IEC

Section 1 - Immediate Emergency Care

Chapter 1 - Principles of IEC

- preserve life
- prevent deterioration
- promote recovery

Section 2 - Scene safety

Chapter 3 - General
- rescuers approaching a scene must perform a dynamic risk assessment

Section 3 - Patient assessment

- Scene Assessment
- Primary Survey
- History Taking
- Secondary Survey
- Reassessment

Chapter 5 - Primary survey

- DR.C.ABCDE
- Danger - risk to rescuers - make area safe
- Response - patient response level - AVPU scale
- Catastrophic Haemorrhage - evidence of life threatening external bleeding -
treat immediately
- Airway - airway open and clear? if not use appropriate method to clear
- Breathing - breathing normally? sufficient to sustain life? if not commence
assisted ventilations
- Circulation - pulse? if not commence CPR - yes, control severe bleeding
- Disability - use AVPU
- Expose/environment - skin colour and temperature (use back of hand, be
mindful of environment

Chapter 6 - History taking

- SAMPLE
- Signs and symptoms - observe signs, ask for symptoms
- Allergies
- Medication - what medication is patient on and when was last taken
- Past medical history - previous occurrences, surgeries or other relevant
history
- Last ate/drank - what and when did patient eat or drink last
- Events - what was patient doing before became ill or injured

Chapter 7 - Secondary survey

- in depth assessment of the patients body before CPR is required
- check all orifices on face
- check scalp and back of neck
- check parts of torso we have access to
- check parts of torso we don’t have access to
- check legs
- check arms

Chapter 8 - Patient Monitoring

- monitor patient constantly whilst waiting for ambulance
- ask patient to rate pain score from 0 (no pain) to 10 (worst pain ever felt)
- record all observation on Patient Report Form in accordance with PN 543
AVPU
- A - is the patient alert
- V - does the patient respond to voice commands
- P - does the patient respond to mild pain stimulus
- U - if there is no response to voice or pain, they are unresponsive

Glasgow Coma Scale

- Eyes opening, verbal response, motor response
- Maximum score 15 (fully conscious), minimum score 3 (unconscious)
- 8 or below is a serious head injury
Breathing
- average respiratory rates per minute
- adult 12-20, child 20-30, infant 30+
Pulse
- average pulse rates per minute
- adult 60-80, child 100-140, infant 140+
Pulse Oximeter
- percentage of oxygen saturation in the blood (SpO2)
- accuracy affected by - bright sunlight, nail varnish, shivery/movement, poor
tissue perfusion, cold, hypovolaemia, vascular compression
- carbon monoxide poisoning victims will display normal SpO2 levels

Chapter 9 - Documentation
- a patient report form must be completed for every patient treated
- SAMPLE
- mechanism of injury
- mechanism of illness (nature of illness)
- presenting condition (complaint) or illness
- other details/treatment given
- all interventions must have a time associated with them

Chapter 10 - Patient Handover

- ATMIST is widely used by ambulance services to handover trauma patients
- Age
- Time of incident
- Mechanism of injury
- Injuries
- Signs and symptoms
- Treatment given/immediate needs
- SAMPLE can be used to handover medical patients

Section 4 - The respiratory system

Chapter 11 - Components of the respiratory system

Principle functions of respiration:
- extract oxygen from the atmosphere and transfer to bloodstream in lungs
- excrete water vapour and carbon dioxide
- maintain the normal acid-base status of the blood
- ventilate the lungs
Organs of respiratory system:
- nose
- pharynx
- larynx
- trachea
- two bronchi
- bronchioles and smaller air passages
- two lungs and pleura
- muscles of breathing (intercostal and diaphragm)
Bronchi
- left and right bronchus
- right is wider, shorter, more vertical, more likely to become blocked by
inhaled foreign bodies, three branches (one for each lobe)
- left is longer and narrower, divides into two branches (one for each lobe)

Chapter 12 - Exchange of gases

- external respiration - takes place in the lungs
- internal respiration - takes places in the tissues

Chapter 13 - Mechanism of respiration

- inspiration (inhalation, breathing in)
- expiration (exhalation, breathing out)

Respiratory rates at rest in breaths per minute

Adult 12-20
Child 20-30
Infant30+
- respiratory rate of <10 or >30 is not sufficient to sustain life

Chapter 14 - Composition of air

Inspired air
- oxygen 21%,
- carbon dioxide 0.04%
- nitrogen and rare gases 78%,
- water vapour variable
Expired air
- oxygen 16%
- carbon dioxide 4%
- nitrogen and rare gases 78%
- water vapour saturated

Section 5 - Respiratory problems

Chapter 15 - Chronic obstructive pulmonary disorder (COPD)

- chronic lung disorders that result in blocked air flow in the lungs

Bronchitis
- mucus membrane in lung’s bronchial passage becomes inflamed
- irritated membrane swells and narrows tiny airways in lungs
- coughing, phlegm, breathlessness
Emphysema
- alveoli gradually damaged
- inner walls of alveoli weaken and rupture
- reduces surface area of the lungs and thus oxygen into blood

Patients with COPD

- insensitive to CO2 levels
- hypoxic
- brain uses hypoxia as breathing stimulus
- high concentration oxygen through mask can raise blood oxygen levels and
affect stimulus to breathe causing patient’s breathing rate to drop/cease
All patients given oxygen therapy via high concentration oxygen mask must
have their breathing rate monitored and recorded

Chapter 16 - Asthma
- inflammation of the airways causes restricted airflow in and out of lungs
- asthma classified by severity
- moderate, severe, life threatening

Chapter 17 - Hyperventilation syndrome (HVS)

- rate of ventilation exceeding metabolic needs, higher than required to
maintain normal CO2 level

Chapter 18 - General treatment for respiratory problems

- patient in comfortable position
- oxygen therapy
- monitor respirations
- record respiration rate, depth, SpO2 on patient report form
- call an ambulance

Chapter 19 - Smoke inhalation and smoke inhalation injury

Three ways damage occurs:
- heat causes thermal damage
- gases cause asphyxiation
- irritation of the lungs or airways
Recognition
- scorched hair or facial hair
- blisters
- soot in the nostrils and in and around the mouth
- difficulty breathing - wheezing or stridor (high pitched wheezing)
- coughing with possible blackened sputum coughed up
- change in voice or difficulty speaking
Patients may not show any signs or symptoms
Any patient who has inhaled smoke/fumes must be treated as being time
critical

Treatment:
- can use V-vac
- use BVM
- oxygen
Chapter 20 - Assisted ventilations
- respiratory rate of <10 or >30 is not sufficient to sustain life
- over ventilation causes gastric distention and vomiting

Chapter 21 - Respiratory arrest

- not breathing but does have a pulse
- can occur from smoke inhalation, head or spinal injuries, asphyxia,
electrocution
JAWS
- Jaw thrust - pull face into mask
- Adjuncts - OP, one or two NP
- Work together - two person better
- Squeeze slowly - squeeze bag slowly over 1 second

Section 6 - Airway management

Chapter 22 - Causes of airway obstruction

- upper airway obstructions - tongue, foreign material, blood, vomit, etc
- lower airway obstructions - bronchial secretions, pulmonary bleeding,
inhalation of regurgitated stomach content
- the tongue is the most common cause of airway obstruction

Chapter 23 - Recognising airway obstruction

- look - chest and abdominal movement
- listen and feel - for normal breathing with cheek and ear
- snoring, stridor

Chapter 24 - Foreign body airway obstruction (choking)

mild airway obstruction
- patient able to answer “are you choking”
- able to speak, cough, breathe
severe airway obstruction
- patient unable to answer the question “are you choking”
- unable to breathe, wheezing, coughing is silent, unconscious

mild airway obstruction - encourage patient to cough, monitor

severe airway obstruction (conscious) - give up to 5 back blows, then 5
abdominal thrusts
- continue alternating until obstruction relieved or patient unconscious
severe airway obstruction (unconscious) - begin BLS
- check mouth quickly during CPR to see if foreign body expelled
Must be transported to hospital after abdominal thrusts
Chapter 25 - Methods of ensuring an airway
- head tilt, chin tilt
- jaw thrust

Chapter 26 - Airway adjuncts

- oropharyngeal airway - unconscious patient or patient in respiratory/cardiac
arrest
- 4 sizes of OP used by IEC trained firefighters
- do not attempt to rotate airway on removal
- nasopharyngeal airway - unresponsive patients are those with altered level
of consciousness
- first consideration
- do not use NPA if base of skull fracture suspected
- LFB carries two sizes - 6mm and 7mm

Chapter 27 - Laryngectomy and Tracheostomy

Laryngectomy
- larynx removed, make a tracheostomy, stoma created, trachea connected
to outside air
- laryngectomee, neck breather, no connection between pharynx and lower
airway
- partial laryngectomy - portion removed, breathe through stoma, nose, or
mouth
Tracheostomy
- tube within the stoma, required 15/22mm adaptor to be compatibly with
ventilatory devices

Section 7 - Oxygen Administration

Chapter 29 - Hypoxia (lack of oxygen)

- a lack of oxygen can result in the death of brains cells in 3 minutes
signs of hypoxia
- rapid breathing
- confusion
- pale, cold, clammy
- cyanosis (blue skin/lips, late stage sign)

Chapter 30 - Indications for oxygen administration

- shock
- trauma
- respiratory or cardiac arrest
- breathing problems
- hypoxia
- heart attack
- medical emergencies

Chapter 31 - Contraindications and cautions for oxygen administration

- explosive environments
- fire scenes
- defibrillation
- COPD patients
- monitor all patients, remove oxygen if patient has to be left unattended

Oxygen must be given to all patients, all patients given oxygen must be
monitored

Chapter 32 - Oxygen equipment

cylinder
- 300 bar
- 2 litre volume, 600 compressed litres
- 15 litres per minute
- 40 minutes duration
bag valve mask
- two BVM in each IEC pack, one adult one paediatric
- single use, clinical waste
- 95-98% delivery
- cannot be used in irrespirable atmosphere

Chapter 33 - Handover to ambulance personnel

LAS should be informed
- length of time on oxygen
- flow rate
- percentage of oxygen received
- SpO2 levels before and after
- any resulting change in condition

Section 8 - The cardiovascular system

Chapter 34 - The heart

- atriums = upper chambers
- ventricles = lower chambers
- pulmonary artery - only artery which carries deoxygenated blood
Chapter 35 - Electrical conduction of the heart
- autorythmicity
- sinoatrial node (SA node) - causes atrial contraction
- atrioventricular node (AV node) - conducts impulses from atria originating
from SA node
- atrioventricular bundle (bundle of His)

Chapter 36 - Heart rates

- adult - 60-80bpm
- child - 100-140bpm
- infant = 140+bpm
affected by
- gender
- age
- autonomic nervous system
- circulating chemicals
- exercise
- temperature
- baroreceptor reflex (nerve endings stimulated by the rise and fall in blood
pressure)
- emotional states
- position

Chapter 37 - Blood
principle functions of blood
- carry oxygen from lungs to tissues
- carry carbon dioxide from tissues to lungs
- carry nutrients to tissues, waste products to excretory organs
- distribute heat generated
- protect body from infection
- clotting
other
- 7% of body weight
- 55% plasma 45% cells
four elements
- plasma
- erythrocytes (red cells) - carry oxygen
- leukocytes (white cells) - fight infection
- platelets - promote clotting

Chapter 38 - Blood vessels

five types
- arteries and arterioles - carry blood from heart, thicker walls than veins
- veins and venules - return blood to hear at low pressure, thinner than
arteries
- capillaries - single thin layer allowing exchange of gases, nutrients, waste

Section 9 - Cardiovascular disorders/diseases

Chapter 39 - Coronary artery disease (CAD)

- narrowing of the arteries due to fatty deposits or artery hardening
- angina - lack of oxygen in the heart tissue, accumulation of CO2 and lactic
acid during period of increased oxygen demand
- work of heart can reduced by use of glycerol trinitrate - widens bloods
vessels increasing flow

Chapter 40 - Acute coronary syndrome (ACS)

- damage or death of heart muscle following blockage of coronary arteries

Chapter 41 - Acute myocardial infarction (MI)

- coronary artery becomes blocked, cardiac muscle deprived of blood,
muscle dies
symptoms
- chest pain, crushing, squeezing, tight
- pain into left arm, neck, jaw, upper back and epigastrium
- nausea, vomiting, belching, hiccups
- sweating
treatment (if conscious)
- oxygen
- ambulance
- place patient in semi-recumbent position
- reassure, comfort
- assist patient in taking their medication of 300mg aspirin
- keep patient still (to stop increase of heart rate)
- monitor vital signs, be prepared to carry out CPR and defibrillation
not all patients have an MI will experience chest pain, others may mistake for
indigestion

Chapter 42 - Pulmonary embolism (PE)

- sudden blockage in a lung artery
- clot travels from leg to lung
- causes low oxygen in the blood and thus damage to organs

Chapter 43 - Cardiac tamponade

- penetrating wound injures the heart
- excessive fluid fills pericardium (sac around heart)
- heart cannot fully expand
- reduces cardiac output until heart cannot beat anymore
- time critical life threatening emergency requiring surgical intervention

Chapter 44 - Aortic aneurysm

- abnormal local dilation of arteries
- if ruptures, haemorrhage follows
- rupture of aorta likely fatal

Section 10 - Nervous System

Chapter 45 - The brain

- central nervous system - thought, perception, feeling, autonomic body
functions
- peripheral nervous system - transmits commands from brain to body and
receives feedback
three layers (the meninges) cover the brain
- dura matter - adheres to skull
- arachnoid matter - layer of fibrous tissue
- pia matter - covers brain completely
dura and arachnoid separated by subdural space
arachnoid and pia separated by subarachnoid space containing cerebrospinal
fluid (CSF)

Chapter 46 - Sympathetic nervous system

- fight or flight response
- energy, oxygen, ability to react to stressful situations

Chapter 47 - Parasympathetic nervous system

- rest and digest response
- slows down cardiac and respiratory activity
- stimulates digestions and absorption of food

Chapter 48 - Neurological emergencies

- stroke
- blood supply to areas of brain become interrupted resulting in ischaemia of
the brain (blood flow/oxygen reduced)
- slurred speech, facial droop, headache, blindness, consciousness problems
FAST
- facial weakness
- arm weakness
- speech
- time
treatment
- oxygen
- monitor pulse, respiratory rate, temperature, consciousness
- ambulance
- no food or fluid
- recovery position, affected side downwards
- monitor breathing, use adjuncts
transient ischaemic attack (TIA)
- brief period present as FAST positive followed by recovery
- may precede a stroke
bacterial meningitis
- inflammation of the subarachnoid space
- severe headache
- neck stiffness
- photophobia
- fever
- petechial rash (late stage)

Section 11 - Trauma

Chapter 49 - Mechanism of injury (MOI)

- the way in which traumatic injuries occur
- the forces that act on the body to cause damage
- any patient in an RTC should be treated for spinal injuries until cleared by
the ambulance service

Chapter 50 - Head injuries

- any trauma that leads to injury of the skull or brain
- often have associated cervical spine injuries and maxilla-facial injuries
- two classifications of traumatic brain injuries
- primary (direct) brain injury - instantaneous
- secondary - after effects
- accumulations of blood within the skull or swelling of the brain can lead to
raise in intracranial pressure (ICP) - if not treated promptly can be fatal
signs and symptoms of raised ICP:
- vomiting (often without nausea)
- headache
- convulsion
- altered level of consciousness
later signs
- hypertension
- bradycardia
- irregular respirations
- unequal and un-reactive pupil (compression of ocular nerve)
- posturing
- coma

Chapter 52 - Eye injuries

- visual loss that does not improve when patient blinks
- double vision suggests trauma involving extraocular muscles (fractured
orbit)
- sensation of foreign body indicates superficial injury to cornea or foreign
body behind eyelids
secondary survey examination of affected eye should include:
- orbital rim
- eyelids
- conjunctivae
- globes
- pupils
- eye movement
- visual acuity
treatment
- don’t forcibly remove any object
- cover both eyes to stop movement
- do not exert pressure on bleeding eye
- irrigate eye with saline or clean water away from unaffected eye for at least
10 minutes
- irrigate chemical burns continuously for 20 minutes

Chapter 53 - Wounds and soft tissue injuries

internal bleeding
- swelling or rigidity
- hematemesis - vomiting blood
- haematuria - urinating blood
- haemoptysis - coughing blood
- malena - blood in stool
- brain - blood and/or CSF escaping through ears, nose, eyes
wound types
- abrasion - superficial, caused by skin rub/scrape
- laceration - cut from blunt trauma
- incision - caused by sharp implement
- puncture - wound from pointed object - can cause significant internal
bleeding, never remove imbedded object
- gun shot - small entry wound, large exit wound
- avulsion - flap of skin
- amputation - never put amputated part directly in water or ice, causes
further cell damage - wrap loosely in saline-moistened gauze securely in
plastic bag
- crush - direct compressive force - extrication or transportation must not be
unnecessarily delayed in order to gain IV access or administer fluids
- blast injuries

bleeding management
- bleeding
- elevate/direct pressure
- dressing
- second dressing (if required)
- bleeding controlled - transfer to further care
- bleeding not controlled - refer to catastrophic haemorrhage management

catastrophic haemorrhage management

- bleeding
- indirect pressure if direct pressure not working (tourniquet if required)
- olaes/blast dressing
- bleeding controlled - time critical transfer to further care
- bleeding not controlled - apply second tourniquet - time critical transfer to
further care

a tourniquet should only be used for a catastrophic haemorrhage

- incorrectly applied tourniquet can actually increase blood loss if venous
vessels are occluded
- correctly applied tourniquets can cause local tissue injury

Chapter 54 - Fractures, dislocations, sprains, and strains

fracture signs:
- deformity
- shortening
- swelling
- guarding/loss of use
- tender
- crepitus - grating sensation over broken bone ends
- exposed bond ends
Chapter 55 - Spinal injuries
signs and symptoms:
- loss of feeling, sensation, pain response, below injury
- complains of pain in back or neck
- tingling, or pins and needles sensation, above injury
- paralysis below injury, loss of internal muscle control, incontinence
- displacement of spinal vertebrae (unnatural lump or depressions)
- fixation of spinal column at site of the injury
- breathing seen more in abdominal area rather than chest
- signs of neurogenic shock

treatment
- likely to be hypoxic, give oxygen
- should not be moved unless necessary
- use jaw-thrust to open airway

cervical spine immobilisation collar

- LFB an LAS use two types of collars
- restrict movement and keep spine in neutral alignment
- Ambu Redi-Ace collar is an adjustable size device
- Stifneck Extrication Collar comes in 4 different sizes
- tall, regular, short, and no-neck
- green, orange, blue, purple
- do not apply wrong size collar
- inline stabilisation of the c-spine must be maintained after any collar has
been fitted

helmet removal
- should only be done if airway cannot be maintained or resuscitation
required
- while removal of helmet causes movement of spine, airway takes priority

Chapter 56 - Chest injuries

- flail segment - two or more adjacent ribs fractured in two or more places
- simple pneumothorax - air in potential space between lungs and chest
- open pneumothorax (sucking chest wound) - defect in chest wall allows airs
to enter plural space (can result from gun shot, stabbing)
- tension pneumothorax - life threatening - continued accumulation of air
under pressure in intrapleural space
- haemothorax - blood in potential space between parietal and visceral pleura
(caused by rib fractures, injuries to lung parts)
- cardiac tamponade - fluid in pericardial cavity, causing compression or
heart, decreased cardiac output
all chest injuries treated with high flow oxygen and early ambulance request

Chapter 57 - Pelvic injuries

recognition
- rigidity of abdomen
- legs in unnatural position
- patient may have urge to pass urine - should be discouraged
- haematuria (blood in urine)
- feeling of pelvic cavity lying open
- abnormal mobility to pelvic region
- inability to bear weight
- bruising or laceration in groin area etc
treatment
- move as little as possible
- do not pass urine - may tear bladder
- unresponsive breathing patient left in position, not turned into recovery
position
- do not attempt to establish if fracture is present

Chapter 58 - Burns
- cool the burn, not the patient
- the area of the burn is more important than the depth
electrical burn
- guarantee your own safety before attempting to deal with a patient
- isolate electrical apparatus before touching patient
- treat as normal, but look for second wound site
- monitor pulse rate, electrical current may have passed through heart
chemical burn
- burn progresses as long as substance in contact with the skin
- PPE
- brush off dry chemicals
- remove contaminated clothes, jewellery (not over head, cut if necessary)
- wash patient with water at least 20 minutes, early irrigation eyes and face

depth of burns
- superficial - reddening of skin, swelling, tenderness
- partial thickness - reddening with blisters
- full thickness - waxy or charred looking skin
assessing the area
- the area of the burn is more significant than the depth
- larger the area burned, the more fluid is lost
- hand is equal to 1% of the body surface area

Time critical features

- burns to more than 25% of the body surface area
- airway burns, soot around mouth and nose
- facial, hand, feet, genital burns
- all full thickness burns
- mixed patterns of depth
- presence of other injuries
if clothing is alight
- stop
- drop
- wrap
- roll

treatment
- cool burn with water for minimum 10 minutes (20 minutes for chemical)
- oxygen
- remove jewellery and clothing
- use clingfilm to cover burn (not applied to burns caused by corrosive
chemicals)
- treat patient for shock
- ambulance (transport to hospital)
- check patient for other injuries
- monitor for hypothermia
clingfilm
- prevents further infection of wound
- non-adhesive
- allows burn to be assessed without exposure to further infection
- allows further cooling to burn after application
- do not wrap around limb as may become constricting if limb swells
- not applied to chemical burns
- water gel burns pack - after burn cooled for 10 minutes if no clingfilm
available - not used on chemical burns

Section 12 - Shock

Three basic causes of shock

- pump failure - heart attack, heart trauma, obstructions
- low fluid volume - trauma to vessels, tissues, fluid loss from gastrointestinal
tract
- poor vessel function - infection, drug overdose, spinal cord injury,
anaphylaxis

Chapter 60 - Hypovolemic shock

- the most common form of shock rescuers are likely to come across
- due to inadequate blood volume
two types
- haemorrhagic shock - volume lost as blood (internal and external)
- non-haemorrhagic - volume lost as plasma (burns) or electrolyte solution
(vomiting etc)
- signs and symptoms - rapid weak pulse, hypotension (low blood pressure),
altered mental state, cyanosis, clammy, increased respiratory rate

Chapter 61 - Septic shock

- substances released from cells as consequence of severe infection
- dilation of blood vessels, tissue capillary leak, defective oxygen utilisation
by tissues produces shock
- takes time to develop after infection onset
- signs and symptoms - warm skin, tachycardia, hypotension (low blood
pressure)

Chapter 62 - Anaphylactic shock

- allergic reaction to foreign protein e.g. nuts, shellfish, insect sting, fruit,
drugs (penicillin)
- also caused by latex
- immune system overdrive
- injected substances can cause cardiac arrest in under a minute
- ingested substances cause cardiac arrest from 10 minutes to 3 hours
- signs and symptoms - mild itching or rash, burning skin, vascular dilation,
oedema (fluid build up) coma, rapid death

Chapter 63 - Cardiogenic shock

- caused by heart failure
- failure by ischaemia (restricted blood flow) of myocardium (muscles of the
heart)
- by myocardial infarction (supply of blood to heart blocked - heart attack)
- by rupture following ischaemia or penetrating injury
- signs and symptoms - anxiety, rapid weak pulse, hypotension, jugular vein
distention (bulging of neck veins), cyanosis, tracheal deviation towards
affected side (cardiac tamponade), chest pain

Chapter 64 - Neurogenic shock

- damage to spinal cord
- blood vessel wall tension interrupted, vessels dilate, pooling of blood
- effective circulating blood volume reduced, shock follows
- signs and symptoms - bradycardia, warm peripheries, hypotension, signs of
neck injury

Section 13 - Medical emergencies

Chapter 65 - Alerted level of consciousness

- ALoC can be caused by many conditions
- time critical assessment - history of illness, preceding symptoms,
environmental factors, evidence of substances, medications
- decreased level of consciousness (DLoC)
- transient loss of conscious (TLoC) - spontaneous loss of consciousness
with complete recovery (e.g. a blackout) - most common cause is cardiac
disorders
- TLoC management - CABC, treat injuries, recovery position (if
unconscious), oxygen

Chapter 66 - Poisoning
recognition
- seizures
- swelling or burns
- breathing difficult
- vomiting, diarrhoea
- unconsciousness
treatment
- do not endanger rescuer
- remove cause
- history
- sample for LAS
- sample vomiting but do not induce
- give oxygen (unless poison is paraquat)

cyanide gas produced in fires involving materials containing nitrogen, plastics,

wool, silk, carpeting, synthetic rubber etc
carbon monoxide poisoning
- firefighters clearing up may be exposed
- boilers, gas fires, engine exhausts
recognition
- CO bonds with haemoglobin 240 times more easily than oxygen - leads to
hypoxia
- patient will not show normal signs of hypoxia
- headaches, confusion, nausea, cherry red appearance (late sign)
treatment
- fresh air, oxygen, kept still, sitting if conscious, recovery position if
unconscious

Chapter 67 - Convulsions
- synchronised and excessive activation of neurons in cerebral cortex (e.g.
epilepsy)
- partial (focal) - simple: butterflies, fear, hallucinations - complex: ALoC,
chewing, lip smacking, hand fiddling
- generalised - tonic-clonic: stiff, falls, jaw clenches, then regular jerking of
limbs, incontinent, may deny epilepsy or taking medication, aggressive -
absence convulsions: day dreaming, eyelid fluttering, head flopping, not
answer questions etc during absence
- status epilepticcus (convulsions are persistent and continual)
- eclamptic convulsions see chapter 82

Chapter 68 - Diabetes mellitus

high blood sugar
- type 1 - unable to produce insulin
- type 2 - insulin resistance, caused by obesity, sedentary lifestyle, age,
genetics - most common type of diabetes, approx 90% of all diabetes in UK
two types of diabetic emergency
- hypoglycaemia - excess insulin in blood
- signs and symptoms - sweating, palpitations, rapid pulse, shaking, etc
- hyperglycaemia:
- diabetic ketoacidosis - type 1
- hyperosmolar hyperglycaemic state - type 2
- signs and symptoms - polyuria (excessive urine), fatigue, vomiting, fruity
breath, kussmaul breathing (deep laboured breathing), dehydration signs

Section 14 - Extremes of body temperature

normal body temperature - 36.8°C

Chapter 69 - Hypothermia
- core body temperature below 35°C
- mild 35-32°C, moderate 32-28°C, severe <28°C
recognition
- shivering
- loss of dexterity
- confused, drowsy
- loss of consciousness
- below 28°C may be no pulse or breathing even though heart still beating
treatment
- remove from cold environment, prevent further heat loss
- oxygen
- keep still
- ambulance

Chapter 70 - Heat related illness

heat stress
- mildly elevated temperature, swelling of feet and ankles, vasodilation,
dehydration, heat cramps
heat exhaustion
- caused by excess fluid loss and electrolyte imbalance
- temperature >37°C and <40°C
- headache, nausea, etc, tachycardia (heart rate over 100)
- hypotension (low blood pressure)
- sweating, muscle pain, weakness, cramp
- haemoconcentration
- hyponatraemia or hypernatraemia (sodium too low or high)
heat stroke
- inflammatory response to core body temperature >40.6°C
- non-exertional (high external temperatures) and exertional (excess heat
production)
- hot, dry skin
- fatigue, headache, fainting, etc
- arrhythmia (irregular heartbeat)
- seizures, coma
- liver and renal failure
- coagulopathy (impaired clotting)
- rhabdomyolysis (damaged muscle tissue released proteins and electrolytes
into blood)
treatment
- ABCD
- remove from hot environment
- remove clothing
- cool - fanning, water mist
- take temperature, pulse, respiratory rate
- check GCS
- ambulance

Section 15 - Basic life support

Chapter 71 - Adult basic life support (BLS)

- maintaining airway, supporting breathing and circulation
- DR C ABC
- commence cpr
- AED should be applied and switched on as early as possible
- compression depth 5-6cm for adults
- 100-120 compressions per minute
- 30-2 compressions to breaths ratio
- if no BVM available, compression only CPR
- always think JAWS (jaw thrust, adjuncts, work together, squeeze slowly)
- stop to recheck ABC only if patient shows signs of recovery
- change rescuer doing compressions every 2 minutes
- if ventilation does not make chest rise, check for obstructions and use v-vac
- 2 breaths only before returning to compressions

if alone, call ambulance before commencing CPR

if patient has drowned, 5 rescue breaths and 1 minute of CPR before leaving
patient to call 999

Chapter 72 - Sudden cardiac arrest

- heart suddenly stops pumping
- used AED on any patient in cardiac arrest (no pulse, no breathing)
heart rhythms - shockable and non-shockable rhythms
shockable
- VF, pulseless VT
non-shockable
- asystole - absence of electrical activity in the heart
- PEA - organised electrical activity in absence of palpable pulse
chain of survival
- early recognition and call for help
- early CPR
- early defibrillation
- post resuscitation care
Chapter 73 - About the Zoll AED
- automated external defibrillator

Section 16 - Recovery position

Chapter 74 - The benefits
- unconscious breathing patients
- ensure airway remains open
- stable patient
- fluids drain out mouth
- tongue will not block airway
- chest off the floor to aid breathing

Chapter 75 - Method of turning

- explain what you are doing
after patient is turned:
- tilt head back to open airway, recheck pulse and breathing
- adjust position, check patient’s back
- oxygen
- recheck breathing every minute until ambulance arrives
- injured patients turned onto injured side
- pregnant women onto left side

Chapter 76 - When not to use

- major trauma, spinal, pelvic, thigh fracture, chest, head injuries
only possible if
- rescuer able to stay with the patient until ambulance arrives
- airway can be maintained
- patient does not vomit
if have to be turned, use log roll, minimised movement of patient

Section 17 - End of life care

Chapter 77 - End of life care

- DNAR
- do not attempt resuscitation if DNAR2 order is in place and handed to crew
or verbally received and recorded by ambulance control
- order seen and corroborated
- relates to condition DNAR in force for only, not coincidental conditions
- if in doubt, resuscitate

Chapter 78 - Conditions unequivocally associated with death

- decapitation
- massive cranial and cerebral destruction
- hermicorporectomy
- massive truncal injury
- decomposition/putrefaction
- incineration
- hypostasis (pooling of blood)
- rigor mortis (stiffness due to enzyme breakdown in muscle fibres)

Section 18 - Consent and capacity

Chapter 79 - Consent
- to enable any health care to be given, consent must first be obtained
- requires capacity to make decision about their care

Chapter 80 - Capacity
- person must be assumed to have capacity unless contrary is established
- person given all practicable help to make decision before being treated as
unable to do so
- not treated as lacking capacity for making unwise decision
- anything done for person lacking capacity done in person’s best interest
- anything done for person lacking capacity least restrictive of person’s rights
and freedom
two stage functional test
- is there an impairment or disturbance in functioning of person’s mind or
brain
- impairment or disturbance sufficient that the person lacks capacity to make
decision in the question of time
not meet second stage of test if cannot do one or more of
- understand information given
- retain information long enough to make decision
- evaluate available information to make decision
- communicate decision

Section 19 - Pregnancy complications

Chapter 81 - The pregnant patient

- best treatment for foetus is good resuscitation of the mother
- best treatment for mother is same as non-pregnant patient
differences
airway:
- greater risk of gastric reflux and aspiration
- adequate airway more difficult
- extend the neck
breathing
- increased oxygen requirements
- elevation of diaphragm, flaring of ribs
circulation
- circulating volume increases up to 50% in late pregnancy due to blood
dilution
- depleted haemoglobin and oxygen carrying capability
- 25% of cardiac output goes to placenta
- pregnant woman can lose up to 35% of circulating volume before showing
signs of hypovolaemia
- third trimester - enlarged uterus capable of compressing vena cava in
supine position
- tilt patient onto left side by 30°

Chapter 82 - Emergencies in pregnancy

ectopic pregnancy
- outside of uterus
- pain in iliac fossa causing referred shoulder tip pain
- sudden collapse due to massive intra-abdominal bleeding
- vaginal bleeding
- treat with oxygen and ambulance
abruption
- placenta sheared off from uterus wall
- abdomina pain
- uterine tenderness, rigidity
- hypovolemic shock
- possible vaginal bleeding, premature labour
pre-eclampsia
- tonic-clonic seizure in pregnancy
- usually due to significantly high blood pressure
- ABC, oxygen, ambulance

Section 20 - Paediatrics

Chapter 83 - Dealing with emergencies in infants/children

airway
- the younger the child, the less neck extension required
- amount of stridor or snoring does not reflect severity and may diminish with
increasing distress as less air is moved
breathing
- respiratory rates 30+ for infant
- 15-30 for other children depending on age
recession
- in-drawing seen between ribs when respiratory effort is high (intercostal)
- along costal margins where diaphragm attached (subcostal)
- sternum drawn in (sternal)
accessory muscle use
- when breathing work increased head may bob up and down
flaring of nostrils
- indicates severe respiratory distress
grunting
- produced by exhalation against partially closed glottis
- severe respiratory distress

effects of respiratory inadequacy on other systems

heat rate
- tachycardia (high heart rate), and eventually bradychardia (low heart rate)
may result from hypoxia (lack of oxygen in blood) and acidosis (acid build
up)
- bradycardia is a pre-terminal sign
skin colour
- flushing of skin is early sign (elevated CO2 levels)
- hypoxia causes vasoconstriction and skin pallor (pale skin)
- cyanosis is a pre-terminal sign
mental status
- hypoxia makes children agitated and drowsy
- drowsiness progresses to unconsciousness

circulation
- infant 110-160 bpm
- >12 years 60-100bpm
heart rate
- tachycardia results from loss of circulatory volume
- bradycardia becomes apparent before cardiac arrest
pulse volume
- peripheral pulses become weak and then absent
- vasoconstriction and cooling starts distally and progresses proximally
capillary refill
- should be measured on forehead or sternum
- should be less than 2 seconds

disability
- AVPU used to assess levels of consciousness
- pinch a digit
- look for signs of child being floppy (hypotonia) - indicates serious illness
- stiffness (hypertonia) or back arching (opisthotonus) suggests severe
cerebral disturbance

Chapter 84 - Foreign body airway obstruction (infant/child)

general signs
- witnessed, coughing or choking, recent history of playing with or eating
small objects
effective coughing
- crying or vocalise
- loud cough
- able to breathe before coughing
ineffective coughing
- quiet cough
- unable to vocalise
- unable to breathe
- cyanosis
- decreasing consciousness

infant
back blows
- head down position
- up to 5 sharp blows with heel of hand between shoulder blades
chest thrusts
- head down position
- up to 5 chest thrusts

unconscious
- open airway
- 5 breaths
- start CPR

Chapter 85 - Paediatric BLS

- do not over extend infant’s airway
- does not have rings of cartilage in airway to prevent over extension
check pulse and breathing
- no more than 10 seconds before deciding no pulse no breathing
- infants - check brachial pulse
infant not breathing with pulse <60 should be given CPR

Chapter 86 - Febrile convulsions

- fever of 37.8°C or higher
- between 6 months and 5 years old
- no precipitating cause
- airway, oxygen, ambulance

Chapter 87 - Meningococcal infection

- inflammation or infection of the meninges (brain covering)
- viral meningitis rare life threatening
- bacterial meningitis rapidly deadly
- fever, aches, photophobia,
- may causes sepsis - meningococcal septicaemia signs - petechial or
purpuric rash