Laryngoscopes
• Bronchoscopes (sterilization is
preferred)
• Respiratory therapy equipment
• Nebulizer cups
• Anesthesia equipment
• Endotrachial tubes
• Specula (nasal, anal, vaginal – disposable equipment is strongly
recommended)
• Ear syringe nozzles
• Ultrasound
equipment/probes that come into
contact with mucous membranes
or non-intact skin (e.g. transrectal
probes)
• Pessary and diaphragm fitting
rings
• Cervical caps
• Breast pump accessories
• Glass thermometers
• Ear cleaning equipment
• 2% Glutaraldehyde (20 minutes at 20°C)
• 6% Hydrogen peroxide (30 minutes)
• 0.55% Orthophthalaldehyde
(OPA) (10 minutes at 20°C)
• Pasteurization (30
minutes at 75°C)
• 7% Accelerated hydrogen peroxide (20 minutes)
• 0.2% Peracetic acid (30 - 45 minutes)
4. Sterilization
The level of reprocessing required when processing critical equipment/devices. Sterilization results in the destruction of all forms of microbial life including bacteria, viruses, spores and fungi.
Critical equipment/devices
(Medical equipment/devices that enter sterile tissues, including the vascular system. Critical medical equipment/devices present a high risk of infection if the equipment/device is contaminated with any microorganisms.)
• Surgical instruments
• Implantable equipment/devices
• Endoscopes that enter sterile
cavities and spaces (e.g. arthroscopes, laparoscopes,
cystoscopes)
• Bronchoscopes
• Colposcopy equipment
• Endocervical curettes
• Fish hook cutters
• Biopsy forceps, brushes and
biopsy equipment associated
with endoscopy (disposable
equipment is strongly
recommended)
• Eye equipment including soft
contact lenses
• Dental equipment including high speed dental hand pieces
• Dry heat
• 100% Ethylene oxide
• Formaldehyde
• 2.5-3.5% Glutaraldehyde
(10 hours at 20°C)
• Hydrogen peroxide gas plasma (75 minutes at 50°C)
• 6-25% Hydrogen peroxide liquid (6 hours)
• 7% Accelerated hydrogen peroxide (6 hours at 20°C)
• 0.2% Peracetic acid (30-45 minutes)
• Steam
• Ozone
** concentration and contact time are dependent on manufacturer’s instructions
Safe disposal of sharp instruments
Activity
Brainstorm the need for safe disposal of sharp instruments.
Healthcare workers often report injuries by sharp instruments. It is, therefore, essential to prevent these avoidable and potentially serious injuries. It is the responsibility of the staff using sharp instruments to dispose them safely in designated containers to prevent accidentally inoculating oneself with blood/body fluids.
Figure 4: Sharp disposal unit
Figure 5: Sharp disposal unit
All healthcare workers must observe the following:
Items to be discarded in a sharps container
· Needles, lancets, scalpel blades
· Syringes
· Glass vials, broken glass, slides
· Biopsy needles
· Disposable razors
· IV sets, cannulae
· Other disposable sharps
Location of sharps containers
The provision of sharps containers is essential for safe practice. Sharps containers should be available in the following areas:
· Treatment rooms
· Nursing bases
· Any area where sharps are used: small portable boxes must be available to take to patient’s bedside.
Disposal of needles/syringes
· Always dispose of sharps immediately after use
· Do not re-sheathe needles
· Needles and syringes must be discarded entire into sharps containers. They must not be disassembled by hand. Do not break or bend needles.
Removal of sharps containers
Many sharp injuries occur because of overfilling of disposal containers.
· Sharps containers should be of adequate capacity for the area where they are used
· The sharps containers should be discarded when they are ¾ full or weekly. They should be labeled with ward/department of origin and dated
· Do not overfill sharps containers
· Always ensure that containers are securely closed for removal
· Wards/departments must formalize arrangements for the removal of sharps containers
· Designated staff should be responsible for removing the containers and providing replacements
· Staff who remove sharps containers must wear suitable protective gloves
Adapted from Dudley Primary Care Trust, National Health Service, United Kingdom
Class room evaluation
Student: _________________________ ID: __________________________
Teacher: _________________________ Unit 7: Sterilization
Date: ________________________
Select the best response for each test item.
How would you describe personal hygiene?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are the three times when hands should be washed?
a. ______________________________________________________________________
b. ______________________________________________________________________
c_______________________________________________________________________
What are the four steps of proper hand washing?
a. _______________________________
b. _______________________________
c. _______________________________
d. _______________________________
What are the three different kinds of hazards in the workplace?
a. _______________________________
b. _______________________________
c. _______________________________
What are the different types of common pathogens that cause diseases? Give two examples of each.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The chain of infection is a circle of ____________ links.
Nosocomial infections are infections which are a result of treatment in a _______________ or other __________________ facility.
The five main routes of transmission of infections are:
a. ________________________________________
b. ________________________________________
c. ________________________________________
d. ________________________________________
e. ________________________________________
Describe Universal precautions.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The three levels of aseptic control are:
a. _______________________________
b. _______________________________
c. _______________________________
Sterilization is described as:
____________________________________________________________________________________________________________________________________________________________
There are__________ types of sterilization (choose one from the following)
a. two
b. three
c. four
Give 10 examples of items which should be discarded in a sharps container.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Notes
Notes
Tuesday, August 18, 2009
Stores , records and DHIS
Table of Contents
Unit 6. 2
Stores, Records and the District Health Management Information System (DHIS) 2
Learning Objectives: 3
1. Stores: 3
Chart of Vital Signs. 6
Vital Signs. 6
Definition 6
Purpose 6
Sample of a Basic Vital Signs Chart 6
Birth Register. 8
Death Registers. 8
Medico-legal Register. 8
Postmortem Register. 8
The District Health Management Information System (DHIS) 9
Introduction. 9
DHIS Vision. 9
DHIS Objectives. 9
DHIS Instruments and Tools. 12
Class room evaluation. 13
Notes. 16
·
Unit 6
Stores, Records and the District Health Management Information System (DHIS)
Learning Objectives:
After completing unit 6 dispenser students will be able to:
define different types of stores and their purpose
manage different types of stores, e.g. medicine stores, general stores etc. according to prescribed government procedures
demonstrate skills and knowledge about how to manage store registers, stock ledgers and other accountable records according to prescribed government procedures
define the purpose and importance of DHIS
identify relevant tools and instruments of DHIS (OPD registers, abstract forms, patients records etc.) and their importance
correctly fill out relevant DHIS forms and reports
define the importance of records vis-à-vis audit.
Activities
Visit a store, show stacking procedures and records to dispenser students
Brainstorm
What will happen if your store is disorganized and dirty?
How would you make sure that you find an item that was received on a particular date?
1. Stores:
Medicines, equipment, linen, furniture, stationery and other general items of use in health facilities are stocked in specialized places called stores. The bigger the health facility the bigger are its stores and the bigger is the variety of items that stores would hold. Managing stores, stocks and supplies has become highly technical and is called supply chain management.
Generally, government procedures on managing stored are quite elaborate and well-documented. All public sector store keepers are required to follow these. However the general principles of a simple store management are:
· Security
o Stores contain accountable items that means that the storekeeper is responsible for the stock. Therefore, it is essential that the security of store is adequate so that pilferage and deterioration of the items stocked is ruled out. Proper attention should be given to doors, windows and walls with a view to ensure safety and security. Procedures for locking, unlocking doors and access to stores should be well-documented so that an audit trail is developed. The audit trail should have records of who has been accessing store at what time.
· First coming items leave the store first (First In First Out).
o This means that we need to keep a track of the receipt date of all items present in the store. The entry in stock register should be made mentioning the batch number and date of expiry on the top corner of the page each time the stock is received. If we have received three deliveries of an item in different quantities on three different dates, while issuing this item, we will look at the receipt date of each and will issue the one that we had received first.
· Cleanliness
o We must keep our stores clean as cleanliness keeps items in stock in good shape and gives a good impression of the performance of the storekeeper.
· Stacking or Storage Arrangements:
o Stacking and placement of stored items should be such that our movement within the store, physical inspection and drawl of stored items is easy and quick. Orderly stacked items make it easy for us to find things whereas disorganized store looks like a junkyard. We should follow the stocking arrangements that our healthcare facility is following, e.g. bin card system or computerized system etc.
· Records or Stock Ledgers
o We use stock ledgers or stock registers for keeping track of ‘receipt and issue’ of different items. The storekeeper is responsible for safe keeping and updating these records. All items or deliveries received are entered in these registers with dates and other details. Similarly, we make relevant entries when we issue items to others.
o All stock ledgers and registers should have page numbers; stock register without page numbers is incomplete and open to tampering. As a rule the incharge of the facility or stores department should give a certificate on the first page of the stock register certifying the page numbers with his/her name clearly written, signatures, date of the certificate and office seal.
o All store records are auditable documents. Therefore it is the duty of the storekeeper to ensure that they are safely locked and unauthorized persons should not have access to them.
· Maintaining Record of Transactions:
o When we receive or issue an item from our store, we are making a transaction. As a rule all transactions must have a written document that accurately records the transaction. Usually, a storekeeper receives a request in writing from a person who is authorized to sign or approve such requests. After issuing items requested for, the storekeeper must take a written receipt. Usually, these receipts are taken on the stock ledgers. However, separate forms or plain papers could also be used for this purpose.
· Audit and physical verification
o Stock ledgers are auditable documents and audit teams whether internal from the healthcare facility or external from the audit office are authorized to check if the ledgers are updated and the stock shown in the register or ledger matches what is physically present in the store. A mismatch between register and physical stock can invoke disciplinary procedure.
Chart of Vital Signs
Vital Signs
Definition
Vital signs, or signs of life, include the following objective measures for a person: temperature, respiratory rate, heart beat (pulse), and blood pressure. When these values are not zero, they indicate that a person is alive. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual is functioning. Normal ranges of measurements of vital signs change with age and medical condition. (please see the chart below for normal values)
Purpose
The purpose of recording vital signs is to establish a base line on admission to a hospital, clinic, professional office, or other encounter with a healthcare provider. Vital signs may be recorded by a nurse, a doctor or a dispenser or another healthcare professional. Dispensers could be asked to prepare a chart of vital signs and record them. Recorded data and information from the vital signs chart are used for interpreting and identifying any abnormalities from a person's normal state, and of establishing if current treatment or medications are having the desired effect. Usually the doctor will instruct on the frequency of recording vital signs, i.e. hourly, 4-hourly or six hourly etc. The person recording vital signs should follow these instructions. Each time vital signs are recorded, the person recording those should sign and record date and time.
Sample of a Basic Vital Signs Chart
Patient’s name and address:
Diagnosis:
Date of admission
Ward:
Name of incharge doctor and nurse:
Date:
Instructions:
Time & Date when recorded
Temperature
Pulse Rate
Blood Pressure
Breathing Rate
Birth Register
Birth register are kept in labor rooms. Incharge gynecologist, WMO, nurse, LHV or dispenser may record entries of births in this register. Technical notes are usually recorded by the person supervising the delivery. Additionally, full address and other contact details of the mother are also entered. Dispensers are usually asked to assist while the supervising person is making entries in the birth register.
Death Registers
Death registers are ward specific in DHQ, THQ and tertiary hospitals. However, at RHCs there is only one death register. For ward specific death registers there is usually a hospital death committee which reviews deaths registers on a weekly basis.
Medico-legal Register
Medico-legal registers are kept at tertiary, DHQ and THQ hospitals and RHCs. Usually there is one register for WMO and one for MO. All entries in these registers are made by doctors. Dispensers only assist doctors when they are carrying out medico-legal examination.
Postmortem Register
Postmortem registers are kept separately by WMOs and MOs. All entries in these registers are made by doctors. Dispensers only assist doctors when they are carrying out postmortem examination.
The District Health Management Information System (DHIS)
Activities
Show DHIS tools and instruments and records to dispenser students
Take dispenser students to the office of district coordinator for DHIS and show them how data is compiled and analyzed, and finally converted into information.
Show dispenser students registers and records related to poisons, births & deaths, medic-legal cases and postmortem. Highlight procedures for making entries in these registers and their importance
Show them a chart for recording vital signs and explain its importance, practice filling out this chart in practical training sessions.
Brainstorm
How will you use DHIS information?
What will you do if you find out that you have missed your monthly targets?
Introduction
Success of departments, organizations and health facilities depends on their ability to collect and use information to support their planning, management and decision making. The value attached to information could be appreciated from the fact that the world’s total store of knowledge is doubling every four years. However, we need to know how to find appropriate information, analyze it correctly and draw meaningful conclusions. Thus, the collection and use of right type of information in the health sector cannot be overemphasized.
Government of Pakistan has introduced DHIS for collecting information about the performance of health facilities and districts.
DHIS Vision
To improve healthcare services through evidence-based planning & management of services. Improved service delivery will contribute to the improvement of health status of the population
DHIS Objectives
To provide information for management and performance improvement of the district health system.
More specifically, the DHIS:
· provides selected key information from first level health facility (FLCF), Vertical Programs, Secondary Hospitals and sub-systems such as logistics, financial, human resource and capital asset management systems for improving the District Health System’s performance.
· caters to the important routine information needs at the federal and provincial levels for policy formulation, planning and monitoring & evaluation of health programs.
DHIS enables a HF or a collection of HFs or a district health system to regularly collect and analyze data in a consistent and planned way to demonstrate progress in achieving its important results using well thought out and properly defined measures. This contributes to monitoring and evaluation process.
Monitoring and evaluation (M&E) is an ongoing process to find out that a particular health facility is properly doing what it is meant to do. It also checks that progress is being made towards achieving targets and results. DHIS is a very good tool for M& E. It looks at the performance of a HF or a district and tells whether it is satisfactorily progressing towards its targets or it has achieved its targets.
Figure 1 below illustrates this process. In monitoring & evaluation we plan an activity ( e.g. at HFs) è then we do itè then we review our progress in that activity after sometime to see if we are in the right direction and are progressing according to our plan è then at the end of a particular period (usually 1 year) è we evaluate the activity to see if we have achieved our targets that we had given in our plan. DHIS gives us good information about how we are progressing towards our targets. Therefore, we should know our targets and review our DHIS data and information on a monthly basis at our health facility with our facility incharge.
Figure 7
DHIS Instruments and Tools
The following DHIS tools and instruments are present at healthcare facilities. As dispenser students we should be familiar with them.
DHIS Instrument No.
DHIS Instrument
DHIS – 01 (R)
Central Registration Point Register
DHIS – 02 (F)
OPD Ticket
DHIS – 03 (R)
Outpatient Department Register
DHIS – 04 (F)
OPD Abstract Form
DHIS – 05 (R)
Laboratory Register
DHIS – 06 (R)
Radiology/Ultrasonography Register
DHIS – 07 (R)
Indoor Patient Register
DHIS – 08 (F)
Indoor Abstract Form
DHIS – 09 (R)
Daily Bed Statement Register
DHIS – 10 (R)
Operation Theater (OT) Register
DHIS – 11 (R)
Family Planning Register
DHIS – 12 (C)
Family Planning Card
DHIS – 13 (R)
Maternal Health Register
DHIS – 14 (C)
Antenatal Card
DHIS – 15 (R)
Obstetric Register
DHIS – 16 (R)
Daily Medicine Expense Register
DHIS – 17 (R)
Stock Register (Medicine/Supplies)
DHIS – 18 (R)
Stock Register (Equipment/Furniture/Linen)
DHIS – 19 (R)
Community Meeting Register
DHIS – 20 (R)
Facility Staff Meeting Register
DHIS – 21 (MR)
PHC Facility Monthly Report Form
DHIS – 22 (MR)
Secondary Hospital Monthly Report Form
DHIS – 24 (YR)
Catchment Area Population Chart
Class room evaluation
Student: _________________________ ID: __________________________
Teacher: _________________________ Unit 6
Date: ________________________
Define monitoring and evaluation?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is DHIS?
________________________________________________________________________________________________________________________________________________
What do we do with DHIS data?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What will happen if we make wrong entries in the DHIS forms?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
How should we manage a store?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are general principles of store management?
______________________
______________________
______________________
______________________
Store records are not auditable.
True False
We should not review our DHIS data.
True False
DHIS data does not tell us if we are making satisfactory progress towards our targets
True False
We should not worry about the results of the activities of our health facility.
True False
DHIS data gives us information that the health facility team can used for planning its future activities.
True False
Notes
Unit 6. 2
Stores, Records and the District Health Management Information System (DHIS) 2
Learning Objectives: 3
1. Stores: 3
Chart of Vital Signs. 6
Vital Signs. 6
Definition 6
Purpose 6
Sample of a Basic Vital Signs Chart 6
Birth Register. 8
Death Registers. 8
Medico-legal Register. 8
Postmortem Register. 8
The District Health Management Information System (DHIS) 9
Introduction. 9
DHIS Vision. 9
DHIS Objectives. 9
DHIS Instruments and Tools. 12
Class room evaluation. 13
Notes. 16
·
Unit 6
Stores, Records and the District Health Management Information System (DHIS)
Learning Objectives:
After completing unit 6 dispenser students will be able to:
define different types of stores and their purpose
manage different types of stores, e.g. medicine stores, general stores etc. according to prescribed government procedures
demonstrate skills and knowledge about how to manage store registers, stock ledgers and other accountable records according to prescribed government procedures
define the purpose and importance of DHIS
identify relevant tools and instruments of DHIS (OPD registers, abstract forms, patients records etc.) and their importance
correctly fill out relevant DHIS forms and reports
define the importance of records vis-à-vis audit.
Activities
Visit a store, show stacking procedures and records to dispenser students
Brainstorm
What will happen if your store is disorganized and dirty?
How would you make sure that you find an item that was received on a particular date?
1. Stores:
Medicines, equipment, linen, furniture, stationery and other general items of use in health facilities are stocked in specialized places called stores. The bigger the health facility the bigger are its stores and the bigger is the variety of items that stores would hold. Managing stores, stocks and supplies has become highly technical and is called supply chain management.
Generally, government procedures on managing stored are quite elaborate and well-documented. All public sector store keepers are required to follow these. However the general principles of a simple store management are:
· Security
o Stores contain accountable items that means that the storekeeper is responsible for the stock. Therefore, it is essential that the security of store is adequate so that pilferage and deterioration of the items stocked is ruled out. Proper attention should be given to doors, windows and walls with a view to ensure safety and security. Procedures for locking, unlocking doors and access to stores should be well-documented so that an audit trail is developed. The audit trail should have records of who has been accessing store at what time.
· First coming items leave the store first (First In First Out).
o This means that we need to keep a track of the receipt date of all items present in the store. The entry in stock register should be made mentioning the batch number and date of expiry on the top corner of the page each time the stock is received. If we have received three deliveries of an item in different quantities on three different dates, while issuing this item, we will look at the receipt date of each and will issue the one that we had received first.
· Cleanliness
o We must keep our stores clean as cleanliness keeps items in stock in good shape and gives a good impression of the performance of the storekeeper.
· Stacking or Storage Arrangements:
o Stacking and placement of stored items should be such that our movement within the store, physical inspection and drawl of stored items is easy and quick. Orderly stacked items make it easy for us to find things whereas disorganized store looks like a junkyard. We should follow the stocking arrangements that our healthcare facility is following, e.g. bin card system or computerized system etc.
· Records or Stock Ledgers
o We use stock ledgers or stock registers for keeping track of ‘receipt and issue’ of different items. The storekeeper is responsible for safe keeping and updating these records. All items or deliveries received are entered in these registers with dates and other details. Similarly, we make relevant entries when we issue items to others.
o All stock ledgers and registers should have page numbers; stock register without page numbers is incomplete and open to tampering. As a rule the incharge of the facility or stores department should give a certificate on the first page of the stock register certifying the page numbers with his/her name clearly written, signatures, date of the certificate and office seal.
o All store records are auditable documents. Therefore it is the duty of the storekeeper to ensure that they are safely locked and unauthorized persons should not have access to them.
· Maintaining Record of Transactions:
o When we receive or issue an item from our store, we are making a transaction. As a rule all transactions must have a written document that accurately records the transaction. Usually, a storekeeper receives a request in writing from a person who is authorized to sign or approve such requests. After issuing items requested for, the storekeeper must take a written receipt. Usually, these receipts are taken on the stock ledgers. However, separate forms or plain papers could also be used for this purpose.
· Audit and physical verification
o Stock ledgers are auditable documents and audit teams whether internal from the healthcare facility or external from the audit office are authorized to check if the ledgers are updated and the stock shown in the register or ledger matches what is physically present in the store. A mismatch between register and physical stock can invoke disciplinary procedure.
Chart of Vital Signs
Vital Signs
Definition
Vital signs, or signs of life, include the following objective measures for a person: temperature, respiratory rate, heart beat (pulse), and blood pressure. When these values are not zero, they indicate that a person is alive. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual is functioning. Normal ranges of measurements of vital signs change with age and medical condition. (please see the chart below for normal values)
Purpose
The purpose of recording vital signs is to establish a base line on admission to a hospital, clinic, professional office, or other encounter with a healthcare provider. Vital signs may be recorded by a nurse, a doctor or a dispenser or another healthcare professional. Dispensers could be asked to prepare a chart of vital signs and record them. Recorded data and information from the vital signs chart are used for interpreting and identifying any abnormalities from a person's normal state, and of establishing if current treatment or medications are having the desired effect. Usually the doctor will instruct on the frequency of recording vital signs, i.e. hourly, 4-hourly or six hourly etc. The person recording vital signs should follow these instructions. Each time vital signs are recorded, the person recording those should sign and record date and time.
Sample of a Basic Vital Signs Chart
Patient’s name and address:
Diagnosis:
Date of admission
Ward:
Name of incharge doctor and nurse:
Date:
Instructions:
Time & Date when recorded
Temperature
Pulse Rate
Blood Pressure
Breathing Rate
Birth Register
Birth register are kept in labor rooms. Incharge gynecologist, WMO, nurse, LHV or dispenser may record entries of births in this register. Technical notes are usually recorded by the person supervising the delivery. Additionally, full address and other contact details of the mother are also entered. Dispensers are usually asked to assist while the supervising person is making entries in the birth register.
Death Registers
Death registers are ward specific in DHQ, THQ and tertiary hospitals. However, at RHCs there is only one death register. For ward specific death registers there is usually a hospital death committee which reviews deaths registers on a weekly basis.
Medico-legal Register
Medico-legal registers are kept at tertiary, DHQ and THQ hospitals and RHCs. Usually there is one register for WMO and one for MO. All entries in these registers are made by doctors. Dispensers only assist doctors when they are carrying out medico-legal examination.
Postmortem Register
Postmortem registers are kept separately by WMOs and MOs. All entries in these registers are made by doctors. Dispensers only assist doctors when they are carrying out postmortem examination.
The District Health Management Information System (DHIS)
Activities
Show DHIS tools and instruments and records to dispenser students
Take dispenser students to the office of district coordinator for DHIS and show them how data is compiled and analyzed, and finally converted into information.
Show dispenser students registers and records related to poisons, births & deaths, medic-legal cases and postmortem. Highlight procedures for making entries in these registers and their importance
Show them a chart for recording vital signs and explain its importance, practice filling out this chart in practical training sessions.
Brainstorm
How will you use DHIS information?
What will you do if you find out that you have missed your monthly targets?
Introduction
Success of departments, organizations and health facilities depends on their ability to collect and use information to support their planning, management and decision making. The value attached to information could be appreciated from the fact that the world’s total store of knowledge is doubling every four years. However, we need to know how to find appropriate information, analyze it correctly and draw meaningful conclusions. Thus, the collection and use of right type of information in the health sector cannot be overemphasized.
Government of Pakistan has introduced DHIS for collecting information about the performance of health facilities and districts.
DHIS Vision
To improve healthcare services through evidence-based planning & management of services. Improved service delivery will contribute to the improvement of health status of the population
DHIS Objectives
To provide information for management and performance improvement of the district health system.
More specifically, the DHIS:
· provides selected key information from first level health facility (FLCF), Vertical Programs, Secondary Hospitals and sub-systems such as logistics, financial, human resource and capital asset management systems for improving the District Health System’s performance.
· caters to the important routine information needs at the federal and provincial levels for policy formulation, planning and monitoring & evaluation of health programs.
DHIS enables a HF or a collection of HFs or a district health system to regularly collect and analyze data in a consistent and planned way to demonstrate progress in achieving its important results using well thought out and properly defined measures. This contributes to monitoring and evaluation process.
Monitoring and evaluation (M&E) is an ongoing process to find out that a particular health facility is properly doing what it is meant to do. It also checks that progress is being made towards achieving targets and results. DHIS is a very good tool for M& E. It looks at the performance of a HF or a district and tells whether it is satisfactorily progressing towards its targets or it has achieved its targets.
Figure 1 below illustrates this process. In monitoring & evaluation we plan an activity ( e.g. at HFs) è then we do itè then we review our progress in that activity after sometime to see if we are in the right direction and are progressing according to our plan è then at the end of a particular period (usually 1 year) è we evaluate the activity to see if we have achieved our targets that we had given in our plan. DHIS gives us good information about how we are progressing towards our targets. Therefore, we should know our targets and review our DHIS data and information on a monthly basis at our health facility with our facility incharge.
Figure 7
DHIS Instruments and Tools
The following DHIS tools and instruments are present at healthcare facilities. As dispenser students we should be familiar with them.
DHIS Instrument No.
DHIS Instrument
DHIS – 01 (R)
Central Registration Point Register
DHIS – 02 (F)
OPD Ticket
DHIS – 03 (R)
Outpatient Department Register
DHIS – 04 (F)
OPD Abstract Form
DHIS – 05 (R)
Laboratory Register
DHIS – 06 (R)
Radiology/Ultrasonography Register
DHIS – 07 (R)
Indoor Patient Register
DHIS – 08 (F)
Indoor Abstract Form
DHIS – 09 (R)
Daily Bed Statement Register
DHIS – 10 (R)
Operation Theater (OT) Register
DHIS – 11 (R)
Family Planning Register
DHIS – 12 (C)
Family Planning Card
DHIS – 13 (R)
Maternal Health Register
DHIS – 14 (C)
Antenatal Card
DHIS – 15 (R)
Obstetric Register
DHIS – 16 (R)
Daily Medicine Expense Register
DHIS – 17 (R)
Stock Register (Medicine/Supplies)
DHIS – 18 (R)
Stock Register (Equipment/Furniture/Linen)
DHIS – 19 (R)
Community Meeting Register
DHIS – 20 (R)
Facility Staff Meeting Register
DHIS – 21 (MR)
PHC Facility Monthly Report Form
DHIS – 22 (MR)
Secondary Hospital Monthly Report Form
DHIS – 24 (YR)
Catchment Area Population Chart
Class room evaluation
Student: _________________________ ID: __________________________
Teacher: _________________________ Unit 6
Date: ________________________
Define monitoring and evaluation?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is DHIS?
________________________________________________________________________________________________________________________________________________
What do we do with DHIS data?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What will happen if we make wrong entries in the DHIS forms?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
How should we manage a store?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are general principles of store management?
______________________
______________________
______________________
______________________
Store records are not auditable.
True False
We should not review our DHIS data.
True False
DHIS data does not tell us if we are making satisfactory progress towards our targets
True False
We should not worry about the results of the activities of our health facility.
True False
DHIS data gives us information that the health facility team can used for planning its future activities.
True False
Notes
Emergencies:Trauma , Overdosage and poisioning
Table of Contents
Unit 5: 3
Emergencies: Trauma, Overdosage and Poisoning. 3
Learning objectives: 4
1. Lesson 1: Common Definitions. 4
Triage. 4
Vital signs. 4
Body temperature. 4
Pulse or heart rate. 8
Blood pressure. 10
Respiratory rate. 13
Bleeding. 15
Intravenous medication. 21
Lesson 2: Cardiopulmonary Resuscitation (CPR) 23
Head injury. 31
Fractures. 31
Dehydration. 31
Burns. 31
Classification of burns by degree. 31
Causes of burns. 32
Concepts of Management of Obstetric Emergencies. 35
Concept of Management of Geriatric Emergencies. 38
Poisoning. 40
Copper Sulphate Poisoning. 42
Sulphuric Acid Poisoning. 45
Insect Stings. 46
Bites/Stings/Scratches. 47
Muscular Injuries. 48
Shock. 51
Heart attack. 52
Roller Bandages. 52
The Safe House. 53
Drowning. 55
Electrical Burn. 55
Hanging and Strangulation. 56
Dressings. 58
Sterile Dressing. 58
Non Sterile Dressing. 59
Adhesive Dressing. 59
Cold Compresses. 59
Principles of Bandaging. 59
Medico-legal Cases and the Dispenser. 61
Unit 5:
Emergencies: Trauma, Overdosage and Poisoning
Learning objectives:
After completing Unit 5 dispenser students will be able to:
define triage
record vital signs
elicit life threatening signs
demonstrate skills and knowledge to stop bleeding and maintain I/V line
carry out CPR and manage Airway, Breathing and Circulation (ABC)
carry out first line handling of patients with suspicion of head or spinal injury
carry out first line handling of patients with fractures.
1. Lesson 1: Common Definitions
Triage
Triage is a process of prioritizing patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately.
Activity
Brainstorm the situations where triaging becomes essential.
Vital signs
Vital signs are measures of various physiological statistics taken in order to assess the most basic body functions. There are four vital signs which are standard measurements in most medical settings:
Body temperature
The normal core body temperature of a healthy, resting adult human being is stated to be at 98.6 degrees Fahrenheit or 37.0 degrees Celsius. Though the body temperature measured on an individual can vary, a healthy human body can maintain a fairly consistent body temperature that is around the mark of 37.0 degrees Celsius.
The normal body temperature varies due to:
a. Metabolic rate: higher metabolic rate results in higher normal body temperature and lower metabolic rate leads to lower normal body temperature.
b. Time of the day: the body temperature is lower in the morning because the body has rested during the night, and is higher at night after a day of muscular activity and food intake.
c. Location in the body where the temperature is recorded:
-Mouth temperature, which is the most convenient type of temperature measurement, measures at 99.0 °F or 37.0 °C. This is the accepted standard for the normal core body temperature.
-Axillary (under the armpit) temperature is an external measurement of body temperature and measures at 97.6 °F or 36.4 °C. This is the longest way of measurement and not as accurate as rectal or oral measurements. An axillary temperature will read approximately 1 degree lower than a simultaneously obtained mouth temperature.
-Rectal temperature is an internal measurement taken in the rectum, and measures at 99.6 °F or 37.6 °C. It is the least time consuming, most accurate but uncomfortable type of body temperature measurement.
Different types of thermometers
§ Digital thermometers (Figure 1) usually provide the quickest, most accurate readings. They come in many sizes and shapes. Digital thermometers usually have a plastic, flexible probe with a temperature sensor at the tip and an easy-to-read digital display on the opposite end.
They can be used for the following temperature-taking methods:
-oral (in the mouth)
-rectal (in the bottom)
-axillary (under the arm)
§ First, turn on the thermometer and make sure the screen is clear of any old readings. If the thermometer uses disposable plastic sleeves or covers, put one on according to the manufacturer's instructions. Remember to discard the sleeve after each use and to clean the thermometer according to the manufacturer's instructions before putting it back in its case. Once the temperature is recorded, the thermometer signals that the reading is complete by a single beep or a series of beeps or the temperature flashes in the digital window on the front of the thermometer.
Figure 4 - Digital Thermometer
§ Electronic ear thermometers (Figure 2) measure the temperature inside the ear canal. Although they are quick and easy to use in older babies and children, electronic ear thermometers are not as accurate for infants 3 months or younger as digital thermometers.
Figure 5 - Electronic ear thermometer
§ Plastic strip or forehead thermometers (small plastic strips that are pressed against a child's forehead, Figure 3) are not reliable for taking an exact measurement, especially in infants and very young children and should not be used.
Figure 6 - Forehead thermometer
§ Glass mercury thermometers (Figure 4): They are most commonly used. They contain mercury in a glass tube.
Figure 4: Glass mercury thermometer
Activity
Learn to take body temperature
Mouth temperature
Older children and adults can have their temperature taken under the tongue with their mouth closed. Mouth temperatures will be inaccurate if the patient has had hot or cold drinks within 20 minutes of temperature measurement.
§ Wait 20 to 30 minutes after the patient finishes eating or drinking to take an oral temperature
§ Place the tip of the thermometer under the tongue and ask the patient to close his or her lips around it. Remind the person not to bite down or talk, and to relax and breathe normally through the nose
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, the thermometer is shaken down before using it. The tip of the thermometer should be placed as far back under the tongue as possible. The thermometer should be left in place for at least three minutes.
Axillary temperature
This is a convenient way to take a child's temperature although not as accurate as a rectal or mouth temperature.
§ Remove the child's shirt and vest, and place the thermometer under an armpit (it must be touching skin only, not clothing)
§ Fold the child's arm across the chest to hold the thermometer in place
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, make sure to shake down the thermometer before using it. Leave the thermometer in place for approximately 10 minutes to correctly record the temperature.
1. Rectal temperature
§ Infants should have rectal temperature measurements. A rectal temperature will read approximately 1 degree higher than a simultaneously obtained mouth temperature.
§ Lubricate the tip of the thermometer with a lubricant, such as petroleum jelly
§ Place the child: - stomach-down across your lap or on a firm, flat surface and keep your palm along the lower back - or face-up with legs bent toward the chest with your hand against the back of the thighs
§ With your other hand, insert the lubricated thermometer into the anal opening about ½ inch to 1 inch (about 1.25 to 2.5 centimeters). Stop if you feel any resistance
§ Steady the thermometer between your second and third fingers as you cup your hand against the baby's bottom
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, make sure to shake down the thermometer before using it. After at least three minutes, remove the thermometer and note the temperature as above.
Pulse or heart rate
§ Heart rate or pulse is measured by touching an artery. The arteries are the vessels with the "pulse". The rhythmic contraction of the artery keeps pace with the beat of the heart. Since an artery is near the surface of the skin, while the heart is deeply protected, an artery can be easily touched and get an accurate measure of the heart's pulse.
§ Children and infants have heart rates that are faster than those of adults as shown in the following table:
Table: Normal pulse or heart rates in different age groups
Age
Normal heart rate (bpm)
Newborn
200-260
0-5 months
90-190
6-12 months
80-140
1-3 years
80-130
3-5 years
80-120
6-10 years
70-110
11-14 years
60-105
14+ years
60-100
Activity
Learn to take radial pulse
Step 1: Find your pulse
To find your radial artery (the most common point from which people take pulses, Figure 5), hold one hand straight out, elbow bent, palm relaxed and facing up. Raise your thumb slightly upward to create a small pocket under your thumb at the top of your wrist. Place the tips of your index and middle fingers of the other hand (don't use your thumb—it has also got a pulse and could cause counting confusion) on the pocket under your thumb. Your fingers should lay across the tendon running down your arm. Adjust your fingertips until you can feel a steady beat under the skin of your wrist.
Step 2: Count, multiply and determine pulse regularity
Get out your watch. First, take a count of how many pulse beats you feel for 30 seconds. Multiply the amount of beats by two to calculate your pulse rate per minute.
Then, keep your fingers on your pulse for another 30 seconds. Is your pulse steady and unwavering? Or is it irregular in any way? Irregularities to note include beats that come closer to the preceding beats than the following ones or abnormal pauses in between beats. These and any other irregularities should be reported to a doctor immediately.
Step 3: Take someone else's pulse
Use your new pulse-taking skills on your friends! The process of taking someone else's pulse is identical to taking your own, except that you'll have both of your hands free to feel around for that fleeting rhythm. Just remember to keep your thumbs out of the way; they'll still interfere even if you're taking someone else's pulse.
Figure 5
Blood pressure
Blood pressure is the force of blood pushing against the walls of arteries. We use the blood flowing through the arteries because it has a higher pressure than the blood in the veins.
Blood pressure is measured using two numbers. The first number, which is higher, is taken when the heart beats during the systole (contraction) phase. This is called systolic pressure. The second number, which is lower, is taken when the heart relaxes, between beats, during the diastole (relaxation) phase. This is the diastolic pressure. The two numbers are written one above or before the other.
It is normal for the blood pressure to increase when a person is exercising and to decrease when a person is sleeping.
Normal blood pressure: 120/80 mmHg or lower
Types of blood pressure apparatus
Blood pressure is measured through the use of a medical instrument called a sphygmomanometer. There are three types of blood pressure apparatus: the mercury sphygmomanometer, the aneroid gauge and digital (electronic) devices. The mercury manometer is the most reliable recorder available for the clinical measurement of blood pressure.
Different types of blood pressure apparatuses
Figure 6: Mercury sphygmomanometer
Figure 7: Aneroid sphygmomanometer
Figure 8: Digital sphygmomanometer
Activity
Learn to take blood pressure (Figure 9)
Step 1
Make your friend sitting comfortably and relaxed. Push the sleeves up or remove the shirt to reveal a naked arm as clothing can interfere with the pressure of the inflated cuff as well as hearing the sounds.
Step 2
The cuff of the sphygmomanometer is placed on the upper arm. It is centered over the brachial artery which is located in the bend of the elbow. Once the cuff is secured, raise the arm to heart level, place your arm underneath it to support it and ask the person to relax their arm.
Step 3
Palpate (feel for) the brachial pulse and place the diaphragm of the stethoscope over this spot. Place the ear pieces of the stethoscope into your ears. Listen to the brachial pulse.
Step 4
Close the valve on the bladder of the cuff and begin to squeeze the bulb. Continue squeezing until the needle on the gauge reads 180 mmHg on the gauge. This closes the major arteries to the arm (that is why it is uncomfortable).
Step 5
Slowly release air by gently turning the air valve and allow the cuff to deflate by 5 mmHg/second while you listen to the artery. When you first hear the sound this is the systolic blood pressure. The sound you hear is the blood now flowing in the artery of the arm.
Step 6
Continue deflating the cuff until you no longer hear the sound. This is the diastolic blood pressure. At this point you can open the valve completely to allow the cuff to deflate rapidly. If you did not hear clearly, wait at least one minute before repeating the procedure.
Figure 9: Recording blood pressure
Respiratory rate
It is the number of breaths taken per minute. Respiratory rates may increase with exercise, excitement, pain, fever, and with other medical conditions. Respiratory rates decline during relaxation and sleep.
Measurement and recording of respiratory rate
The respiration rate is usually measured when a person is at rest.
Activity
Learn to take respiratory rate
Step 1
Observe patient’s stomach or chest and watch until you see it rise and fall. Each rise/fall cycle counts as one respiration.
Step 2
Count the number of times the stomach or chest rises for 30 seconds and multiply by 2, or count for a full 1 minute. This tells you the respiratory rate per minute.
Step 3
Note the rhythm of the breathing. Is it regular or irregular?
Step 4
Note how much effort it takes for the person to breathe. Is the breath labored, or effortless?
Step 5
Note if the breathing is deep (slow) or shallow (fast).
Step 6
Smell the breath for any unusual odor, especially noting a fruity odor or a fecal odor.
Step 7
Record your findings in the following manner: rate, rhythm, effort, depth, noise and odors. For example: "Respiratory rate is 30, irregular, labored, shallow, gurgling and with no odor."
Table 1: Normal respiratory rates in different age groups
Age
Normal respiratory rate
(breaths per minute)
Newborn
30-50
0-5 months
25-40
6-12 months
20-30
1-3 years
20-30
3-5 years
20-30
6-10 years
15-30
11-14 years
12-20
14+ years
12-20
Note: during strenuous exercise adults respiratory rate could go up to 35-45 breaths per minute; athletes' peak rate could be 60-70 breaths per minute.
Activity
Ask students to form pairs and go for a 5 minute run. As soon as they come back they should note their friend’s respiratory rate. Ask if there has been any change in the rate from before. And if yes, what?
Bleeding
Bleeding, (hemorrhage) is the loss of blood from the circulatory system (See Unit 1, Sub-unit 1, Cardiovascular System). Bleeding can occur:
internally, where blood leaks from blood vessels inside the body
externally, through a natural opening such as the vagina, mouth or rectum, or
externally, through a break (wound, cut) in the skin.
Bleeding is classified into the following classes.1
1. Manning, JE "Fluid and Blood Resuscitation" in Emergency Medicine: A Comprehensive Study Guide. JE Tintinalli Ed. McGraw-Hill: New York 2004. p227
Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs (i.e. heart rate, respiratory rate, blood pressure, body temperature) and volume replacement is not usually necessary.
Class II Hemorrhage involves 15-30% of blood volume. A patient often has rapid heartbeat with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate the blood loss with narrowing of the peripheral (skin, skeletal muscles) blood vessels. Skin may start to look pale in color and be cool to the touch. The patient might start acting differently. Volume replacement with intravenous saline solution or Ringer's Lactate solution is all that is usually required. Blood transfusion is not typically required.
Class III Hemorrhage involves loss of 30-40% of blood volume. The patient's blood pressure drops, the heart rate increases, and the mental status worsens. Volume replacement with saline solution or Ringer's Lactate solution and blood transfusion are usually necessary.
Class IV Hemorrhage involves loss of >40% of blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
Activity
Ask the class to break into four groups. Assign one class of hemorrhage to each group. Ask the groups to discuss their class of hemorrhage and report back starting from Class I Hemorrhage.
Symptoms
External bleeding through skin
Blood coming from an open wound
Bruising
Shock
Paleness
Clammy skin
Dizziness or light-headedness after an injury
Rapid pulse, increased heart rate
Low blood pressure
Shortness of breath
Confusion or decreasing alertness
Weakness
Internal bleeding will show any of the above symptoms plus:
Abdominal pain
Swollen abdomen
Signs of shock (see above)
External bleeding through a natural opening will also show:
· Blood in the stool (appears black, maroon, or bright red)
· Blood in the urine (appears red, pink, or tea-colored)
· Vaginal bleeding (heavier menstrual bleeding than usual or after menopause)
· Blood in the vomit (looks bright red, or brown)
Procedure to stop external bleeding from a wound
First aid is appropriate for external bleeding. If bleeding is severe, or if shock or internal bleeding is suspected, get a doctor’s help immediately.
Calm and reassure the patient as the sight of blood can be very frightening
Always wash your hands before (if possible) and after giving first aid to someone who is bleeding to avoid infections. Try to use latex gloves when treating a bleeding person. Latex gloves should be in every first aid kit. Viral hepatitis can be transmitted by skin contact with infected blood, and HIV can be contracted if infected blood gets into an open wound - even a small one
If the wound is superficial, wash it with soap and warm water and pat dry.
Lay the patient down. This will reduce the chances of fainting by increasing the blood flow to the brain. When possible, elevate the bleeding area
Remove any obvious loose debris or dirt from a wound. If an object such as a knife or stick, becomes embedded in the body, do not remove it. Doing so may cause more damage to the patient and may increase the amount of bleeding. The object also might be embedded in an artery or organ. Place pads and bandages around the object and tape the object in place
Put pressure directly on an external wound with a sterile bandage, clean cloth, or even a piece of clothing. If nothing else is available, use your hand. Direct pressure is best for external bleeding, except for an eye injury. See Figure 9
Maintain pressure until the bleeding stops. When it has stopped, bind the wound dressing with adhesive tape or a piece of clean clothing. A cold pack should be applied over the dressing. See Figure 10
If bleeding continues and seeps through the material being held on the wound, do not remove it. Simply place another cloth over the first one. Be sure to seek medical attention
If the bleeding is severe, get medical help and take steps to prevent shock. Immobilize the injured body part. Lay the patient flat; raise the feet about 12 inches, and cover the victim with a coat or blanket. However, do not place the patient in this position if there has been a head, neck, back, or leg injury or if the position makes the patient uncomfortable. Get medical help as soon as possible.
Figure 10: Stopping bleeding with direct pressure
Figure 11: Stopping bleeding with pressure and ice
Figure 12: Stopping bleeding with a tourniquet
DO NOT DO THE FOLLOWING WHILE MANAGING BLEEDING
DO NOT apply a tourniquet to control bleeding, except as a last resort. Doing so may cause more harm than good. A tourniquet should be used only in a life-threatening situation and should be applied by an experienced person. A tourniquet can be used if there is torrential bleeding and if continuous pressure is not stopping the bleeding. A tourniquet should be applied to the limb between the bleeding site and the heart. The tourniquet should be tightened to the point where the bleeding can be controlled by applying direct pressure over the wound. To make a tourniquet, use bandages 2 to 4 inches wide and wrap them around the limb several times. Tie a half or square knot, leaving loose ends long enough to tie another knot. A stick or a stiff rod should be placed between the two knots. Twist the stick until the bandage is tight enough to stop the bleeding and then secure it in place. Check the tourniquet every 10 to 15 minutes. If the bleeding becomes controllable, (manageable by applying direct pressure), release the tourniquet. See Figure 11
DO NOT probe a wound or pull out any embedded object from a wound. This will usually cause more bleeding and harm
DO NOT try to clean a large wound. This can cause heavier bleeding
DO NOT remove a dressing if it becomes soaked with blood. Instead, add a new one on top
DO NOT peek at a wound to see if the bleeding is stopping. The less a wound is disturbed, the more likely it is that you will be able to control the bleeding.
Important points to remember while managing bleeding
Direct pressure will stop most external bleeding, and is the most important initial first aid.
Blood loss can cause bruises, which usually result from a blow or a fall. They are dark, discolored areas on the skin. Apply a cool compress to the area as soon as possible to reduce swelling. Wrap the ice in a towel and place the towel over the injury. Do not place ice directly on the skin.
Serious injuries do not always bleed heavily, and some relatively minor injuries (for example, scalp wounds) can bleed profusely. People who take blood-thinning medication or who have a bleeding disorder, such as hemophilia, may bleed excessively and quickly because their blood cannot clot properly. Bleeding in such people requires immediate medical attention.
Although puncture wounds usually do not bleed very much, they carry a high risk of infection. Seek medical care to prevent tetanus or other infection.
Abdominal wounds can be very serious because of the possibility of severe internal bleeding, which may not be obvious from looking at a person, but which may result in shock. Seek medical care immediately for any penetrating abdominal wound. If organs are showing through the wound, do not try to push them back into the abdomen unless they slide back in without your assistance. Cover the injury with a moistened cloth or bandage, and do not apply more than very gentle pressure to stop the bleeding.
Always call a doctor if internal bleeding is suspected. This can rapidly become life-threatening. Immediate medical intervention may be needed. This can range from medications and intravenous fluids, to use of an endoscope, to surgery.
Activity
Ask the class to break into three groups. To the first group assign “Procedure to stop external bleeding from a wound”. To the second group assign “Do not do the following while managing bleeding”. To the third group assign, “Important points to remember while managing bleeding”. Each group to discuss their assigned role and report back to the whole class.
Intravenous medication
Intravenous (IV) medication administration refers to the process of giving medication directly into a patient's vein. Methods of administering IV medication may include giving the medication by rapid injection (push) into the vein using a syringe, giving the medication intermittently over a specific amount of time using an IV secondary line, or giving the medication continuously mixed in the main IV solution.
The primary purpose of giving IV medications is to initiate a rapid systemic response to medication. It is one of the fastest ways to deliver medication. The drug is immediately available to the body. It is easier to control the actual amount of drug delivered to the body by using the IV method and it is also easier to maintain drug levels in the blood for therapeutic response.
The IV route for medication administration may also be used if the medication to be delivered would be destroyed by digestive enzymes if given by mouth, is poorly absorbed by the tissue, or is painful or irritating when given by intra-muscular or subcutaneous injection.
Proper IV administration should follow the five "rights" of medication administration to avoid medication errors. Be sure it is:
· the right patient
· the right drug
· the right dose
· the right time, and
· the right route before giving any medication.
The IV line must be intact before any IV medication can be administered. Some IV medications can cause severe tissue damage if injected into the tissue through an infiltrated IV site.
Some IV push medications must be diluted before injection. Check the directions for giving the specific drug IV before performing the injection.
The drug delivery rate is an important factor when administering IV medication. Some IV drugs are meant to be delivered rapidly over several minutes to obtain therapeutic effect. Other drugs are most effective when delivered slowly and intermittently throughout the day. Each drug delivery rate is unique. Administration guidelines for giving IV medications must be followed to achieve the therapeutic effect desired.
IV drugs may not be compatible with certain IV fluids or other drugs. Drug incompatibility is a true risk to the patient because it can cause crystallization of the medication that may at the least clog the IV line or have adverse effects on the patient. Check compatibility warnings before giving IV drugs. The line must be flushed with saline before and after giving medications IV to avoid contact of incompatible solutions or medications.
The effects of medication appear rapidly after an IV injection. As such you must know the indications, actions, and adverse effects of the medication that is to be delivered and must observe the patient closely for adverse medication reactions or allergic reactions and be prepared to respond with supportive therapy or drug reversing agents.
IV push medication techniques deliver a bolus (a dose of medication injected all at once intravenously) of medication directly into a vein or access port to produce an immediate peak drug level in the patient's bloodstream. Large quantities of fluid IV push can cause severe complications; follow the recommendations of the drug administration guidelines. To deliver an IV bolus medication, draw the appropriate amount of medication that has been prepared, diluted, and/or reconstituted according to IV drug administration guidelines into a syringe. A bolus injection is most often given through a peripheral IV line, a saline lock, directly into a vein, or through a vascular access port.
When giving an IV bolus medication through a peripheral line with compatible fluid:
· Shut off the IV line using the control clamp.
· Clean the Y-port closest to the insertion site with an alcohol or povidone-iodine pad to prevent bacterial contamination.
· Connect the medication needle or needle-less system connector to the port.
· Inject the medication over the period of time ordered, after which disconnect the syringe and remove.
· Reopen the IV line using the control clamp and reset the IV flow to the appropriate setting.
· If the peripheral line fluid is not compatible with the IV bolus medication, prepare two syringes with 3cc of normal saline before giving the medication.
· Flush the line before and after the IV medication administration with the prepared saline syringes. The Y-port is quite vulnerable to contamination when switching syringes. After the IV line is flushed the second time, the line can be reopened and the IV flow rate reset to the appropriate setting.
Aftercare
After an IV medication has been delivered
· Observe the patient for adverse or allergic reactions
· Discard the used needles, IV tubing, bags, gloves, and disposable supplies
· Wash your hands and note in the patient files that the medication has been given
· If reverting to a primary IV line, reset the IV flow rate to the correct hourly rate that is ordered for the IV fluids.
Lesson 2: Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which a person’s breathing or heartbeat has stopped. When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you are helping an unconscious person who is not breathing.
CPR involves a combination of mouth-to-mouth rescue breathing and chest compressions that keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
Before you begin
Assess the situation before starting CPR:
Is the person conscious or unconscious?
If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?"
If the person does not respond call a doctor and begin CPR.
Remember the ABCs
Think ABC — Airway, Breathing and Circulation — to remember the steps explained below.
Step 1 Airway: Clear the airway
Put the person on his or her back on a firm surface.
Kneel next to the person's neck and shoulders.
Open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.
Check for normal breathing, taking no more than five or 10 seconds: look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person is not breathing normally, begin mouth-to-mouth breathing. If you believe the person is unconscious from a heart attack, skip Step 2 – Breathing, and proceed directly to Step 3 – Chest compressions.
Step 2 Breathing: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or cannot be opened.
With the airway open (using the head-tilt, chin-lift maneuver) pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
Prepare to give two breaths. Give the first breath — for one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
Begin Step 3 - Chest compressions, to restore circulation.
Step 3 Circulation: Restore blood circulation with chest compressions
Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 5 centimeters. Push hard and push fast — give two compressions per second, or about 120 compressions per minute.
After 30 compressions (15 seconds), tilt the head back and lift the chin up to open the airway. Prepare to give two breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. This is one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
Continue CPR until there are signs of movement or until a doctor takes over.
Figure13: Cardiopulmonary resuscitation (Courtesy McKesson Health Solutions LLC)
Concepts of Management of Pediatric Emergencies
Sick children present unique challenges to health care professionals. Assessment and treatment of children and infants are unique because children’s perceptions may be radically different from those of adults. Depending on age, children may or may not be able to say what is bothering them. Or they may be unconscious. Patience and understanding are the key to overcoming these problems.
The basic concept of management of pediatric emergencies is the same ABC (Airway, Breathing and Circulation). However, the anatomy and structure of children and infants are different from adults. Therefore, specialized training and equipment are required for managing pediatric emergencies. Immediately contact a doctor or refer the child to a hospital, if you spot a pediatric emergency.
To perform CPR on a child:
The procedure for giving CPR to a child aged 1 to 8 years is essentially the same as that for an adult. The differences are as follows:
§ Use only one hand to perform heart compressions.
§ Breathe more gently.
Use the same compression-breath rate as is used for adults: 30 chest compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the child moves or a doctor arrives.
Able to maintain cardiac output for long periods of time: strong
compensatory mechanisms
- Less total circulatory blood volume than adults
5. Skin temperature
- May lose heat rapidly; keep covered (especially head in small
infants)
Figure 14: Step 1 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
Figure15: Step 2 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
Figure 16: Step 3 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
To perform CPR on a baby
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but do not shake the child. If there is no response, follow the ABC procedures below:
Step 1 Airway: Clear the airway
Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do.
Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear. If the infant is not breathing, begin mouth-to-mouth breathing immediately.
Step 2 Breathing: Breathe for the infant
Cover the baby's mouth and nose with your mouth.
Prepare to give two breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
If the chest still does not rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger.
Begin chest compressions to restore blood circulation.
Step 3 Circulation: Restore blood circulation with chest compressions
Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
Gently compress the chest to about one-third to one-half the depth of the chest.
Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 to 120 pumps a minute.
Give two breaths after every 30 chest compressions.
Continue CPR until you see signs of life or until a doctor arrives.
Figure 17: Step 3 of Cardiopulmonary resuscitation on a baby
Head injury
See Unit 2, Sub-unit 2.5, Nervous System
Fractures
See Unit 2, Sub-unit 2.4, Musculoskeletal System
Dehydration
See Unit 2, Sub-unit 2.2, Digestive System
Burns
A burn is damage to body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.
Burns can cause severe damage to blood vessels. This type of damage causes fluid to seep out of the blood vessels, which cause swelling and blistering. In very severe cases with extensive burns, loss of fluid can lead to depletion of blood volume, shock, and very low blood pressure. Death is likely if fluids are not replaced. Burns often lead to infections because the protective layer of skin is destroyed.
Classification of burns by degree
There are three types of burns:
1st degree burns are the mildest of the three and damage only the outer layer of skin.
Signs and symptoms
These burns produce redness, pain, and minor swelling. The skin is dry without blisters.
Healing time
Healing time is about 3 to 6 days; the superficial skin layer over the burn may peel off in 1 or 2 days. 1st degree burns can heal over time without skin grafts as there is enough underlying skin tissue to rebuild the skin.
2nd degree burns are more serious and damage the outer and the inner layers of skin. They appear as redness with superficial blistering of the skin, and are usually very painful.
Signs and symptoms
These burns produce blisters, severe pain, and redness. The blisters sometimes break open and the area is wet looking with a bright pink to dark red color.
Healing time
Healing time varies depending on the severity of the burn. 2nd degree burns can heal over time without skin grafts as there is enough underlying skin tissue to rebuild the skin.
3rd degree burns are the most serious type of burn and damage or destroy all the layers of the skin and underlying tissues (ligaments, tendons and muscle). Third degree burns result in scarring and may be fatal if the affected area is significantly large.
Signs and symptoms
These burns are painless. Areas may be charred black or appear dry and white.
Healing time
Healing time depends on the severity of the burn. Deep second- and third-degree burns (called full-thickness burns) will likely need to be treated with skin grafts, in which healthy skin is taken from another part of the body and surgically placed over the burn wound to help the area heal. 3rd degree burns require skin grafts or application of artificial materials to cover and protect the exposed areas, as well as encourage new skin to grow.
Causes of burns
Burns may be caused by:
· Chemicals: from swallowing things, like drain cleaner or watch batteries, or spilling chemicals, such as bleach, onto the skin
· Electricity: electrical burns from being struck by lightning, biting on electrical cords or sticking fingers or objects in electrical outlets, etc.
· Radiation: UV light (as from over-exposure to the sun), radiation therapy (as patients who are undergoing cancer therapy), and X-rays
· Extreme hot temperatures: steam, hot water, tipped-over tea cups, cooking fluids, contact with flames or hot objects
· Extreme cold temperatures: a cold burn (frostbite) is a kind of burn which arises when the skin is in contact with something which has a low-temperature. It can be caused by exposure to, for example, snow, cold air, dry ice, and liquid nitrogen.
Management of burns
First-degree burns and second-degree burns limited to an area no larger than 3 inches (7.5 centimeters) in diameter:
Remove the person from the heat source
Remove clothing from the burned area immediately
Run cool (not cold) water over the burned area (if water is not available, any cold, drinkable fluid can be used) or hold a clean, cold compress on the burn for approximately 3 to 5 minutes (do not use ice, as it may cause the burn to take longer to heal). Cooling the burn reduces swelling by conducting heat away from the skin
Do not apply butter, grease, powder, or any other remedies to the burn, as this increase the risk of infection
If the burned area is small, loosely cover it with a sterile gauze pad or bandage. Wrap the gauze loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain and protects blistered skin. Do not use fluffy cotton, which may irritate the skin.
Give aspirin, paracetamol or ibuprofen for pain. Never give aspirin to children or teenagers
If the area affected is small (the size of a coin or smaller), keep the area clean and continue to use cool compresses and a loose dressing over the next 24 hours. Antibiotic cream could also be applied two to three times a day, although this is not absolutely necessary.
These minor burns usually heal without further treatment. They may heal with skin color changes, meaning the healed area may be a different color from the surrounding skin. Ask the patient or family members to watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, they should seek medical help.
Second-degree burns (covering an area larger than 3 inches in diameter) and third-degree burns:
1 Call doctor, then follow these steps until the doctor arrives:
o Keep the person lying down with the burned area elevated
o Follow the instructions for first-degree burns
o Remove all jewellery and clothing from around the burn (in case there is any swelling after the injury), except for clothing that is stuck to the skin. If you are having difficulty removing clothing, you may need to cut it off or wait until doctor arrives
o Do not break any blisters
o Apply cool water over the area for at least 3 to 5 minutes, then cover the area with a clean white cloth or sheet until doctor arrives
Caution
Do not use ice. Putting ice directly on a burn can cause frostbite, further damaging skin.
Do not apply butter or ointments to the burn. This could prevent proper healing.
Do not break blisters. Broken blisters can get infected.
Concepts of Management of Obstetric Emergencies
Every minute, one woman dies during pregnancy and birth because she did not receive adequate care and prompt treatment. By increasing interventions for safe motherhood, we can save the lives of half a million women and seven million infants, each year, and at the same time prevent millions of women from suffering from infections, injury and disability (UNFPA website, June 2008).
The management of obstetric emergencies is usually the responsibility of hospital obstetricians. However, dispensers may come across obstetric emergencies as part of first line healthcare providers, especially at BHUs or RHCs. The essential thing to remember is that all obstetric cases as well as emergencies should be referred to appropriate healthcare providers or facilities.
The first principles of dealing with obstetric emergencies are the same as for any other emergency (maintaining the Airway, Breathing, and Circulation). But remember that in obstetrics there are two patients and two lives; the mother and the fetus that is very vulnerable to maternal hypoxia or low concentration of oxygen in blood.
Emphasis on making emergency obstetric and newborn care available to all women who develop obstetric complications should be the ultimate goal in order to reduce maternal mortality. All five of the major causes of maternal mortality –Hemorrhage, Sepsis, Unsafe abortion, Hypertensive disorders and Obstructed labor -- can be treated at a well-staffed, well-equipped health facility. In such settings, many newborns who might otherwise die can also be saved, thus reducing neo-natal mortality.
In the long term, this means that all births should take place in appropriate health facilities, as is the case in all countries that have managed to significantly reduce their maternal mortality. However, where these conditions are not available, all women and newborns with complications should have rapid access to well-functioning facilities, whether that is a district hospital or an upgraded maternity centre at RHC or BHU.
Overwhelmingly, the following “the Three Delays” result in pregnancy-related deaths:
1 DELAY in deciding to seek appropriate medical help for an obstetric emergency.
2 DELAY in reaching an appropriate obstetric facility.
3 DELAY in receiving adequate care when a facility is reached.
We should therefore make all efforts to reduce these delays so that we could reduce deaths of mothers and children.
Rules of Managing Obstetric Emergencies
A. Apply oxygen with the woman rolled into the left lateral position (by at least a bag of IV fluid under the right hip) even if the woman is unconscious.
B. In general, it is best to concentrate on the resuscitation and transfer of the mother, as the infant is safer in utero.
C. In the young and healthy pregnant women, tachycardia and hypotension are very late features of shock and need to be considered extremely seriously.
Common Obstetric Emergencies
· Ante-partum Hemorrhage (APH)
APH is bleeding after 20 weeks, until the birth of the baby. The blood loss may be revealed or concealed, usually both, and is easily underestimated. Pain in abdomen is intense and constant, and the uterus large and rigid.
· Pre Eclemptic Toxemia and Eclampsia
Around the world, each year approximately 5 lakh (half million) women die of pregnancy related causes. Ninety-nine percent (99%) of these occur in the developing world, usually of infection or hemorrhage. But in the developed countries, HT is the major preventable cause of fetal and maternal morbidity and mortality, affecting up to 5% of pregnancies. Worldwide, toxemia accounts for approx. 10% of maternal deaths (Duley 1992), or 50 000 maternal deaths per year
Pre-eclamptic Toxemia (PET) is defined as a pregnant women having any two of following three criteria:
· BP more then140/90 or an increase of 30/15 from baseline BP
· Proteinuria which means proteins in the urine of more than 1+, or more than 300mg / L over 24 hours
· Edema or swelling, generalized body swelling visible on face, hands and feet
Having fits during or shortly after pregnancy is called Eclampsia. It may progress to status epilepticus, with cerebral, liver, kidney, heart, lungs or blood related complication. It is important to know that Eclampsia can occur without preceding signs. However, it is often preceded by:
severe generalized headache
visual disturbance e.g. photophobia, blurred vision
restlessness, agitation
pain in upper abdomen, nausea and vomiting
increased reflexes
altered level of consciousness, confusion
rapid progression of PET
A dispenser’s contribution is mainly in advocating to the community so that families bring their pregnant women to health facilities for antenatal registration and then pregnant mothers follow the schedule given to them by the concerned staff.
Concept of Management of Geriatric Emergencies
In Pakistan the demographic pattern and therefore the disease pattern is in transition. Old age brings degenerative changes in the entire body. Usually, people above 60 years display these changes, but it depends and varies from person to person and what kind f lifestyle the person has been following during his or her younger years. A healthy life style, i.e. balanced diet, regular exercise, absence of chronic diseases and health habits (abstinence from smoking, drinking and positive attitude) ensure a reasonable healthy old age. However, with advancing age all systems get affected. Typical signs and symptoms of emergencies such as myocardial infarction are not very pronounced and marked. Therefore, they are likely to be missed if we are looking for them in old age people (above 65 or 70 years) are brought to a health facility in emergency. Hence the golden rule to follow is to refer all old age emergency patients to a doctor after giving initial first aid.
1. Spinal Injuries
Recognition
· Patient will complain of pain in the neck or back
· There will be tenderness over the spine
· A twist might be noticeable in the spinal curvature
· There may be weakness or loss of movements in the limbs
· There may be loss of sensation or abnormal sensation
· There may be loss of balder tone and bowel control
· The could be difficulty in breathing.
Precautions
Do not move the person if a spinal injury is suspected. Leave it to specially trained professionals. Careless handling of such patients by untrained people can cause permanent disability to patients.
Poisoning
Introduction
Poisons are substances that cause damage to the cells of the body when they come into contact with them. Poisons can be ingested, inhaled, injected or they can be absorbed through skin or eyes. There are lots of different poisonous substances including medications, household products, such as bleach and industrial chemicals, and certain plants and berries. Also, substances that we may not usually think of as poisons, such as alcohol and tobacco, can be very harmful.
Methods of poisoning
Poisoning can occur in several different ways. The most common method of poisoning is by ingestion (where the poison is swallowed), but poisons can also be inhaled (breathed in), splashed onto the skin or eyes, or be injected, or through a bite (as with snake bites).
Accidental poisoning
Most cases of poisoning are accidental and occur in the home. Children are most at risk from poisoning, although cases involving fatal child poisonings are very rare. Elderly people also have a greater risk of being poisoned accidentally.
Intentional poisoning
Occasionally, poisoning may be deliberate. For example, a person may attempt to poison themselves by taking an overdose of prescription medication, such as antidepressants, or paracetamol. Intentional poisoning may also be carried out by someone who uses a poisonous substance to deliberately harm someone else.
Causes of Poisoning
Many common household substances can be harmful if they are not stored properly, or used in the correct way. Children under the age of five have the highest risk of accidental poisoning, with medicines being the most common cause of poisoning in children under 5 years of age.
Lots of substances are poisonous if they are eaten, inhaled (breathed in), or come into contact with the skin, or eyes.
Some common items that can cause poisoning are listed below.
Prescription drugs and medicines, such as calamine lotion, petroleum jelly, evening primrose oil, folic acid, oral contraceptive and hormone replacement preparations, simple steroid creams, zinc oxide creams and lotions.
Household products, such as bleach, cleaners, floor and furniture polish, washing powders, or liquids, washing up liquid and liquid soap.
Products, such as emulsion paint, putty and PVA (polyvinyl alcohol) glue
Cosmetics, such as baby oil, shampoo, hair conditioner, hair dye, moisturizing cream, or lotion, and solid cosmetics, such as lipstick and eye shadow.
Agriculture insecticides and chemicals, such as weed killers, ant, rat or mouse poison, insect repellents, methylated spirits, paint thinner, copper sulphate, insecticides such as organo-phosphorous compounds and acids such as sulphuric acid.
Insects and snakes, such as bees, wasps and hornets, inject venom (poison) into the skin when they sting us, which can cause pain, swelling and itching in the area of the bite or sting. Bites from snakes that contain venom can cause symptoms such as diarrhea, sickness, bleeding and drowsiness leading to unconsciousness depending on the type of snake.
Food can cause poisoning if it contains harmful bacteria. This can happen if it goes mouldy and bad, if cross contamination occurs, for example, between cooked and raw meat, or if it has not been cleaned or prepared properly.
Carbon monoxide is a poisonous, odorless gas that is produced by incomplete burning of fuels, such as gas, wood or petrol. These types of fuels are used in many household appliances, such as heaters, fires and cookers. If appliances are not regularly serviced, and well maintained, carbon monoxide can leak from them without you realizing, which can have serious consequences and, in some cases, can cause death.
Symptoms of poisoning
Different poisons affect the body in different ways, they can take effect quickly or over time. Some, such as carbon monoxide, interfere with the blood's ability to carry oxygen. Others, like bleach, burn and irritate the digestive tract.
The range of symptoms can be broad and varied depend upon the poison. However, poisoning should be considered as a cause if someone suddenly becomes ill for no apparent reason, or acts strangely, particularly if they are found near a poisonous substance.
Symptoms of poisoning can include:
abdominal pain, vomiting, diarrhea, or nausea
dizziness, weakness or drowsiness
fever
chills (shivering)
loss of appetite
headache or irritability
pain on swallowing or production of more saliva than usual
skin rash
burns around the nose or mouth
double or blurred vision
muscle twitching
seizures (fits)
stupor or unconsciousness
Preventing poisoning at home
People can reduce the likelihood of accidental poisoning by the following steps. A dispenser should advocate these:
Store all medicines, vitamins and poisonous substances in child-proof containers and lock them in an area that is well out of reach of children. Be vigilant not only with medicines but also with common household products, such as bleach, polishes, paint thinners, spirit, cleaners and paint.
Never store dangerous products in everyday containers such as milk bottles or drinking glasses. A child may associate these with food or drink and try them out. Check the garden for poisonous plants and berries and remove them.
Have the boiler and gas fire serviced regularly to reduce the risk of carbon monoxide poisoning, and make sure that bedrooms, in particular, have adequate ventilation.
Turn off fire heating (gas or coal) before going to sleep.
Don't block air vents, flues or chimneys and don't have indoor fires or stoves without proper ventilation to the outdoors.
What should a dispenser do in case a patient with suspected poisoning is brought at the health facility?
Correct first aid can significantly improve a person's chances of a full recovery – Remember ABC (Airway, Breathing and Circulation--- and CPR (Cardio Pulmonary Resuscitation). These should be immediate steps. Then refer the patient to a doctor or call the doctor on emergency duty.
Copper Sulphate Poisoning
It is a fungicide, herbicide and a commercial chemical. The anhydrous form is white, the pentahydrate is blue.
Toxicity
Copper sulphate is a powerful oxidizing agent and irritant to mucous membranes. A dose-response effect following ingestion is difficult to define but approximately 10 g may be fatal in an adult (Akintonwa etal, 1989).
Chronic inhalation of copper sulphate-containing pesticides produces pulmonary and hepatic toxicity. Copper sulphate contact sensitivity is a recognized disease entity.
Features
Dermal: Mild irritant to intact skin. Systemic copper uptake may result from repeated application to broken skin. Contact dermatitis may result.
Ocular: Irritant to eyes and my cause corneal necrosis and opacification of cornea if crystals remain in the conjunctival sac.
Ingestion: Very small ingestions (milligrams) are likely to cause only nausea and vomiting.
Moderate/substantial ingestions lead to nausea, vomiting and a metallic taste occur within minutes followed by abdominal pain and diarrhea. Secretions may be blue/green. Severe gastrointestinal irritation may result in hematemesis and/or melena with hypovolemic shock.
Severe poisoning is associated with the development of renal failure, intravascular hemolysis (usually manifest 24-48 hours after-poisoning) and cellular and obstructive liver damage. Coma, convulsions, muscle weakness and cardiac arrhythmias may also result. There is a high risk of aspiration of the gastric contents in drowsy patients.
Inhalation: This has been reported only as chronic occupational inhalation of copper sulphate-containing fungicides, presenting as 'Vineyard sprayer's lung' with progressive dyspnea, cough, wheeze, myalgia, malaise and a restrictive lung function defect. Other features include liver damage.
Management
Dermal
· Irrigate with copious lukewarm water.
· Consider the possibility of systemic copper uptake if there has been significant or repeated exposure to broken skin.
· Copper sulphate irritant dermatitis and contact sensitivity are managed most effectively by discontinuing exposure.
For other forms of Copper Sulphate poisoning call a doctor or refer the patient to a health facility where a doctor could attend the patient.
Sulphuric Acid Poisoning
Sulphuric acid is a very strong chemical that is corrosive. Corrosive means it can cause severe burns and tissue damage when it comes into contact with the skin.
Where Found:
It is present in car batteries as battery acid, certain detergents, some fertilizers and toilet cleaners.
Symptoms
Initial symptoms include severe pain on site of contact. Symptoms from swallowing may include:
· Breathing difficulty due to throat swelling
· Burns in the mouth and throat
· Drooling
· Fever
· Rapid development of low blood pressure
· Severe pain in the mouth and throat due to corrosion
· Speech problems
· Vomiting with blood
· Vision loss
Symptoms from breathing in the poison may include:
· Bluish skin, lips, and fingernails
· Breathing difficulty
· Body weakness
· Chest pain (tightness)
· Choking
· Coughing up blood
· Coughing
· Dizziness
· Low blood pressure
· Rapid pulse
· Shortness of breath
Management
Do NOT make a person throw up or vomit. Never pass a naso-gatric tube. Give first aid and refer the patient to a doctor or call the doctor.
If sulphuric acid is on the skin or in the eyes, flush with lots of water for at least 15 minutes.
If sulphuric acid was swallowed, immediately give the person water or milk. Do NOT give water or milk if the patient is vomiting or has a decreased level of alertness.
If the person breathed in the poison, immediately move him or her to fresh air.
Insect Stings
Insects injects venom through their stings causing local inflammation and local pain. I case of acute allergies and extra sensitivity to stings, there may be a severe reaction even loss of consciousness. In such cases seek medical aid urgently.
Treatment for Stings in the Skin
Sometimes insects leave their sting in the skin along with the poison bag. Sting and poison bag should be removed immediately with using forceps. In order to prevent more poison from going into the skin, apply forceps to the poison bag and sting nearest to the skin. Treat the wound with antiseptic dressing.
Treatment of Stings in the Mouth
Stings in the mouth can cause swelling that could lead to difficulty in breathing. In such situation give the patient ice cubes to such and refer the patient to doctor. If the patient becomes unconscious ensure patency of the airway, breathing and take care of bleeding if any. If there is no difficulty in breathing rinse mouth with weak solution of sodium bicarbonate.
Minor Wounds (cuts, scratches, bruises)
Small wounds or cuts act as an entry point for germs. Every care must be taken to keep it clean with dressing and antiseptic dressings.
· Wash your hands thoroughly before dressing the wound.
· Do not touch or cough or breathe over the wound.
· Stop any bleeding by applying pressure over the wound for sufficient time.
· For dressing clean the wound and surrounding skin, cut away any hair near the wound, cover it with dry sterile dressing, thoroughly, clean the surrounding skin with a swab taking care not to push dirt towards the wound. Use diluted antiseptics or running water for cleaning the wound and surrounding skin.
· Do not disturb any blood clots that are present on the wound as disturbing them might re-start bleeding.
· Cover the wound with dry sterile dressing and bandage.
· If there is raw area around the wound or a small surface burn, use a non-adhesive dressing and bandage.
· Cover small abrasions with small adhesive dressings.
Bites/Stings/Scratches
Animal Bites and Scratches
In countries where rabies is present all animal bites must be reported and proper medical treatment obtained. Wash the site of injury thoroughly with water. If bleeding is severe apply pressure to stop it. Cover wound with a dry sterile piece of dressing. For anti tetanus vaccination the advice of a doctor should be sought.
Snake Bites
Snake bites could be extremely painful. The patient is often very frightened. It is important to identify the snake for proper treatment. However in countries where poisonous snakes are common, stock of anti snake venom is routinely kept at all health centers.
Treatment of Snake Bites
Calm the patient and make him or her lie down. Clean the wound with water and wash off any venom present at the site of bite. Do not cut or suck the wound. Cover it with sterile dressing. Immobilize the limb, if the bite is on a limb. Arrange for the transfer of the patient to a hospital. Watch for airway, breathing, bleeding (ABC) and arrange for CPR. If the snake has been killed take it to the doctor for identification.
Nose Bleeding or Epistaxis
Nose bleeding is quite common in young children. A bang on the nose or a small collision with nose taking the pressure could result in nose bleed. It can also occur spontaneously in the elderly, especially if they are suffering from hypertension. Bleeding from nose after a blow on the head indicates a fractured skull.
Treatment of Nose Bleeding
· Do not plug the nose.
· Sit the person in a chair in a way that the head is in the upright position.
· Tilt the head slightly forwards to prevent blood from running back down the throat.
· Ask patient to spit out any blood in the mouth and let blood drip from nose into a bowl.
· Tell the patient to firmly pinch soft part of nostrils for about 5-10 minutes and to breathe through the mouth. After 5-10 minutes release nostrils slowly. If the bleeding does not stop repeat the process for another 5 minutes.
· Do not blow the nose as it will restart bleeding.
· If bleeding persists or if there are continued bouts of bleeding call a doctor.
Muscular Injuries
Muscle Cramps
Muscle cramps are sudden, involuntary contractions or spasms in one or more muscles. They come as a sudden pain and tightness in the muscles with legs being affected the most. They often occur after exercise or at night, lasting a few seconds to several minutes. It is a very common muscle problem.
Muscle cramps can be caused by nerves that malfunction. Sometimes this malfunction is due to a health problem, such as a spinal cord injury or a pinched nerve in the neck or back. Other causes are
Straining or overusing a muscle
Dehydration
A lack of minerals in your diet or the depletion of minerals in your body
Not enough blood getting to your muscles
Treatment of Cramps
Cramps can be very painful. Stretching or gently massaging the muscle can relieve this pain.
Stretch the affected muscle, e.g. if the sprain is in the calf of the leg, straighten the knee and pull the foot up towards the shin. This will force the opposite set of muscles to contract so that the affected muscle will relax and the pain and cramp will disappear.
Sprain (Joint)
A sprain occurs at a joint after wrenching, stretching or partial or complete tearing of ligaments.
Signs of Sprain
Pain especially on movement, swelling and sometimes bruising can be seen in sprains.
Treatment of Sprain
Place the patient in a comfortable position. Uncover the joint by removing clothes covering it. Then pad and bandage it heavily to give it support. If the ankle is injured, the bandage can be put over the shoe. In case an arm is injured put it in a sling. Sprained joints should be x-rayed to confirm or rule out fractures.
Strain
A strain occurs when a muscle has been pulled or over stretched so that the muscle fibers are torn .It can follow sudden severe exertion or the lifting of heavy weights.
Signs of Strain
Sudden pain, which is worse on movement. Sometimes bruising and swelling in the affected area.
Treatment of strain
Place the patient in a comfortable position and support the injured part until it can be seen by a doctor.
Stitch
It is characterized by the onset of pain in the side of the abdomen, occurring suddenly during games and running. No treatment is necessary, just rest will lead to recovery.
Winding
Winding is caused by a blow in the upper abdomen, which may cause a person to double up or coil up with pain.
Treatment of winding
Let the person stay in the most comfortable position until pain passes. If there is loss of consciousness, place the person in the recovery position.
Shock
Recognition
1. Rapid pulse
2. Pale, Cold, Clammy skin
3. Sweating
Later
1. Grey-blue skin, especially in side lips
2. Weakness and giddiness Nausea or thirst
3. Rapid, shallow breathing
Eventually
1. Restlessness
2. Gasping for air
3. Unconsciousness.
First Aid
1. Help the person to lie down
· Use a blanket to insulate the person from ground.
· Raise and support legs (foot end) as high as possible so that blood is available for vital organs such as brain and heart.
· Treat any cause of shock, such as bleeding
2. Loosen tight clothing
· Undo anything that constricts neck, chest or waist
· Cover the person with a blanket
3. Call for medical help and ambulance.
4. Monitor breathing, pulse and response.
Heart attack
1. There may be chest pain, spreading to one or both arm.
2. Breathlessness
3. Discomfort, like indigestion in upper abdomen.
4. Sudden faintness.
5. Sudden Collapse.
6. Ashen skin and bluish lips.
7. Rapid, thin and weakening pulse.
8. Profuse sweating.
First Aid
1. Make casualty comfortable:-
· Help the person in half sitting position.
· Support head, shoulders and knees.
· Reassure the person.
2. Call an ambulance:-
· Tell the Doctor that you suspect a heart attack
3. Give emergency medication:-
· If the casualty is consciousness, give one tablet of aspirin
· If the person is carrying medicines, help him/her to take those
4. Monitor casualty:-
· Encourage the person to rest
· Monitor and record vital signs
Actions taken:-
· Make person comfortable
· Call ambulance give person aspirin
· Monitor person.
Roller Bandages
These are made of cotton, gauze, elasticized fabric, or linen and are wrapped around the injured part in spiral turns. There are three main types of roller bandages:-
1. Open weave bandages
Because of their loose weave they allow good ventilation, but they cannot be used to apply direct pressure on the wound or give support to joints.
2. Elasticized bandages
These moulds to the body shapes. These are used to secure dressings and support soft tissue injuries.
3. Crape bandages:-
Are used to give firm support to injured joints and bony areas.
Rules for applying a roller bandage
1. Keep the rolled part of the bandage (head) upper most as you work.(The unrolled part is called tail)
2. Position yourself towards the front or injured side.
3. While you are working make sure that the injured part is supported in the position in which it will remain after bandaging.
The Safe House
We may think that home is a safe place, but almost as many people die from accidents in the homes as on the roads. Most at risks are the very young and the very old.
Fires and falls cause most accidental deaths in the home. Other frequent causes include poisoning and suffocation. But very many home accidents, especially in kitchen and bathroom, can be prevented by continuous care and thought. Always have permanent gas and electrical appliances installed by qualified fitters and buy only those appliances that carry official acknowledgement.
Remember that water conducts electricity, and never touch a switch or appliances if your hands are wet.
Safety Indoors (Important points)
· Adequate lighting for passage ways.
· Access to main lights from bed.
· Escape facility from upstairs.
· Never smoke in the bed.
· Proper safety covers on electric outlets.
· High sided cots, no pillows.
· Safety bars on windows.
· Appropriate storage of drugs so that they are kept out of the reach of children.
· Non slip mats on floors.
· Hand rails for providing support to the elderly.
· Access to stairs light switch.
· Adequate lighting for stairs.
· Safety gates on stairs.
· Secure carpets, no obstruction.
· Adequate light for entrance.
· Safe wires and connections.
· Safety gate for kitchen.
· Ventilation for gas.
· Hygienic waste can.
· Cleaning materials locked and kept out of children reach.
· Play area visible from house.
· No objects are placed on heaters.
Drowning
Death by drowning occurs when air cannot get into the lungs, usually because a small amount of water has entered the lungs, this may also cause spasm of the throat.
When a drowning person is rescued, water may gush from the month. This water is from the stomach and should be left to drain of its own. Do not attempt to force water from the stomach because the person may vomit and inhale it.
A person from a drowning incident should always receive medical attention even if he seems to recover at the time. Any water entering the lungs cause them to become irritated, and the air passages may begin to swell several hours later a condition known as secondary drowning.
The person may also need to be treated for hypothermia.
Aims:
· To restore adequate breathing
· To keep the person warm
· To arrange urgent removal to hospital.
· If you are rescuing a person from the water to safety, keep the person’s head lower than the rest of the body to reduce the risk of inhaling water.
· Lay the person down on back. Open the airway and check breathing is prepared to give rescue breaths and chest compression if necessary (CPR). If the person is breathing, place in recovery position.
· Treat the person for hypothermia, remove wet clothing if possible and cover with dry blanket. If the person regains full consciousness give warm drink.
· Call for a medical help
Electrical Burn
Burn may occur when electricity passes through the body, much of the visible damage occurs at the points of entry and exit of the current.
However, there may also be a tract of internal damage. The position and direction of entry and exit wound will alert you to the site and extent of hidden injury and the degree of shock that the patient may have suffered.
Burns may be caused by a lightning strike or by low or high voltage electric current. An electric shock can also cause cardiac arrest. If the person is unconscious, your immediate priority, when you are sure that the area is safe, is to open the person’s air way and check for breathing and circulation.
Aim of Treatment is to
· treat burns
· treat the shock
· arrange urgent removal to hospital
Hanging and Strangulation
If pressure is exerted on the outside of the neck, the airway is squeezed and the flow of air to the lungs is cut off. Main causes of such pressure are:
· Hanging: Suspension of the body by a noose around the neck
· Strangulation: Constriction or squeezing around the neck or throat is called strangulation. Sometimes hanging and strangulation may occur accidently for example by neckties and clothing which become caught in machinery. Hanging may cause a broken neck, for this reason, a casualty in this situation must be handled very carefully.
Aims:
· To restore adequate breathing
· To arrange urgent removal to hospital
Recognition:
· A constricting article around neck will be present
· Marks around the casualty’s neck
· Rapid difficult breathing
· Impaired consciousness
· Grey- Blue skin
· Congestion of the face with prominent veins and possibly tiny red spots on the face or the white of eyes.
First Aid
· Quickly remove the constriction if any around the person’s neck
· Immediately remove the parson to the hospital.
Dressings
Aims
Dressing helps to prevent infection by creating a barrier between the wound and other harmful agents. Dressings are also used to stop bleeding as they aid blood clotting process by exerting pressure on the wound.
Rules for Using Dressing:
1. Always wear disposable gloves if available, before handling any dressing other than plaster of Paris casts.
2. Always use a large dressing that covers the wound and extends beyond the edges of wound.
3. Place the dressing directly on top of the wound (do not slide it on from the side)
4. Remove and replace any dressing that slips out of position.
5. If there is only one sterile dressing, use this to cover the wound and apply other clean material on the top of the dressing.
6. If blood seeps through the dressing, do not remove it; put another one on top of the old dressing. If still the blood seeps, remove both and apply a new one, making sure that you apply pressure over the bleeding point.
7. After doing the dressing, remove gloves. Used dressing materials and contaminated items are put in a suitable plastic bag for safe disposal.
8. Do not remove gloves till you have finished the work.
Sterile Dressing
This type of dressing consists of a dressing pad attached to a roller bandage and is available in different sizes. (Dressing pad consists of a piece of gauze padded by a layer of cotton wool.)
How to Using Sterile Dressings
1. Break open the seal and remove the wrapping. Unwind (unroll) the bandage, taking care not to drop the roll or touch the dressing pad.
2. Unfold the dressing pad, holding the bandage on each side of it. Lay the pad directly on the wound.
3. Wind the short end (tail) of the bandage once around the limb and dressing to secure the pad.
4. Wind the other long end (head) of bandage around the limb to cover the whole pad. Leave the tail of bandage hanging free.
5. To secure the bandage, tie the ends in a “reef knot”. Tie the knot directly over the wound
6. Once you have secured the bandage, check the circulation in the limb in vessels distal to it. Loosen the bandage if it is too tight.
Non Sterile Dressing
· If sterile dressing is not available, you can use gauze pads or any other clean material or apply cotton wool to the wound to absorb blood or other fluids. While using non sterile dressing, make sure the item is clean. Secure dressing with a bandage or tape or sticking plaster.
Adhesive Dressing
· Plasters are useful for dressing small cuts and grazes. They consist of gauze and an adhesive plaster. They are of different sizes.
Cold Compresses
Cooling an injury such as a bruise or sprain can reduce swelling and pain, although it will not relieve the injury itself.
Cold compress are of two types. Cold pads made up of material filled with cold water and ice packs.
Method for Making Cold Compresses
Cold Pad
1. Soak a towel in cold water, wring it out lightly and fold it into a pad, then place it firmly on the injury.
2. Re-soak the pad in the cold water every 3-5 minutes. Cool the injury for at least 10 minutes.
Ice Pack
1. Partly fill a plastic bag with ice cubes or broken ice or pack of frozen vegetables. Place it firmly on the injury after wrapping it in a dry cloth.
2. Hold the pack firmly for 10 minutes on the area.
Principles of Bandaging
There are a number of different first aid uses of bandages. They can be used to secure dressings, control bleeding, support and immobilize limbs and reduce swellings in an injured part.
There are three main types of bandages.
1. Roller bandages that secure dressings and support injured limbs.
2. Tubular Bandages that hold dressings on fingers or toes or support injured joints.
3. Triangular Bandages can be used as large dressings, as slings, to secure large dressings or to immobilize limbs.
Rules of Applying a Bandage
1. Before applying a bandage, reassure the person and explain what you are going to do.
2. Make the person comfortable in a suitable sitting or lying position.
3. Keep the injured part supported while you are working on it. Ask the person or a helper to do this.
4. Always work from the front or injured side of person
5. If casualty is lying down, pass the bandages under the body’s natural allows at the ankles, knees, waist and seek then slide the bandages into position by moving them back forward under the body.
6. Apply the bandages firmly but not so tightly that they interfere with circulation of the area beyond the bandage.
7. Leave the fingers or toes out of the bandages if possible to check the circulation.
8. Use reef knots to the bandages (Do not tie the knot over a long area).
9. Regularly check the circulation in the area beyond the bandage.
Checking Circulation after Bandaging
When bandaging a limb or using a sling, you must check the circulation in the hand or foot immediately after you have finished bandaging and every 10 minutes thereafter. These checks are essential because limbs swell after injury and a bandage can rapidly become too tight and interfere with blood circulation to the area beyond it. The symptoms of injured circulation enhance as first the veins and then the arteries become constricted.
Circulation Check
1. Briefly press one of the nails, or the skin until it turns pale, and then release the pressure. If the color does not return or returns slowly, the bandage may be too tight.
2. Loosen the bandage.
If Circulation is Impaired there may be:
1. Swollen limb
2. Blue skin with prominent veins
3. Painfully distended skin
Later there may be:
1. Pale, Waxy skin
2. Cold and numbness
3. Tingling
4. Deep pain
5. In ability to move, attached fingers or toes.
Medico-legal Cases and the Dispenser
The following act defines the context of medico-legal cases and should be adhered to without fail.
THE INJURED PERSONS MEDICAL AID BILL 2004
To make provision for medical aid and treatment of injured persons.
Whereas there is a misconception about the law and procedure with regard to medical aid and treatment of injured persons before completion of medico-legal formalities;
WHEREAS due to this misconception the medical aid and treatment of injured persons is very often delayed and many causalities have occurred because of delayed treatment;
AND WHEREAS it is necessary to make provisions for medical aid and treatment of injured persons to save their lives and protect their health during emergency;
It is hereby enacted as follows;
1. Short title, extent and commencement; - (1) This act may be called the Injured persons (medical Aid) Act, 2004.
(2) It extends to the whole of Pakistan
(3) It shall come into force at once
2. Definitions; - In this act, unless there is anything repugnant in the subject or context;-
(a) “Doctor” means a medical practitioner registered under the Medical and dental council Ordinance, 1962(XXXII of 1962);
(b) “Government” means the Federal government or a Provincial government, as the case may be;
(c) “Hospital” means a hospital notified under section 7; and
(d) “Injured person” means a person seriously injured due to traffic accident, assault or any other cause.
3. Injured persons to be treated on priority basis; - Whereas an injured person is brought to a hospital, he shall be provided medical aid without delay on priority basis over all other medico-legal formalities.
4. Non-interference by the police; - No police official of officer shall interrupt or interfere during the period an injured person is under treatment in a hospital except with the written permission of the Incharge of the hospital;
Provided that such permission shall not be given unless it is in the interest of justice and necessary in connection with the investigation which shall be carried out in the hospital so long as the injured person is under treatment.
5. Consent of relatives not required in certain cases; - Where an injured person requires emergency treatment or operation, the doctor treating or operating the injured persons need not wait for the consent of the relatives:
Provided if the relatives are present it would desirable that such treatment or operation may be carried out with the consent of such relatives.
6. Hospital not to shift injured persons until stabilized;-
(1) An injured persons shall not be shifted from a hospital until he stabilized while shifting him to another hospital, the doctor concerned shall complete the relevant documents with regard to the clinical conditions of the patient and handover such document to concerned doctor of the receiving hospital.
(2) The record referred to in sub-section (1) shall be maintained by the referring hospital as well as the receiving hospital and the Incharge of the hospital shall be responsible for ensuring that such record is kept in a safe custody where it cannot be tempered with.
Provided that where necessary an injured person shall not be shifted unless he is accompanied by a doctor of the referring hospital.
7. Hospital to be notified; - The government shall, be notification in the official gazette, notify the government hospital having at least fifty in-patient beds and also have facilities to deal with the emergencies to provide medical aid and treat the injured persons;
Provided that in areas where above referred facility is not available, a rural health centre established by a government in that area having facility to deal with the emergencies, may be notified as hospital for the purposes of this act.
8. The injured person not to be taken to police station; - Under no circumstances, an injured person be taken to a police station before necessary medical aid and treatment is given to him. The police officer is bound to ensure that the injured person is treated in a hospital as provided in this act before any medico-legal procedure is undertaken. The police officer must not in any way influence the doctor or to give any opinion about the type and details of injury of the injured person.
9. The person bringing the injured person to hospital not to be harassed; - The person who on humanitarian basis in particular in traffic accident cases, brings an injured person to a hospital must not be harassed. He must be shown due respect and acknowledged for helping the injured. He should be allowed to leave the hospital after taking down his name, address, telephone number and he shall provide his national identity card number within three days;
Provided that nothing herein contained shall absolve the person bringing an injured person to a hospital form the liability to which he may be liable under the law for the time being enforced for causing injury to such person.
10. Awareness campaign; - An awareness campaign shall be a regular feature to educate the public, medical professionals and police on regular basis about medico-legal procedures by the government through media and training programs.
11. Penalty; - Whoever contravenes or violates the provisions of this act or the rules made there under shall be punishable with imprisonment which may extend to two years, or with fine not less than ten thousand rupees, or with both, in addition to any other penalty to which he may be liable under any other law for the time being in force.
Provided that where penalty of fine is imposed half of such fine shall be paid to injured person or his heirs, as the case may be, as compensation;
Provided further that the court may direct the medical and dental council under the medical and dental council ordinance, 1962 (XXXII of 1962) to cancel the registration of a doctor convicted by the court.
12. Cognizance of cases; - (1) No court shall take cognizance of a case under this act, except upon a complaint made by an officer authorized in writing in this behalf by the government.
(2) The government shall notify authorized officers under sub-section (1) within thirty days of the commencement of this act.
13. Instructions; - The government may issue instructions from time to time carry out the purposes of this act and the defaulting doctor or the police official or officer shall be liable to disciplinary action for contravention of such instructions, besides the penalty to which he may be liable under section II.
14. Rule making power; - The federal or provincial government, as the case may be, may make rules to carry out the purposes of this act.
Class room evaluation
Student: _________________________ ID: __________________________
Teacher: _________________________Unit 5: Emergencies: Trauma, Overdosage and poisoning
Date: ________________________
Select the best response for each test item.
How would you describe triage?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
There are ______ vital signs which are standard measurements in most medical settings (choose one).
a. two
b. three
c. four
Body temperature is normally recorded in the following three sites in the body.
a. _______________________________
b. _______________________________
c. _______________________________
The normal core body temperature of a healthy, resting adult human being is stated to be (choose one)
a. 98.6 degrees Fahrenheit or 37.0 degrees Celsius
b. ___________
c. ______________
Demonstrate the various steps of recording mouth temperature in an adult.
Demonstrate the various steps of recording axillary temperature in a child.
The normal pulse or heart rate in a 0-5 months baby is ________beats per minute and in an adult is ________beats per minute.
What are the two numbers used to measure blood pressure? Describe them. What is the normal blood pressure?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Respiratory rates may increase with __________, _________, _____________, and______________.
The normal respiratory rate in a newborn is ________breaths per minute and in an adult is ________ breaths per minute.
What are the three ways of bleeding to occur?
a. _____________________________________
b. _____________________________________
c. _____________________________________
Symptoms of internal bleeding include:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
First-line management to control bleeding is to apply a tourniquet.
True False
Direct pressure stops most external bleeding, and is the most important initial first aid.
True False
Serious injuries always bleed heavily and minor injuries do not bleed profusely.
True False
What are the three methods of administering IV medication?
a. _____________________________________
b. _____________________________________
c. _____________________________________
What are the three steps of giving cardiopulmonary resuscitation to an adult? Explain fully.
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
What are the two differences between the procedure of giving cardiopulmonary resuscitation to a child aged 1 to 8 years and an adult?
________________________________________________________________________________________________________________________________________________
What are the three steps of giving cardiopulmonary resuscitation to a baby? Explain fully.
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
Explain the different types of burns.
________________________________________________________________________________________________________________________________________________
What are the different causes of burns?
________________________________________________________________________________________________________________________________________________
Explain the management of first-degree and second-degree burns limited to an area no larger than 3 inches in diameter.
________________________________________________________________________________________________________________________________________________
Notes
Unit 5: 3
Emergencies: Trauma, Overdosage and Poisoning. 3
Learning objectives: 4
1. Lesson 1: Common Definitions. 4
Triage. 4
Vital signs. 4
Body temperature. 4
Pulse or heart rate. 8
Blood pressure. 10
Respiratory rate. 13
Bleeding. 15
Intravenous medication. 21
Lesson 2: Cardiopulmonary Resuscitation (CPR) 23
Head injury. 31
Fractures. 31
Dehydration. 31
Burns. 31
Classification of burns by degree. 31
Causes of burns. 32
Concepts of Management of Obstetric Emergencies. 35
Concept of Management of Geriatric Emergencies. 38
Poisoning. 40
Copper Sulphate Poisoning. 42
Sulphuric Acid Poisoning. 45
Insect Stings. 46
Bites/Stings/Scratches. 47
Muscular Injuries. 48
Shock. 51
Heart attack. 52
Roller Bandages. 52
The Safe House. 53
Drowning. 55
Electrical Burn. 55
Hanging and Strangulation. 56
Dressings. 58
Sterile Dressing. 58
Non Sterile Dressing. 59
Adhesive Dressing. 59
Cold Compresses. 59
Principles of Bandaging. 59
Medico-legal Cases and the Dispenser. 61
Unit 5:
Emergencies: Trauma, Overdosage and Poisoning
Learning objectives:
After completing Unit 5 dispenser students will be able to:
define triage
record vital signs
elicit life threatening signs
demonstrate skills and knowledge to stop bleeding and maintain I/V line
carry out CPR and manage Airway, Breathing and Circulation (ABC)
carry out first line handling of patients with suspicion of head or spinal injury
carry out first line handling of patients with fractures.
1. Lesson 1: Common Definitions
Triage
Triage is a process of prioritizing patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately.
Activity
Brainstorm the situations where triaging becomes essential.
Vital signs
Vital signs are measures of various physiological statistics taken in order to assess the most basic body functions. There are four vital signs which are standard measurements in most medical settings:
Body temperature
The normal core body temperature of a healthy, resting adult human being is stated to be at 98.6 degrees Fahrenheit or 37.0 degrees Celsius. Though the body temperature measured on an individual can vary, a healthy human body can maintain a fairly consistent body temperature that is around the mark of 37.0 degrees Celsius.
The normal body temperature varies due to:
a. Metabolic rate: higher metabolic rate results in higher normal body temperature and lower metabolic rate leads to lower normal body temperature.
b. Time of the day: the body temperature is lower in the morning because the body has rested during the night, and is higher at night after a day of muscular activity and food intake.
c. Location in the body where the temperature is recorded:
-Mouth temperature, which is the most convenient type of temperature measurement, measures at 99.0 °F or 37.0 °C. This is the accepted standard for the normal core body temperature.
-Axillary (under the armpit) temperature is an external measurement of body temperature and measures at 97.6 °F or 36.4 °C. This is the longest way of measurement and not as accurate as rectal or oral measurements. An axillary temperature will read approximately 1 degree lower than a simultaneously obtained mouth temperature.
-Rectal temperature is an internal measurement taken in the rectum, and measures at 99.6 °F or 37.6 °C. It is the least time consuming, most accurate but uncomfortable type of body temperature measurement.
Different types of thermometers
§ Digital thermometers (Figure 1) usually provide the quickest, most accurate readings. They come in many sizes and shapes. Digital thermometers usually have a plastic, flexible probe with a temperature sensor at the tip and an easy-to-read digital display on the opposite end.
They can be used for the following temperature-taking methods:
-oral (in the mouth)
-rectal (in the bottom)
-axillary (under the arm)
§ First, turn on the thermometer and make sure the screen is clear of any old readings. If the thermometer uses disposable plastic sleeves or covers, put one on according to the manufacturer's instructions. Remember to discard the sleeve after each use and to clean the thermometer according to the manufacturer's instructions before putting it back in its case. Once the temperature is recorded, the thermometer signals that the reading is complete by a single beep or a series of beeps or the temperature flashes in the digital window on the front of the thermometer.
Figure 4 - Digital Thermometer
§ Electronic ear thermometers (Figure 2) measure the temperature inside the ear canal. Although they are quick and easy to use in older babies and children, electronic ear thermometers are not as accurate for infants 3 months or younger as digital thermometers.
Figure 5 - Electronic ear thermometer
§ Plastic strip or forehead thermometers (small plastic strips that are pressed against a child's forehead, Figure 3) are not reliable for taking an exact measurement, especially in infants and very young children and should not be used.
Figure 6 - Forehead thermometer
§ Glass mercury thermometers (Figure 4): They are most commonly used. They contain mercury in a glass tube.
Figure 4: Glass mercury thermometer
Activity
Learn to take body temperature
Mouth temperature
Older children and adults can have their temperature taken under the tongue with their mouth closed. Mouth temperatures will be inaccurate if the patient has had hot or cold drinks within 20 minutes of temperature measurement.
§ Wait 20 to 30 minutes after the patient finishes eating or drinking to take an oral temperature
§ Place the tip of the thermometer under the tongue and ask the patient to close his or her lips around it. Remind the person not to bite down or talk, and to relax and breathe normally through the nose
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, the thermometer is shaken down before using it. The tip of the thermometer should be placed as far back under the tongue as possible. The thermometer should be left in place for at least three minutes.
Axillary temperature
This is a convenient way to take a child's temperature although not as accurate as a rectal or mouth temperature.
§ Remove the child's shirt and vest, and place the thermometer under an armpit (it must be touching skin only, not clothing)
§ Fold the child's arm across the chest to hold the thermometer in place
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, make sure to shake down the thermometer before using it. Leave the thermometer in place for approximately 10 minutes to correctly record the temperature.
1. Rectal temperature
§ Infants should have rectal temperature measurements. A rectal temperature will read approximately 1 degree higher than a simultaneously obtained mouth temperature.
§ Lubricate the tip of the thermometer with a lubricant, such as petroleum jelly
§ Place the child: - stomach-down across your lap or on a firm, flat surface and keep your palm along the lower back - or face-up with legs bent toward the chest with your hand against the back of the thighs
§ With your other hand, insert the lubricated thermometer into the anal opening about ½ inch to 1 inch (about 1.25 to 2.5 centimeters). Stop if you feel any resistance
§ Steady the thermometer between your second and third fingers as you cup your hand against the baby's bottom
§ If using a digital thermometer, wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
§ If using a glass and mercury thermometer, make sure to shake down the thermometer before using it. After at least three minutes, remove the thermometer and note the temperature as above.
Pulse or heart rate
§ Heart rate or pulse is measured by touching an artery. The arteries are the vessels with the "pulse". The rhythmic contraction of the artery keeps pace with the beat of the heart. Since an artery is near the surface of the skin, while the heart is deeply protected, an artery can be easily touched and get an accurate measure of the heart's pulse.
§ Children and infants have heart rates that are faster than those of adults as shown in the following table:
Table: Normal pulse or heart rates in different age groups
Age
Normal heart rate (bpm)
Newborn
200-260
0-5 months
90-190
6-12 months
80-140
1-3 years
80-130
3-5 years
80-120
6-10 years
70-110
11-14 years
60-105
14+ years
60-100
Activity
Learn to take radial pulse
Step 1: Find your pulse
To find your radial artery (the most common point from which people take pulses, Figure 5), hold one hand straight out, elbow bent, palm relaxed and facing up. Raise your thumb slightly upward to create a small pocket under your thumb at the top of your wrist. Place the tips of your index and middle fingers of the other hand (don't use your thumb—it has also got a pulse and could cause counting confusion) on the pocket under your thumb. Your fingers should lay across the tendon running down your arm. Adjust your fingertips until you can feel a steady beat under the skin of your wrist.
Step 2: Count, multiply and determine pulse regularity
Get out your watch. First, take a count of how many pulse beats you feel for 30 seconds. Multiply the amount of beats by two to calculate your pulse rate per minute.
Then, keep your fingers on your pulse for another 30 seconds. Is your pulse steady and unwavering? Or is it irregular in any way? Irregularities to note include beats that come closer to the preceding beats than the following ones or abnormal pauses in between beats. These and any other irregularities should be reported to a doctor immediately.
Step 3: Take someone else's pulse
Use your new pulse-taking skills on your friends! The process of taking someone else's pulse is identical to taking your own, except that you'll have both of your hands free to feel around for that fleeting rhythm. Just remember to keep your thumbs out of the way; they'll still interfere even if you're taking someone else's pulse.
Figure 5
Blood pressure
Blood pressure is the force of blood pushing against the walls of arteries. We use the blood flowing through the arteries because it has a higher pressure than the blood in the veins.
Blood pressure is measured using two numbers. The first number, which is higher, is taken when the heart beats during the systole (contraction) phase. This is called systolic pressure. The second number, which is lower, is taken when the heart relaxes, between beats, during the diastole (relaxation) phase. This is the diastolic pressure. The two numbers are written one above or before the other.
It is normal for the blood pressure to increase when a person is exercising and to decrease when a person is sleeping.
Normal blood pressure: 120/80 mmHg or lower
Types of blood pressure apparatus
Blood pressure is measured through the use of a medical instrument called a sphygmomanometer. There are three types of blood pressure apparatus: the mercury sphygmomanometer, the aneroid gauge and digital (electronic) devices. The mercury manometer is the most reliable recorder available for the clinical measurement of blood pressure.
Different types of blood pressure apparatuses
Figure 6: Mercury sphygmomanometer
Figure 7: Aneroid sphygmomanometer
Figure 8: Digital sphygmomanometer
Activity
Learn to take blood pressure (Figure 9)
Step 1
Make your friend sitting comfortably and relaxed. Push the sleeves up or remove the shirt to reveal a naked arm as clothing can interfere with the pressure of the inflated cuff as well as hearing the sounds.
Step 2
The cuff of the sphygmomanometer is placed on the upper arm. It is centered over the brachial artery which is located in the bend of the elbow. Once the cuff is secured, raise the arm to heart level, place your arm underneath it to support it and ask the person to relax their arm.
Step 3
Palpate (feel for) the brachial pulse and place the diaphragm of the stethoscope over this spot. Place the ear pieces of the stethoscope into your ears. Listen to the brachial pulse.
Step 4
Close the valve on the bladder of the cuff and begin to squeeze the bulb. Continue squeezing until the needle on the gauge reads 180 mmHg on the gauge. This closes the major arteries to the arm (that is why it is uncomfortable).
Step 5
Slowly release air by gently turning the air valve and allow the cuff to deflate by 5 mmHg/second while you listen to the artery. When you first hear the sound this is the systolic blood pressure. The sound you hear is the blood now flowing in the artery of the arm.
Step 6
Continue deflating the cuff until you no longer hear the sound. This is the diastolic blood pressure. At this point you can open the valve completely to allow the cuff to deflate rapidly. If you did not hear clearly, wait at least one minute before repeating the procedure.
Figure 9: Recording blood pressure
Respiratory rate
It is the number of breaths taken per minute. Respiratory rates may increase with exercise, excitement, pain, fever, and with other medical conditions. Respiratory rates decline during relaxation and sleep.
Measurement and recording of respiratory rate
The respiration rate is usually measured when a person is at rest.
Activity
Learn to take respiratory rate
Step 1
Observe patient’s stomach or chest and watch until you see it rise and fall. Each rise/fall cycle counts as one respiration.
Step 2
Count the number of times the stomach or chest rises for 30 seconds and multiply by 2, or count for a full 1 minute. This tells you the respiratory rate per minute.
Step 3
Note the rhythm of the breathing. Is it regular or irregular?
Step 4
Note how much effort it takes for the person to breathe. Is the breath labored, or effortless?
Step 5
Note if the breathing is deep (slow) or shallow (fast).
Step 6
Smell the breath for any unusual odor, especially noting a fruity odor or a fecal odor.
Step 7
Record your findings in the following manner: rate, rhythm, effort, depth, noise and odors. For example: "Respiratory rate is 30, irregular, labored, shallow, gurgling and with no odor."
Table 1: Normal respiratory rates in different age groups
Age
Normal respiratory rate
(breaths per minute)
Newborn
30-50
0-5 months
25-40
6-12 months
20-30
1-3 years
20-30
3-5 years
20-30
6-10 years
15-30
11-14 years
12-20
14+ years
12-20
Note: during strenuous exercise adults respiratory rate could go up to 35-45 breaths per minute; athletes' peak rate could be 60-70 breaths per minute.
Activity
Ask students to form pairs and go for a 5 minute run. As soon as they come back they should note their friend’s respiratory rate. Ask if there has been any change in the rate from before. And if yes, what?
Bleeding
Bleeding, (hemorrhage) is the loss of blood from the circulatory system (See Unit 1, Sub-unit 1, Cardiovascular System). Bleeding can occur:
internally, where blood leaks from blood vessels inside the body
externally, through a natural opening such as the vagina, mouth or rectum, or
externally, through a break (wound, cut) in the skin.
Bleeding is classified into the following classes.1
1. Manning, JE "Fluid and Blood Resuscitation" in Emergency Medicine: A Comprehensive Study Guide. JE Tintinalli Ed. McGraw-Hill: New York 2004. p227
Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs (i.e. heart rate, respiratory rate, blood pressure, body temperature) and volume replacement is not usually necessary.
Class II Hemorrhage involves 15-30% of blood volume. A patient often has rapid heartbeat with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate the blood loss with narrowing of the peripheral (skin, skeletal muscles) blood vessels. Skin may start to look pale in color and be cool to the touch. The patient might start acting differently. Volume replacement with intravenous saline solution or Ringer's Lactate solution is all that is usually required. Blood transfusion is not typically required.
Class III Hemorrhage involves loss of 30-40% of blood volume. The patient's blood pressure drops, the heart rate increases, and the mental status worsens. Volume replacement with saline solution or Ringer's Lactate solution and blood transfusion are usually necessary.
Class IV Hemorrhage involves loss of >40% of blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
Activity
Ask the class to break into four groups. Assign one class of hemorrhage to each group. Ask the groups to discuss their class of hemorrhage and report back starting from Class I Hemorrhage.
Symptoms
External bleeding through skin
Blood coming from an open wound
Bruising
Shock
Paleness
Clammy skin
Dizziness or light-headedness after an injury
Rapid pulse, increased heart rate
Low blood pressure
Shortness of breath
Confusion or decreasing alertness
Weakness
Internal bleeding will show any of the above symptoms plus:
Abdominal pain
Swollen abdomen
Signs of shock (see above)
External bleeding through a natural opening will also show:
· Blood in the stool (appears black, maroon, or bright red)
· Blood in the urine (appears red, pink, or tea-colored)
· Vaginal bleeding (heavier menstrual bleeding than usual or after menopause)
· Blood in the vomit (looks bright red, or brown)
Procedure to stop external bleeding from a wound
First aid is appropriate for external bleeding. If bleeding is severe, or if shock or internal bleeding is suspected, get a doctor’s help immediately.
Calm and reassure the patient as the sight of blood can be very frightening
Always wash your hands before (if possible) and after giving first aid to someone who is bleeding to avoid infections. Try to use latex gloves when treating a bleeding person. Latex gloves should be in every first aid kit. Viral hepatitis can be transmitted by skin contact with infected blood, and HIV can be contracted if infected blood gets into an open wound - even a small one
If the wound is superficial, wash it with soap and warm water and pat dry.
Lay the patient down. This will reduce the chances of fainting by increasing the blood flow to the brain. When possible, elevate the bleeding area
Remove any obvious loose debris or dirt from a wound. If an object such as a knife or stick, becomes embedded in the body, do not remove it. Doing so may cause more damage to the patient and may increase the amount of bleeding. The object also might be embedded in an artery or organ. Place pads and bandages around the object and tape the object in place
Put pressure directly on an external wound with a sterile bandage, clean cloth, or even a piece of clothing. If nothing else is available, use your hand. Direct pressure is best for external bleeding, except for an eye injury. See Figure 9
Maintain pressure until the bleeding stops. When it has stopped, bind the wound dressing with adhesive tape or a piece of clean clothing. A cold pack should be applied over the dressing. See Figure 10
If bleeding continues and seeps through the material being held on the wound, do not remove it. Simply place another cloth over the first one. Be sure to seek medical attention
If the bleeding is severe, get medical help and take steps to prevent shock. Immobilize the injured body part. Lay the patient flat; raise the feet about 12 inches, and cover the victim with a coat or blanket. However, do not place the patient in this position if there has been a head, neck, back, or leg injury or if the position makes the patient uncomfortable. Get medical help as soon as possible.
Figure 10: Stopping bleeding with direct pressure
Figure 11: Stopping bleeding with pressure and ice
Figure 12: Stopping bleeding with a tourniquet
DO NOT DO THE FOLLOWING WHILE MANAGING BLEEDING
DO NOT apply a tourniquet to control bleeding, except as a last resort. Doing so may cause more harm than good. A tourniquet should be used only in a life-threatening situation and should be applied by an experienced person. A tourniquet can be used if there is torrential bleeding and if continuous pressure is not stopping the bleeding. A tourniquet should be applied to the limb between the bleeding site and the heart. The tourniquet should be tightened to the point where the bleeding can be controlled by applying direct pressure over the wound. To make a tourniquet, use bandages 2 to 4 inches wide and wrap them around the limb several times. Tie a half or square knot, leaving loose ends long enough to tie another knot. A stick or a stiff rod should be placed between the two knots. Twist the stick until the bandage is tight enough to stop the bleeding and then secure it in place. Check the tourniquet every 10 to 15 minutes. If the bleeding becomes controllable, (manageable by applying direct pressure), release the tourniquet. See Figure 11
DO NOT probe a wound or pull out any embedded object from a wound. This will usually cause more bleeding and harm
DO NOT try to clean a large wound. This can cause heavier bleeding
DO NOT remove a dressing if it becomes soaked with blood. Instead, add a new one on top
DO NOT peek at a wound to see if the bleeding is stopping. The less a wound is disturbed, the more likely it is that you will be able to control the bleeding.
Important points to remember while managing bleeding
Direct pressure will stop most external bleeding, and is the most important initial first aid.
Blood loss can cause bruises, which usually result from a blow or a fall. They are dark, discolored areas on the skin. Apply a cool compress to the area as soon as possible to reduce swelling. Wrap the ice in a towel and place the towel over the injury. Do not place ice directly on the skin.
Serious injuries do not always bleed heavily, and some relatively minor injuries (for example, scalp wounds) can bleed profusely. People who take blood-thinning medication or who have a bleeding disorder, such as hemophilia, may bleed excessively and quickly because their blood cannot clot properly. Bleeding in such people requires immediate medical attention.
Although puncture wounds usually do not bleed very much, they carry a high risk of infection. Seek medical care to prevent tetanus or other infection.
Abdominal wounds can be very serious because of the possibility of severe internal bleeding, which may not be obvious from looking at a person, but which may result in shock. Seek medical care immediately for any penetrating abdominal wound. If organs are showing through the wound, do not try to push them back into the abdomen unless they slide back in without your assistance. Cover the injury with a moistened cloth or bandage, and do not apply more than very gentle pressure to stop the bleeding.
Always call a doctor if internal bleeding is suspected. This can rapidly become life-threatening. Immediate medical intervention may be needed. This can range from medications and intravenous fluids, to use of an endoscope, to surgery.
Activity
Ask the class to break into three groups. To the first group assign “Procedure to stop external bleeding from a wound”. To the second group assign “Do not do the following while managing bleeding”. To the third group assign, “Important points to remember while managing bleeding”. Each group to discuss their assigned role and report back to the whole class.
Intravenous medication
Intravenous (IV) medication administration refers to the process of giving medication directly into a patient's vein. Methods of administering IV medication may include giving the medication by rapid injection (push) into the vein using a syringe, giving the medication intermittently over a specific amount of time using an IV secondary line, or giving the medication continuously mixed in the main IV solution.
The primary purpose of giving IV medications is to initiate a rapid systemic response to medication. It is one of the fastest ways to deliver medication. The drug is immediately available to the body. It is easier to control the actual amount of drug delivered to the body by using the IV method and it is also easier to maintain drug levels in the blood for therapeutic response.
The IV route for medication administration may also be used if the medication to be delivered would be destroyed by digestive enzymes if given by mouth, is poorly absorbed by the tissue, or is painful or irritating when given by intra-muscular or subcutaneous injection.
Proper IV administration should follow the five "rights" of medication administration to avoid medication errors. Be sure it is:
· the right patient
· the right drug
· the right dose
· the right time, and
· the right route before giving any medication.
The IV line must be intact before any IV medication can be administered. Some IV medications can cause severe tissue damage if injected into the tissue through an infiltrated IV site.
Some IV push medications must be diluted before injection. Check the directions for giving the specific drug IV before performing the injection.
The drug delivery rate is an important factor when administering IV medication. Some IV drugs are meant to be delivered rapidly over several minutes to obtain therapeutic effect. Other drugs are most effective when delivered slowly and intermittently throughout the day. Each drug delivery rate is unique. Administration guidelines for giving IV medications must be followed to achieve the therapeutic effect desired.
IV drugs may not be compatible with certain IV fluids or other drugs. Drug incompatibility is a true risk to the patient because it can cause crystallization of the medication that may at the least clog the IV line or have adverse effects on the patient. Check compatibility warnings before giving IV drugs. The line must be flushed with saline before and after giving medications IV to avoid contact of incompatible solutions or medications.
The effects of medication appear rapidly after an IV injection. As such you must know the indications, actions, and adverse effects of the medication that is to be delivered and must observe the patient closely for adverse medication reactions or allergic reactions and be prepared to respond with supportive therapy or drug reversing agents.
IV push medication techniques deliver a bolus (a dose of medication injected all at once intravenously) of medication directly into a vein or access port to produce an immediate peak drug level in the patient's bloodstream. Large quantities of fluid IV push can cause severe complications; follow the recommendations of the drug administration guidelines. To deliver an IV bolus medication, draw the appropriate amount of medication that has been prepared, diluted, and/or reconstituted according to IV drug administration guidelines into a syringe. A bolus injection is most often given through a peripheral IV line, a saline lock, directly into a vein, or through a vascular access port.
When giving an IV bolus medication through a peripheral line with compatible fluid:
· Shut off the IV line using the control clamp.
· Clean the Y-port closest to the insertion site with an alcohol or povidone-iodine pad to prevent bacterial contamination.
· Connect the medication needle or needle-less system connector to the port.
· Inject the medication over the period of time ordered, after which disconnect the syringe and remove.
· Reopen the IV line using the control clamp and reset the IV flow to the appropriate setting.
· If the peripheral line fluid is not compatible with the IV bolus medication, prepare two syringes with 3cc of normal saline before giving the medication.
· Flush the line before and after the IV medication administration with the prepared saline syringes. The Y-port is quite vulnerable to contamination when switching syringes. After the IV line is flushed the second time, the line can be reopened and the IV flow rate reset to the appropriate setting.
Aftercare
After an IV medication has been delivered
· Observe the patient for adverse or allergic reactions
· Discard the used needles, IV tubing, bags, gloves, and disposable supplies
· Wash your hands and note in the patient files that the medication has been given
· If reverting to a primary IV line, reset the IV flow rate to the correct hourly rate that is ordered for the IV fluids.
Lesson 2: Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which a person’s breathing or heartbeat has stopped. When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you are helping an unconscious person who is not breathing.
CPR involves a combination of mouth-to-mouth rescue breathing and chest compressions that keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
Before you begin
Assess the situation before starting CPR:
Is the person conscious or unconscious?
If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?"
If the person does not respond call a doctor and begin CPR.
Remember the ABCs
Think ABC — Airway, Breathing and Circulation — to remember the steps explained below.
Step 1 Airway: Clear the airway
Put the person on his or her back on a firm surface.
Kneel next to the person's neck and shoulders.
Open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.
Check for normal breathing, taking no more than five or 10 seconds: look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person is not breathing normally, begin mouth-to-mouth breathing. If you believe the person is unconscious from a heart attack, skip Step 2 – Breathing, and proceed directly to Step 3 – Chest compressions.
Step 2 Breathing: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or cannot be opened.
With the airway open (using the head-tilt, chin-lift maneuver) pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
Prepare to give two breaths. Give the first breath — for one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
Begin Step 3 - Chest compressions, to restore circulation.
Step 3 Circulation: Restore blood circulation with chest compressions
Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 5 centimeters. Push hard and push fast — give two compressions per second, or about 120 compressions per minute.
After 30 compressions (15 seconds), tilt the head back and lift the chin up to open the airway. Prepare to give two breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. This is one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
Continue CPR until there are signs of movement or until a doctor takes over.
Figure13: Cardiopulmonary resuscitation (Courtesy McKesson Health Solutions LLC)
Concepts of Management of Pediatric Emergencies
Sick children present unique challenges to health care professionals. Assessment and treatment of children and infants are unique because children’s perceptions may be radically different from those of adults. Depending on age, children may or may not be able to say what is bothering them. Or they may be unconscious. Patience and understanding are the key to overcoming these problems.
The basic concept of management of pediatric emergencies is the same ABC (Airway, Breathing and Circulation). However, the anatomy and structure of children and infants are different from adults. Therefore, specialized training and equipment are required for managing pediatric emergencies. Immediately contact a doctor or refer the child to a hospital, if you spot a pediatric emergency.
To perform CPR on a child:
The procedure for giving CPR to a child aged 1 to 8 years is essentially the same as that for an adult. The differences are as follows:
§ Use only one hand to perform heart compressions.
§ Breathe more gently.
Use the same compression-breath rate as is used for adults: 30 chest compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the child moves or a doctor arrives.
Able to maintain cardiac output for long periods of time: strong
compensatory mechanisms
- Less total circulatory blood volume than adults
5. Skin temperature
- May lose heat rapidly; keep covered (especially head in small
infants)
Figure 14: Step 1 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
Figure15: Step 2 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
Figure 16: Step 3 of Cardiopulmonary resuscitation on a child aged 1 to 8 years
To perform CPR on a baby
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but do not shake the child. If there is no response, follow the ABC procedures below:
Step 1 Airway: Clear the airway
Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do.
Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear. If the infant is not breathing, begin mouth-to-mouth breathing immediately.
Step 2 Breathing: Breathe for the infant
Cover the baby's mouth and nose with your mouth.
Prepare to give two breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
If the chest still does not rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger.
Begin chest compressions to restore blood circulation.
Step 3 Circulation: Restore blood circulation with chest compressions
Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
Gently compress the chest to about one-third to one-half the depth of the chest.
Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 to 120 pumps a minute.
Give two breaths after every 30 chest compressions.
Continue CPR until you see signs of life or until a doctor arrives.
Figure 17: Step 3 of Cardiopulmonary resuscitation on a baby
Head injury
See Unit 2, Sub-unit 2.5, Nervous System
Fractures
See Unit 2, Sub-unit 2.4, Musculoskeletal System
Dehydration
See Unit 2, Sub-unit 2.2, Digestive System
Burns
A burn is damage to body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.
Burns can cause severe damage to blood vessels. This type of damage causes fluid to seep out of the blood vessels, which cause swelling and blistering. In very severe cases with extensive burns, loss of fluid can lead to depletion of blood volume, shock, and very low blood pressure. Death is likely if fluids are not replaced. Burns often lead to infections because the protective layer of skin is destroyed.
Classification of burns by degree
There are three types of burns:
1st degree burns are the mildest of the three and damage only the outer layer of skin.
Signs and symptoms
These burns produce redness, pain, and minor swelling. The skin is dry without blisters.
Healing time
Healing time is about 3 to 6 days; the superficial skin layer over the burn may peel off in 1 or 2 days. 1st degree burns can heal over time without skin grafts as there is enough underlying skin tissue to rebuild the skin.
2nd degree burns are more serious and damage the outer and the inner layers of skin. They appear as redness with superficial blistering of the skin, and are usually very painful.
Signs and symptoms
These burns produce blisters, severe pain, and redness. The blisters sometimes break open and the area is wet looking with a bright pink to dark red color.
Healing time
Healing time varies depending on the severity of the burn. 2nd degree burns can heal over time without skin grafts as there is enough underlying skin tissue to rebuild the skin.
3rd degree burns are the most serious type of burn and damage or destroy all the layers of the skin and underlying tissues (ligaments, tendons and muscle). Third degree burns result in scarring and may be fatal if the affected area is significantly large.
Signs and symptoms
These burns are painless. Areas may be charred black or appear dry and white.
Healing time
Healing time depends on the severity of the burn. Deep second- and third-degree burns (called full-thickness burns) will likely need to be treated with skin grafts, in which healthy skin is taken from another part of the body and surgically placed over the burn wound to help the area heal. 3rd degree burns require skin grafts or application of artificial materials to cover and protect the exposed areas, as well as encourage new skin to grow.
Causes of burns
Burns may be caused by:
· Chemicals: from swallowing things, like drain cleaner or watch batteries, or spilling chemicals, such as bleach, onto the skin
· Electricity: electrical burns from being struck by lightning, biting on electrical cords or sticking fingers or objects in electrical outlets, etc.
· Radiation: UV light (as from over-exposure to the sun), radiation therapy (as patients who are undergoing cancer therapy), and X-rays
· Extreme hot temperatures: steam, hot water, tipped-over tea cups, cooking fluids, contact with flames or hot objects
· Extreme cold temperatures: a cold burn (frostbite) is a kind of burn which arises when the skin is in contact with something which has a low-temperature. It can be caused by exposure to, for example, snow, cold air, dry ice, and liquid nitrogen.
Management of burns
First-degree burns and second-degree burns limited to an area no larger than 3 inches (7.5 centimeters) in diameter:
Remove the person from the heat source
Remove clothing from the burned area immediately
Run cool (not cold) water over the burned area (if water is not available, any cold, drinkable fluid can be used) or hold a clean, cold compress on the burn for approximately 3 to 5 minutes (do not use ice, as it may cause the burn to take longer to heal). Cooling the burn reduces swelling by conducting heat away from the skin
Do not apply butter, grease, powder, or any other remedies to the burn, as this increase the risk of infection
If the burned area is small, loosely cover it with a sterile gauze pad or bandage. Wrap the gauze loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain and protects blistered skin. Do not use fluffy cotton, which may irritate the skin.
Give aspirin, paracetamol or ibuprofen for pain. Never give aspirin to children or teenagers
If the area affected is small (the size of a coin or smaller), keep the area clean and continue to use cool compresses and a loose dressing over the next 24 hours. Antibiotic cream could also be applied two to three times a day, although this is not absolutely necessary.
These minor burns usually heal without further treatment. They may heal with skin color changes, meaning the healed area may be a different color from the surrounding skin. Ask the patient or family members to watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, they should seek medical help.
Second-degree burns (covering an area larger than 3 inches in diameter) and third-degree burns:
1 Call doctor, then follow these steps until the doctor arrives:
o Keep the person lying down with the burned area elevated
o Follow the instructions for first-degree burns
o Remove all jewellery and clothing from around the burn (in case there is any swelling after the injury), except for clothing that is stuck to the skin. If you are having difficulty removing clothing, you may need to cut it off or wait until doctor arrives
o Do not break any blisters
o Apply cool water over the area for at least 3 to 5 minutes, then cover the area with a clean white cloth or sheet until doctor arrives
Caution
Do not use ice. Putting ice directly on a burn can cause frostbite, further damaging skin.
Do not apply butter or ointments to the burn. This could prevent proper healing.
Do not break blisters. Broken blisters can get infected.
Concepts of Management of Obstetric Emergencies
Every minute, one woman dies during pregnancy and birth because she did not receive adequate care and prompt treatment. By increasing interventions for safe motherhood, we can save the lives of half a million women and seven million infants, each year, and at the same time prevent millions of women from suffering from infections, injury and disability (UNFPA website, June 2008).
The management of obstetric emergencies is usually the responsibility of hospital obstetricians. However, dispensers may come across obstetric emergencies as part of first line healthcare providers, especially at BHUs or RHCs. The essential thing to remember is that all obstetric cases as well as emergencies should be referred to appropriate healthcare providers or facilities.
The first principles of dealing with obstetric emergencies are the same as for any other emergency (maintaining the Airway, Breathing, and Circulation). But remember that in obstetrics there are two patients and two lives; the mother and the fetus that is very vulnerable to maternal hypoxia or low concentration of oxygen in blood.
Emphasis on making emergency obstetric and newborn care available to all women who develop obstetric complications should be the ultimate goal in order to reduce maternal mortality. All five of the major causes of maternal mortality –Hemorrhage, Sepsis, Unsafe abortion, Hypertensive disorders and Obstructed labor -- can be treated at a well-staffed, well-equipped health facility. In such settings, many newborns who might otherwise die can also be saved, thus reducing neo-natal mortality.
In the long term, this means that all births should take place in appropriate health facilities, as is the case in all countries that have managed to significantly reduce their maternal mortality. However, where these conditions are not available, all women and newborns with complications should have rapid access to well-functioning facilities, whether that is a district hospital or an upgraded maternity centre at RHC or BHU.
Overwhelmingly, the following “the Three Delays” result in pregnancy-related deaths:
1 DELAY in deciding to seek appropriate medical help for an obstetric emergency.
2 DELAY in reaching an appropriate obstetric facility.
3 DELAY in receiving adequate care when a facility is reached.
We should therefore make all efforts to reduce these delays so that we could reduce deaths of mothers and children.
Rules of Managing Obstetric Emergencies
A. Apply oxygen with the woman rolled into the left lateral position (by at least a bag of IV fluid under the right hip) even if the woman is unconscious.
B. In general, it is best to concentrate on the resuscitation and transfer of the mother, as the infant is safer in utero.
C. In the young and healthy pregnant women, tachycardia and hypotension are very late features of shock and need to be considered extremely seriously.
Common Obstetric Emergencies
· Ante-partum Hemorrhage (APH)
APH is bleeding after 20 weeks, until the birth of the baby. The blood loss may be revealed or concealed, usually both, and is easily underestimated. Pain in abdomen is intense and constant, and the uterus large and rigid.
· Pre Eclemptic Toxemia and Eclampsia
Around the world, each year approximately 5 lakh (half million) women die of pregnancy related causes. Ninety-nine percent (99%) of these occur in the developing world, usually of infection or hemorrhage. But in the developed countries, HT is the major preventable cause of fetal and maternal morbidity and mortality, affecting up to 5% of pregnancies. Worldwide, toxemia accounts for approx. 10% of maternal deaths (Duley 1992), or 50 000 maternal deaths per year
Pre-eclamptic Toxemia (PET) is defined as a pregnant women having any two of following three criteria:
· BP more then140/90 or an increase of 30/15 from baseline BP
· Proteinuria which means proteins in the urine of more than 1+, or more than 300mg / L over 24 hours
· Edema or swelling, generalized body swelling visible on face, hands and feet
Having fits during or shortly after pregnancy is called Eclampsia. It may progress to status epilepticus, with cerebral, liver, kidney, heart, lungs or blood related complication. It is important to know that Eclampsia can occur without preceding signs. However, it is often preceded by:
severe generalized headache
visual disturbance e.g. photophobia, blurred vision
restlessness, agitation
pain in upper abdomen, nausea and vomiting
increased reflexes
altered level of consciousness, confusion
rapid progression of PET
A dispenser’s contribution is mainly in advocating to the community so that families bring their pregnant women to health facilities for antenatal registration and then pregnant mothers follow the schedule given to them by the concerned staff.
Concept of Management of Geriatric Emergencies
In Pakistan the demographic pattern and therefore the disease pattern is in transition. Old age brings degenerative changes in the entire body. Usually, people above 60 years display these changes, but it depends and varies from person to person and what kind f lifestyle the person has been following during his or her younger years. A healthy life style, i.e. balanced diet, regular exercise, absence of chronic diseases and health habits (abstinence from smoking, drinking and positive attitude) ensure a reasonable healthy old age. However, with advancing age all systems get affected. Typical signs and symptoms of emergencies such as myocardial infarction are not very pronounced and marked. Therefore, they are likely to be missed if we are looking for them in old age people (above 65 or 70 years) are brought to a health facility in emergency. Hence the golden rule to follow is to refer all old age emergency patients to a doctor after giving initial first aid.
1. Spinal Injuries
Recognition
· Patient will complain of pain in the neck or back
· There will be tenderness over the spine
· A twist might be noticeable in the spinal curvature
· There may be weakness or loss of movements in the limbs
· There may be loss of sensation or abnormal sensation
· There may be loss of balder tone and bowel control
· The could be difficulty in breathing.
Precautions
Do not move the person if a spinal injury is suspected. Leave it to specially trained professionals. Careless handling of such patients by untrained people can cause permanent disability to patients.
Poisoning
Introduction
Poisons are substances that cause damage to the cells of the body when they come into contact with them. Poisons can be ingested, inhaled, injected or they can be absorbed through skin or eyes. There are lots of different poisonous substances including medications, household products, such as bleach and industrial chemicals, and certain plants and berries. Also, substances that we may not usually think of as poisons, such as alcohol and tobacco, can be very harmful.
Methods of poisoning
Poisoning can occur in several different ways. The most common method of poisoning is by ingestion (where the poison is swallowed), but poisons can also be inhaled (breathed in), splashed onto the skin or eyes, or be injected, or through a bite (as with snake bites).
Accidental poisoning
Most cases of poisoning are accidental and occur in the home. Children are most at risk from poisoning, although cases involving fatal child poisonings are very rare. Elderly people also have a greater risk of being poisoned accidentally.
Intentional poisoning
Occasionally, poisoning may be deliberate. For example, a person may attempt to poison themselves by taking an overdose of prescription medication, such as antidepressants, or paracetamol. Intentional poisoning may also be carried out by someone who uses a poisonous substance to deliberately harm someone else.
Causes of Poisoning
Many common household substances can be harmful if they are not stored properly, or used in the correct way. Children under the age of five have the highest risk of accidental poisoning, with medicines being the most common cause of poisoning in children under 5 years of age.
Lots of substances are poisonous if they are eaten, inhaled (breathed in), or come into contact with the skin, or eyes.
Some common items that can cause poisoning are listed below.
Prescription drugs and medicines, such as calamine lotion, petroleum jelly, evening primrose oil, folic acid, oral contraceptive and hormone replacement preparations, simple steroid creams, zinc oxide creams and lotions.
Household products, such as bleach, cleaners, floor and furniture polish, washing powders, or liquids, washing up liquid and liquid soap.
Products, such as emulsion paint, putty and PVA (polyvinyl alcohol) glue
Cosmetics, such as baby oil, shampoo, hair conditioner, hair dye, moisturizing cream, or lotion, and solid cosmetics, such as lipstick and eye shadow.
Agriculture insecticides and chemicals, such as weed killers, ant, rat or mouse poison, insect repellents, methylated spirits, paint thinner, copper sulphate, insecticides such as organo-phosphorous compounds and acids such as sulphuric acid.
Insects and snakes, such as bees, wasps and hornets, inject venom (poison) into the skin when they sting us, which can cause pain, swelling and itching in the area of the bite or sting. Bites from snakes that contain venom can cause symptoms such as diarrhea, sickness, bleeding and drowsiness leading to unconsciousness depending on the type of snake.
Food can cause poisoning if it contains harmful bacteria. This can happen if it goes mouldy and bad, if cross contamination occurs, for example, between cooked and raw meat, or if it has not been cleaned or prepared properly.
Carbon monoxide is a poisonous, odorless gas that is produced by incomplete burning of fuels, such as gas, wood or petrol. These types of fuels are used in many household appliances, such as heaters, fires and cookers. If appliances are not regularly serviced, and well maintained, carbon monoxide can leak from them without you realizing, which can have serious consequences and, in some cases, can cause death.
Symptoms of poisoning
Different poisons affect the body in different ways, they can take effect quickly or over time. Some, such as carbon monoxide, interfere with the blood's ability to carry oxygen. Others, like bleach, burn and irritate the digestive tract.
The range of symptoms can be broad and varied depend upon the poison. However, poisoning should be considered as a cause if someone suddenly becomes ill for no apparent reason, or acts strangely, particularly if they are found near a poisonous substance.
Symptoms of poisoning can include:
abdominal pain, vomiting, diarrhea, or nausea
dizziness, weakness or drowsiness
fever
chills (shivering)
loss of appetite
headache or irritability
pain on swallowing or production of more saliva than usual
skin rash
burns around the nose or mouth
double or blurred vision
muscle twitching
seizures (fits)
stupor or unconsciousness
Preventing poisoning at home
People can reduce the likelihood of accidental poisoning by the following steps. A dispenser should advocate these:
Store all medicines, vitamins and poisonous substances in child-proof containers and lock them in an area that is well out of reach of children. Be vigilant not only with medicines but also with common household products, such as bleach, polishes, paint thinners, spirit, cleaners and paint.
Never store dangerous products in everyday containers such as milk bottles or drinking glasses. A child may associate these with food or drink and try them out. Check the garden for poisonous plants and berries and remove them.
Have the boiler and gas fire serviced regularly to reduce the risk of carbon monoxide poisoning, and make sure that bedrooms, in particular, have adequate ventilation.
Turn off fire heating (gas or coal) before going to sleep.
Don't block air vents, flues or chimneys and don't have indoor fires or stoves without proper ventilation to the outdoors.
What should a dispenser do in case a patient with suspected poisoning is brought at the health facility?
Correct first aid can significantly improve a person's chances of a full recovery – Remember ABC (Airway, Breathing and Circulation--- and CPR (Cardio Pulmonary Resuscitation). These should be immediate steps. Then refer the patient to a doctor or call the doctor on emergency duty.
Copper Sulphate Poisoning
It is a fungicide, herbicide and a commercial chemical. The anhydrous form is white, the pentahydrate is blue.
Toxicity
Copper sulphate is a powerful oxidizing agent and irritant to mucous membranes. A dose-response effect following ingestion is difficult to define but approximately 10 g may be fatal in an adult (Akintonwa etal, 1989).
Chronic inhalation of copper sulphate-containing pesticides produces pulmonary and hepatic toxicity. Copper sulphate contact sensitivity is a recognized disease entity.
Features
Dermal: Mild irritant to intact skin. Systemic copper uptake may result from repeated application to broken skin. Contact dermatitis may result.
Ocular: Irritant to eyes and my cause corneal necrosis and opacification of cornea if crystals remain in the conjunctival sac.
Ingestion: Very small ingestions (milligrams) are likely to cause only nausea and vomiting.
Moderate/substantial ingestions lead to nausea, vomiting and a metallic taste occur within minutes followed by abdominal pain and diarrhea. Secretions may be blue/green. Severe gastrointestinal irritation may result in hematemesis and/or melena with hypovolemic shock.
Severe poisoning is associated with the development of renal failure, intravascular hemolysis (usually manifest 24-48 hours after-poisoning) and cellular and obstructive liver damage. Coma, convulsions, muscle weakness and cardiac arrhythmias may also result. There is a high risk of aspiration of the gastric contents in drowsy patients.
Inhalation: This has been reported only as chronic occupational inhalation of copper sulphate-containing fungicides, presenting as 'Vineyard sprayer's lung' with progressive dyspnea, cough, wheeze, myalgia, malaise and a restrictive lung function defect. Other features include liver damage.
Management
Dermal
· Irrigate with copious lukewarm water.
· Consider the possibility of systemic copper uptake if there has been significant or repeated exposure to broken skin.
· Copper sulphate irritant dermatitis and contact sensitivity are managed most effectively by discontinuing exposure.
For other forms of Copper Sulphate poisoning call a doctor or refer the patient to a health facility where a doctor could attend the patient.
Sulphuric Acid Poisoning
Sulphuric acid is a very strong chemical that is corrosive. Corrosive means it can cause severe burns and tissue damage when it comes into contact with the skin.
Where Found:
It is present in car batteries as battery acid, certain detergents, some fertilizers and toilet cleaners.
Symptoms
Initial symptoms include severe pain on site of contact. Symptoms from swallowing may include:
· Breathing difficulty due to throat swelling
· Burns in the mouth and throat
· Drooling
· Fever
· Rapid development of low blood pressure
· Severe pain in the mouth and throat due to corrosion
· Speech problems
· Vomiting with blood
· Vision loss
Symptoms from breathing in the poison may include:
· Bluish skin, lips, and fingernails
· Breathing difficulty
· Body weakness
· Chest pain (tightness)
· Choking
· Coughing up blood
· Coughing
· Dizziness
· Low blood pressure
· Rapid pulse
· Shortness of breath
Management
Do NOT make a person throw up or vomit. Never pass a naso-gatric tube. Give first aid and refer the patient to a doctor or call the doctor.
If sulphuric acid is on the skin or in the eyes, flush with lots of water for at least 15 minutes.
If sulphuric acid was swallowed, immediately give the person water or milk. Do NOT give water or milk if the patient is vomiting or has a decreased level of alertness.
If the person breathed in the poison, immediately move him or her to fresh air.
Insect Stings
Insects injects venom through their stings causing local inflammation and local pain. I case of acute allergies and extra sensitivity to stings, there may be a severe reaction even loss of consciousness. In such cases seek medical aid urgently.
Treatment for Stings in the Skin
Sometimes insects leave their sting in the skin along with the poison bag. Sting and poison bag should be removed immediately with using forceps. In order to prevent more poison from going into the skin, apply forceps to the poison bag and sting nearest to the skin. Treat the wound with antiseptic dressing.
Treatment of Stings in the Mouth
Stings in the mouth can cause swelling that could lead to difficulty in breathing. In such situation give the patient ice cubes to such and refer the patient to doctor. If the patient becomes unconscious ensure patency of the airway, breathing and take care of bleeding if any. If there is no difficulty in breathing rinse mouth with weak solution of sodium bicarbonate.
Minor Wounds (cuts, scratches, bruises)
Small wounds or cuts act as an entry point for germs. Every care must be taken to keep it clean with dressing and antiseptic dressings.
· Wash your hands thoroughly before dressing the wound.
· Do not touch or cough or breathe over the wound.
· Stop any bleeding by applying pressure over the wound for sufficient time.
· For dressing clean the wound and surrounding skin, cut away any hair near the wound, cover it with dry sterile dressing, thoroughly, clean the surrounding skin with a swab taking care not to push dirt towards the wound. Use diluted antiseptics or running water for cleaning the wound and surrounding skin.
· Do not disturb any blood clots that are present on the wound as disturbing them might re-start bleeding.
· Cover the wound with dry sterile dressing and bandage.
· If there is raw area around the wound or a small surface burn, use a non-adhesive dressing and bandage.
· Cover small abrasions with small adhesive dressings.
Bites/Stings/Scratches
Animal Bites and Scratches
In countries where rabies is present all animal bites must be reported and proper medical treatment obtained. Wash the site of injury thoroughly with water. If bleeding is severe apply pressure to stop it. Cover wound with a dry sterile piece of dressing. For anti tetanus vaccination the advice of a doctor should be sought.
Snake Bites
Snake bites could be extremely painful. The patient is often very frightened. It is important to identify the snake for proper treatment. However in countries where poisonous snakes are common, stock of anti snake venom is routinely kept at all health centers.
Treatment of Snake Bites
Calm the patient and make him or her lie down. Clean the wound with water and wash off any venom present at the site of bite. Do not cut or suck the wound. Cover it with sterile dressing. Immobilize the limb, if the bite is on a limb. Arrange for the transfer of the patient to a hospital. Watch for airway, breathing, bleeding (ABC) and arrange for CPR. If the snake has been killed take it to the doctor for identification.
Nose Bleeding or Epistaxis
Nose bleeding is quite common in young children. A bang on the nose or a small collision with nose taking the pressure could result in nose bleed. It can also occur spontaneously in the elderly, especially if they are suffering from hypertension. Bleeding from nose after a blow on the head indicates a fractured skull.
Treatment of Nose Bleeding
· Do not plug the nose.
· Sit the person in a chair in a way that the head is in the upright position.
· Tilt the head slightly forwards to prevent blood from running back down the throat.
· Ask patient to spit out any blood in the mouth and let blood drip from nose into a bowl.
· Tell the patient to firmly pinch soft part of nostrils for about 5-10 minutes and to breathe through the mouth. After 5-10 minutes release nostrils slowly. If the bleeding does not stop repeat the process for another 5 minutes.
· Do not blow the nose as it will restart bleeding.
· If bleeding persists or if there are continued bouts of bleeding call a doctor.
Muscular Injuries
Muscle Cramps
Muscle cramps are sudden, involuntary contractions or spasms in one or more muscles. They come as a sudden pain and tightness in the muscles with legs being affected the most. They often occur after exercise or at night, lasting a few seconds to several minutes. It is a very common muscle problem.
Muscle cramps can be caused by nerves that malfunction. Sometimes this malfunction is due to a health problem, such as a spinal cord injury or a pinched nerve in the neck or back. Other causes are
Straining or overusing a muscle
Dehydration
A lack of minerals in your diet or the depletion of minerals in your body
Not enough blood getting to your muscles
Treatment of Cramps
Cramps can be very painful. Stretching or gently massaging the muscle can relieve this pain.
Stretch the affected muscle, e.g. if the sprain is in the calf of the leg, straighten the knee and pull the foot up towards the shin. This will force the opposite set of muscles to contract so that the affected muscle will relax and the pain and cramp will disappear.
Sprain (Joint)
A sprain occurs at a joint after wrenching, stretching or partial or complete tearing of ligaments.
Signs of Sprain
Pain especially on movement, swelling and sometimes bruising can be seen in sprains.
Treatment of Sprain
Place the patient in a comfortable position. Uncover the joint by removing clothes covering it. Then pad and bandage it heavily to give it support. If the ankle is injured, the bandage can be put over the shoe. In case an arm is injured put it in a sling. Sprained joints should be x-rayed to confirm or rule out fractures.
Strain
A strain occurs when a muscle has been pulled or over stretched so that the muscle fibers are torn .It can follow sudden severe exertion or the lifting of heavy weights.
Signs of Strain
Sudden pain, which is worse on movement. Sometimes bruising and swelling in the affected area.
Treatment of strain
Place the patient in a comfortable position and support the injured part until it can be seen by a doctor.
Stitch
It is characterized by the onset of pain in the side of the abdomen, occurring suddenly during games and running. No treatment is necessary, just rest will lead to recovery.
Winding
Winding is caused by a blow in the upper abdomen, which may cause a person to double up or coil up with pain.
Treatment of winding
Let the person stay in the most comfortable position until pain passes. If there is loss of consciousness, place the person in the recovery position.
Shock
Recognition
1. Rapid pulse
2. Pale, Cold, Clammy skin
3. Sweating
Later
1. Grey-blue skin, especially in side lips
2. Weakness and giddiness Nausea or thirst
3. Rapid, shallow breathing
Eventually
1. Restlessness
2. Gasping for air
3. Unconsciousness.
First Aid
1. Help the person to lie down
· Use a blanket to insulate the person from ground.
· Raise and support legs (foot end) as high as possible so that blood is available for vital organs such as brain and heart.
· Treat any cause of shock, such as bleeding
2. Loosen tight clothing
· Undo anything that constricts neck, chest or waist
· Cover the person with a blanket
3. Call for medical help and ambulance.
4. Monitor breathing, pulse and response.
Heart attack
1. There may be chest pain, spreading to one or both arm.
2. Breathlessness
3. Discomfort, like indigestion in upper abdomen.
4. Sudden faintness.
5. Sudden Collapse.
6. Ashen skin and bluish lips.
7. Rapid, thin and weakening pulse.
8. Profuse sweating.
First Aid
1. Make casualty comfortable:-
· Help the person in half sitting position.
· Support head, shoulders and knees.
· Reassure the person.
2. Call an ambulance:-
· Tell the Doctor that you suspect a heart attack
3. Give emergency medication:-
· If the casualty is consciousness, give one tablet of aspirin
· If the person is carrying medicines, help him/her to take those
4. Monitor casualty:-
· Encourage the person to rest
· Monitor and record vital signs
Actions taken:-
· Make person comfortable
· Call ambulance give person aspirin
· Monitor person.
Roller Bandages
These are made of cotton, gauze, elasticized fabric, or linen and are wrapped around the injured part in spiral turns. There are three main types of roller bandages:-
1. Open weave bandages
Because of their loose weave they allow good ventilation, but they cannot be used to apply direct pressure on the wound or give support to joints.
2. Elasticized bandages
These moulds to the body shapes. These are used to secure dressings and support soft tissue injuries.
3. Crape bandages:-
Are used to give firm support to injured joints and bony areas.
Rules for applying a roller bandage
1. Keep the rolled part of the bandage (head) upper most as you work.(The unrolled part is called tail)
2. Position yourself towards the front or injured side.
3. While you are working make sure that the injured part is supported in the position in which it will remain after bandaging.
The Safe House
We may think that home is a safe place, but almost as many people die from accidents in the homes as on the roads. Most at risks are the very young and the very old.
Fires and falls cause most accidental deaths in the home. Other frequent causes include poisoning and suffocation. But very many home accidents, especially in kitchen and bathroom, can be prevented by continuous care and thought. Always have permanent gas and electrical appliances installed by qualified fitters and buy only those appliances that carry official acknowledgement.
Remember that water conducts electricity, and never touch a switch or appliances if your hands are wet.
Safety Indoors (Important points)
· Adequate lighting for passage ways.
· Access to main lights from bed.
· Escape facility from upstairs.
· Never smoke in the bed.
· Proper safety covers on electric outlets.
· High sided cots, no pillows.
· Safety bars on windows.
· Appropriate storage of drugs so that they are kept out of the reach of children.
· Non slip mats on floors.
· Hand rails for providing support to the elderly.
· Access to stairs light switch.
· Adequate lighting for stairs.
· Safety gates on stairs.
· Secure carpets, no obstruction.
· Adequate light for entrance.
· Safe wires and connections.
· Safety gate for kitchen.
· Ventilation for gas.
· Hygienic waste can.
· Cleaning materials locked and kept out of children reach.
· Play area visible from house.
· No objects are placed on heaters.
Drowning
Death by drowning occurs when air cannot get into the lungs, usually because a small amount of water has entered the lungs, this may also cause spasm of the throat.
When a drowning person is rescued, water may gush from the month. This water is from the stomach and should be left to drain of its own. Do not attempt to force water from the stomach because the person may vomit and inhale it.
A person from a drowning incident should always receive medical attention even if he seems to recover at the time. Any water entering the lungs cause them to become irritated, and the air passages may begin to swell several hours later a condition known as secondary drowning.
The person may also need to be treated for hypothermia.
Aims:
· To restore adequate breathing
· To keep the person warm
· To arrange urgent removal to hospital.
· If you are rescuing a person from the water to safety, keep the person’s head lower than the rest of the body to reduce the risk of inhaling water.
· Lay the person down on back. Open the airway and check breathing is prepared to give rescue breaths and chest compression if necessary (CPR). If the person is breathing, place in recovery position.
· Treat the person for hypothermia, remove wet clothing if possible and cover with dry blanket. If the person regains full consciousness give warm drink.
· Call for a medical help
Electrical Burn
Burn may occur when electricity passes through the body, much of the visible damage occurs at the points of entry and exit of the current.
However, there may also be a tract of internal damage. The position and direction of entry and exit wound will alert you to the site and extent of hidden injury and the degree of shock that the patient may have suffered.
Burns may be caused by a lightning strike or by low or high voltage electric current. An electric shock can also cause cardiac arrest. If the person is unconscious, your immediate priority, when you are sure that the area is safe, is to open the person’s air way and check for breathing and circulation.
Aim of Treatment is to
· treat burns
· treat the shock
· arrange urgent removal to hospital
Hanging and Strangulation
If pressure is exerted on the outside of the neck, the airway is squeezed and the flow of air to the lungs is cut off. Main causes of such pressure are:
· Hanging: Suspension of the body by a noose around the neck
· Strangulation: Constriction or squeezing around the neck or throat is called strangulation. Sometimes hanging and strangulation may occur accidently for example by neckties and clothing which become caught in machinery. Hanging may cause a broken neck, for this reason, a casualty in this situation must be handled very carefully.
Aims:
· To restore adequate breathing
· To arrange urgent removal to hospital
Recognition:
· A constricting article around neck will be present
· Marks around the casualty’s neck
· Rapid difficult breathing
· Impaired consciousness
· Grey- Blue skin
· Congestion of the face with prominent veins and possibly tiny red spots on the face or the white of eyes.
First Aid
· Quickly remove the constriction if any around the person’s neck
· Immediately remove the parson to the hospital.
Dressings
Aims
Dressing helps to prevent infection by creating a barrier between the wound and other harmful agents. Dressings are also used to stop bleeding as they aid blood clotting process by exerting pressure on the wound.
Rules for Using Dressing:
1. Always wear disposable gloves if available, before handling any dressing other than plaster of Paris casts.
2. Always use a large dressing that covers the wound and extends beyond the edges of wound.
3. Place the dressing directly on top of the wound (do not slide it on from the side)
4. Remove and replace any dressing that slips out of position.
5. If there is only one sterile dressing, use this to cover the wound and apply other clean material on the top of the dressing.
6. If blood seeps through the dressing, do not remove it; put another one on top of the old dressing. If still the blood seeps, remove both and apply a new one, making sure that you apply pressure over the bleeding point.
7. After doing the dressing, remove gloves. Used dressing materials and contaminated items are put in a suitable plastic bag for safe disposal.
8. Do not remove gloves till you have finished the work.
Sterile Dressing
This type of dressing consists of a dressing pad attached to a roller bandage and is available in different sizes. (Dressing pad consists of a piece of gauze padded by a layer of cotton wool.)
How to Using Sterile Dressings
1. Break open the seal and remove the wrapping. Unwind (unroll) the bandage, taking care not to drop the roll or touch the dressing pad.
2. Unfold the dressing pad, holding the bandage on each side of it. Lay the pad directly on the wound.
3. Wind the short end (tail) of the bandage once around the limb and dressing to secure the pad.
4. Wind the other long end (head) of bandage around the limb to cover the whole pad. Leave the tail of bandage hanging free.
5. To secure the bandage, tie the ends in a “reef knot”. Tie the knot directly over the wound
6. Once you have secured the bandage, check the circulation in the limb in vessels distal to it. Loosen the bandage if it is too tight.
Non Sterile Dressing
· If sterile dressing is not available, you can use gauze pads or any other clean material or apply cotton wool to the wound to absorb blood or other fluids. While using non sterile dressing, make sure the item is clean. Secure dressing with a bandage or tape or sticking plaster.
Adhesive Dressing
· Plasters are useful for dressing small cuts and grazes. They consist of gauze and an adhesive plaster. They are of different sizes.
Cold Compresses
Cooling an injury such as a bruise or sprain can reduce swelling and pain, although it will not relieve the injury itself.
Cold compress are of two types. Cold pads made up of material filled with cold water and ice packs.
Method for Making Cold Compresses
Cold Pad
1. Soak a towel in cold water, wring it out lightly and fold it into a pad, then place it firmly on the injury.
2. Re-soak the pad in the cold water every 3-5 minutes. Cool the injury for at least 10 minutes.
Ice Pack
1. Partly fill a plastic bag with ice cubes or broken ice or pack of frozen vegetables. Place it firmly on the injury after wrapping it in a dry cloth.
2. Hold the pack firmly for 10 minutes on the area.
Principles of Bandaging
There are a number of different first aid uses of bandages. They can be used to secure dressings, control bleeding, support and immobilize limbs and reduce swellings in an injured part.
There are three main types of bandages.
1. Roller bandages that secure dressings and support injured limbs.
2. Tubular Bandages that hold dressings on fingers or toes or support injured joints.
3. Triangular Bandages can be used as large dressings, as slings, to secure large dressings or to immobilize limbs.
Rules of Applying a Bandage
1. Before applying a bandage, reassure the person and explain what you are going to do.
2. Make the person comfortable in a suitable sitting or lying position.
3. Keep the injured part supported while you are working on it. Ask the person or a helper to do this.
4. Always work from the front or injured side of person
5. If casualty is lying down, pass the bandages under the body’s natural allows at the ankles, knees, waist and seek then slide the bandages into position by moving them back forward under the body.
6. Apply the bandages firmly but not so tightly that they interfere with circulation of the area beyond the bandage.
7. Leave the fingers or toes out of the bandages if possible to check the circulation.
8. Use reef knots to the bandages (Do not tie the knot over a long area).
9. Regularly check the circulation in the area beyond the bandage.
Checking Circulation after Bandaging
When bandaging a limb or using a sling, you must check the circulation in the hand or foot immediately after you have finished bandaging and every 10 minutes thereafter. These checks are essential because limbs swell after injury and a bandage can rapidly become too tight and interfere with blood circulation to the area beyond it. The symptoms of injured circulation enhance as first the veins and then the arteries become constricted.
Circulation Check
1. Briefly press one of the nails, or the skin until it turns pale, and then release the pressure. If the color does not return or returns slowly, the bandage may be too tight.
2. Loosen the bandage.
If Circulation is Impaired there may be:
1. Swollen limb
2. Blue skin with prominent veins
3. Painfully distended skin
Later there may be:
1. Pale, Waxy skin
2. Cold and numbness
3. Tingling
4. Deep pain
5. In ability to move, attached fingers or toes.
Medico-legal Cases and the Dispenser
The following act defines the context of medico-legal cases and should be adhered to without fail.
THE INJURED PERSONS MEDICAL AID BILL 2004
To make provision for medical aid and treatment of injured persons.
Whereas there is a misconception about the law and procedure with regard to medical aid and treatment of injured persons before completion of medico-legal formalities;
WHEREAS due to this misconception the medical aid and treatment of injured persons is very often delayed and many causalities have occurred because of delayed treatment;
AND WHEREAS it is necessary to make provisions for medical aid and treatment of injured persons to save their lives and protect their health during emergency;
It is hereby enacted as follows;
1. Short title, extent and commencement; - (1) This act may be called the Injured persons (medical Aid) Act, 2004.
(2) It extends to the whole of Pakistan
(3) It shall come into force at once
2. Definitions; - In this act, unless there is anything repugnant in the subject or context;-
(a) “Doctor” means a medical practitioner registered under the Medical and dental council Ordinance, 1962(XXXII of 1962);
(b) “Government” means the Federal government or a Provincial government, as the case may be;
(c) “Hospital” means a hospital notified under section 7; and
(d) “Injured person” means a person seriously injured due to traffic accident, assault or any other cause.
3. Injured persons to be treated on priority basis; - Whereas an injured person is brought to a hospital, he shall be provided medical aid without delay on priority basis over all other medico-legal formalities.
4. Non-interference by the police; - No police official of officer shall interrupt or interfere during the period an injured person is under treatment in a hospital except with the written permission of the Incharge of the hospital;
Provided that such permission shall not be given unless it is in the interest of justice and necessary in connection with the investigation which shall be carried out in the hospital so long as the injured person is under treatment.
5. Consent of relatives not required in certain cases; - Where an injured person requires emergency treatment or operation, the doctor treating or operating the injured persons need not wait for the consent of the relatives:
Provided if the relatives are present it would desirable that such treatment or operation may be carried out with the consent of such relatives.
6. Hospital not to shift injured persons until stabilized;-
(1) An injured persons shall not be shifted from a hospital until he stabilized while shifting him to another hospital, the doctor concerned shall complete the relevant documents with regard to the clinical conditions of the patient and handover such document to concerned doctor of the receiving hospital.
(2) The record referred to in sub-section (1) shall be maintained by the referring hospital as well as the receiving hospital and the Incharge of the hospital shall be responsible for ensuring that such record is kept in a safe custody where it cannot be tempered with.
Provided that where necessary an injured person shall not be shifted unless he is accompanied by a doctor of the referring hospital.
7. Hospital to be notified; - The government shall, be notification in the official gazette, notify the government hospital having at least fifty in-patient beds and also have facilities to deal with the emergencies to provide medical aid and treat the injured persons;
Provided that in areas where above referred facility is not available, a rural health centre established by a government in that area having facility to deal with the emergencies, may be notified as hospital for the purposes of this act.
8. The injured person not to be taken to police station; - Under no circumstances, an injured person be taken to a police station before necessary medical aid and treatment is given to him. The police officer is bound to ensure that the injured person is treated in a hospital as provided in this act before any medico-legal procedure is undertaken. The police officer must not in any way influence the doctor or to give any opinion about the type and details of injury of the injured person.
9. The person bringing the injured person to hospital not to be harassed; - The person who on humanitarian basis in particular in traffic accident cases, brings an injured person to a hospital must not be harassed. He must be shown due respect and acknowledged for helping the injured. He should be allowed to leave the hospital after taking down his name, address, telephone number and he shall provide his national identity card number within three days;
Provided that nothing herein contained shall absolve the person bringing an injured person to a hospital form the liability to which he may be liable under the law for the time being enforced for causing injury to such person.
10. Awareness campaign; - An awareness campaign shall be a regular feature to educate the public, medical professionals and police on regular basis about medico-legal procedures by the government through media and training programs.
11. Penalty; - Whoever contravenes or violates the provisions of this act or the rules made there under shall be punishable with imprisonment which may extend to two years, or with fine not less than ten thousand rupees, or with both, in addition to any other penalty to which he may be liable under any other law for the time being in force.
Provided that where penalty of fine is imposed half of such fine shall be paid to injured person or his heirs, as the case may be, as compensation;
Provided further that the court may direct the medical and dental council under the medical and dental council ordinance, 1962 (XXXII of 1962) to cancel the registration of a doctor convicted by the court.
12. Cognizance of cases; - (1) No court shall take cognizance of a case under this act, except upon a complaint made by an officer authorized in writing in this behalf by the government.
(2) The government shall notify authorized officers under sub-section (1) within thirty days of the commencement of this act.
13. Instructions; - The government may issue instructions from time to time carry out the purposes of this act and the defaulting doctor or the police official or officer shall be liable to disciplinary action for contravention of such instructions, besides the penalty to which he may be liable under section II.
14. Rule making power; - The federal or provincial government, as the case may be, may make rules to carry out the purposes of this act.
Class room evaluation
Student: _________________________ ID: __________________________
Teacher: _________________________Unit 5: Emergencies: Trauma, Overdosage and poisoning
Date: ________________________
Select the best response for each test item.
How would you describe triage?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
There are ______ vital signs which are standard measurements in most medical settings (choose one).
a. two
b. three
c. four
Body temperature is normally recorded in the following three sites in the body.
a. _______________________________
b. _______________________________
c. _______________________________
The normal core body temperature of a healthy, resting adult human being is stated to be (choose one)
a. 98.6 degrees Fahrenheit or 37.0 degrees Celsius
b. ___________
c. ______________
Demonstrate the various steps of recording mouth temperature in an adult.
Demonstrate the various steps of recording axillary temperature in a child.
The normal pulse or heart rate in a 0-5 months baby is ________beats per minute and in an adult is ________beats per minute.
What are the two numbers used to measure blood pressure? Describe them. What is the normal blood pressure?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Respiratory rates may increase with __________, _________, _____________, and______________.
The normal respiratory rate in a newborn is ________breaths per minute and in an adult is ________ breaths per minute.
What are the three ways of bleeding to occur?
a. _____________________________________
b. _____________________________________
c. _____________________________________
Symptoms of internal bleeding include:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
First-line management to control bleeding is to apply a tourniquet.
True False
Direct pressure stops most external bleeding, and is the most important initial first aid.
True False
Serious injuries always bleed heavily and minor injuries do not bleed profusely.
True False
What are the three methods of administering IV medication?
a. _____________________________________
b. _____________________________________
c. _____________________________________
What are the three steps of giving cardiopulmonary resuscitation to an adult? Explain fully.
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
What are the two differences between the procedure of giving cardiopulmonary resuscitation to a child aged 1 to 8 years and an adult?
________________________________________________________________________________________________________________________________________________
What are the three steps of giving cardiopulmonary resuscitation to a baby? Explain fully.
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
Explain the different types of burns.
________________________________________________________________________________________________________________________________________________
What are the different causes of burns?
________________________________________________________________________________________________________________________________________________
Explain the management of first-degree and second-degree burns limited to an area no larger than 3 inches in diameter.
________________________________________________________________________________________________________________________________________________
Notes
Subscribe to:
Posts (Atom)