Wound, Bleeding and Shock

2. Type of Wound

2.1. Close Wound
Injury to tissue under the skin cause by bumping, contusion or falling down OR the breaking of a blood vessel under the skin due to a blow to the skin like bruise.

2.2. Open Wound
Any break or opening in the skin or an organ caused by violence or surgical incision.

2.1. Close Wound & Treatment

Bruise/Contusion
Definition
Bruise due to blunt blow on the body that cause injury to tissue under the skin like bumping, contusion or falling down.

Sign and symptoms
- Pain on the injured area
- Injury to tissue and capillary that leaking the blood flow. The blood and the human excretion( sweat & fluid) will pool around the injured tissue causing bluish skin discoloration.
- Serious injury called ‘Hematoma” happen when there’re higher amount of blood and fluid. Hematoma can cause severe blood lost and shock.

Type of Bruise
- hematoma : Bruise becomes firm and seems to become larger due to large amount of blood wall is off the wound, rather than clean it up. It may need to be drained by doctor.
- heterotopic ossification: When the body deposits calcium in the area of the injury that cause it becomes tender and firm and requires x-rays and a trip to the doctor.
- Petechiae: Little (3-3 millimeters) red dots; are tiny little accumulations of blood. Often there are few of them and they usually indicate some sort of serious health problem.

- Bruising around the belly button could be a result of bleeding in the abdomen
- Bruising behind the ear can indicate a skull fracture
- Bruises that are raised, firm, and occur without any injury may be signs of a “autoimmune” disease, in which the body attacks it’s own blood vessels.


First Aid Treatment
Apply the RICE method
- Rest : Rest the injured body part
- Ice : Put wrap-up ice on the injured part
- Compress : Bandage the injured area over a thick cotton layer
- Elevate : Raise the injured part
Get help if needed

Caution
- Dont put ice directly on the injured area without cover
- Don’t elevate the injured part if there is any symptom of internal bleeding.

2.2. Open Wound & Treatment



Classification of Open Wounds

i. Incision:
o These cuts result of some sharp object such as broken glass, knives and sharp edges.
o The amount of bleeding varies on the depth and extension of the cut.
o Some of these wounds require stitches.


ii. Laceration:
o These are jagged irregularly shaped cuts or tears in the skin. Most lacerations are serious and require stitches, because of heavy bleeding.
o Chances of infection depend on the size, cause, and depth of the laceration. Severe laceration should be treated by a doctor.

iii. Punctures:
o Puncture wounds are caused by an object piercing the skin.
o These wounds range from minor to severe and should often be looked at by a doctor.
o Because the wound penetrates the skin (and in some cases, several layers of skin) they are often difficult to clean and infections are common.
o If bone puncture is suspected, visit doctor as soon as possible.

iv. Abrasion
o Abrasion happen when layer of skin loose due to continuous friction on the skin.
o The skin outer layer loose and exist several drop of bloods or body fluid on the injured area.

Treatment
Abrasion Treatment:
- Clean the skin with water and soap to rid of any foreign object embedded on the wound (Don’t scrub)
- Put antiseptic cream /solution.
- Cover the whole area using padding or plaster .
If the abrasion is only on the skin first layer, leave the wound open without padding after applying antiseptic cream/solution for faster healing.

Cuts and Scrapes Treatment
- Clean out the wound. Make sure you wash your hands before cleaning a wound to avoid transferring more dirt to the cut.
- Wipe away from the wound when removing dirt and other particles that may be in the wound.
- Washing the wound use soap and water, but do not scrub because that may do more damage.
- Apply direct pressure with a clean dry cloth or sterile gauze bandage, while elevating limb (if possible) above the heart. This will slow bleeding and help a clot to form.
- If bleeding is spurting out of wound or bleeding continues heavily after pressure has been applied for 5-10 minutes stitches may be needed, so go to the hospital and have the wound checked out by doctor as soon as possible.
- If the bleeding slows, cover the wound with a clean bandage.
- Apply a thin layer of antibacterial ointment to the wound first, to protect against infection.
- If the wounds are on the hands or feet avoid using these ointments after the first day. Make sure the wound is kept clean and dry while it heals.
- Caution:
o Apply only a thin layer of ointment to ensure the best protection.
o Always apply the ointment with a clean swab or gauze. Applying ointment from the tube may contaminate the tube and put future wounds at risk.
o Make sure to wash the wound before applying fresh ointment.
o When applying fresh bandages make sure your hands are clean and the bandage remains sterile. It is advised that the bandage is opened over the wound and that the pad remains untouched except by the wound.

Severe bleeding injuries
- Lay the person down. If possible, position the person's head slightly lower than the trunk, or elevate the legs. This position reduces the chances of fainting by increasing blood flow to the brain. If possible, elevate the site of bleeding.
- Remove any obvious debris or dirt from the wound using sterile tools.
- Do not remove any objects pierced into the victim.
- Do not probe the wound or attempt to clean it at this point. Your principal concern is to stop the loss of blood.
o Apply pressure directly on the wound with a sterile bandage, clean cloth or even a piece of clothing. (Avoid direct contact with wound)
o Maintain pressure until the bleeding stops for 10 minutes or more.
o When bleeding stop:
- bind the wound tightly with adhesive tape or a bandage. If none is available, use a piece of clean clothing.
- If the bleeding continues and seeps through the gauze or other material you are holding on the wound, do not remove it. Instead, add more absorbent material on top of it.
o If the bleeding does not stop with direct pressure:
- apply pressure to the major artery that delivers blood to the area of the wound.
- In the case of a wound on the hand or lower arm, for example, squeeze the main artery in the upper arm against the bone. Keep your fingers flat; with the other hand, continue to exert pressure on the wound itself.
- Immobilize the injured body part once the bleeding has been stopped. Leave the bandages in place and get the injured person to the emergency room as soon as possible or, if they cannot be moved for help.




SHOCK
Shock happens when the heart and blood vessels are unable to pump enough oxygen-rich blood to the vital organs of the body.
Although every illness involves shock to some degree, it can be a life-threatening problem.
The best way to protect people from the serious damages that shock can have on the system is to recognize the symptoms before the person gets into serious trouble.
In most cases, only a few of the symptoms will be present, and many do not appear for some time.

1. Common Symptoms
- Pale, cold, clammy and moist skin
- Vacant or dull eyes, dilated pupils
- Anxiety, restlessness, and fainting
- Weak, rapid, or absent pulse
- Nausea and vomiting
- Shallow, rapid, and irregular
breathing
- Excessive thirst
- Person may seem confused
- Look tired and fatigue

2. Classification of shock:
i. Hypovolemic Shock:
• Brought on by a decrease in the amount of blood vessels or other fluids in the body.
• Cause by excessive bleeding from internal and external injuries, fluid loss due to diarrhea, burns, dehydration, and severe vomiting.

ii. Neurogenic Shock:
• The blood vessels become abnormally enlarged and the pooling of the blood disallows an adequate blood flow to be maintained.
• Fainting is an example of this sort of shock, as the blood temporarily pools as the person stands. When the person falls the blood rushes back to the head and the problem is solved.


iii. Psychogenic Shock:
• This shock is more common, and is known as a “shock like condition”. It is produced by excessive fear, joy, anger, or grief. “Shell shock” is a psychological adjustment reaction to stressful wartime experiences.
• Treatment for shell shock is limited to emotional support and help from a medical facility.

iv. Anaphylactic Shock:
This form of shock is brought on by an allergic reaction from a food, bee sting or other insect bite, and inhalants.

3. General Treatment
- Call local emergency help provider for help
- Lay the victim face up, on a blanket or coat if possible, and raise the feet above the head unless they are fractured.
- Check the injured person's airway, breathing and circulation. Open and maintain the airway, and perform rescue breathing or CPR if necessary
If the person is bleeding from the mouth or vomiting, tilt their head to the side to avoid fluids going into the lungs and airways. If you are unsure of injuries keep the person laying flat.
- Loosen tight clothing, braces, belts, jewelry etc to avoid constriction of the waist, neck and chest.
- Keep the victims comfortable and warm enough to be able to maintain their own body heat. If possible, remove wet clothing and place blankets beneath the victim. NEVER use artificial sources of heat eg electric blanket.
If they are bleeding severely do not apply heat to the wounded area, as it will prevent the blood from clotting as easily.
- Check for other injuries, such as bleeding and burns and treat the other injuries according to first aid procedures.

If possible try to splint sprains or broken bones. If you are unsure of how to do this, leave them as they are to avoid further damage.
- If they claim they are thirsty moisten their lips with water but DO NOT give them anything to drink, as it may induce vomiting.
- Try to keep the victim calm, excitement and excessive handling will worsen their condition try to assure them help is on the way.
These treatment if apply before shock has completely developed you may prevent its occurrence and if it had developed you may stop it from becoming fatal.
If shock is left unattended to the victim will die, it is extremely important that first aid be performed as soon as possible.

Give fluids only if the following conditions are met:
The injured person can hold the cup and drink by himself;
surgery is not likely within six hours;
there is no abdominal injury;
evacuation is more than six hours away; and
there are no downward changes in the person's level of consciousness.


FIRST AID KIT


Remember the Three Mechanisms of Injury:
• Trauma – due to high impact e.g. car accident
• Medical – illness e.g high blood pressure, diabetic
• Environmental- e.g tsunami
The Complete KIT
The First aid kit must be well organized, weather proof, accessible in an emergency, and user friendly. The simplest way to organize is:
- to separate bandages, dressings, meds, etc. with ziplocks, or some sort of waterproof dividers.
- Writing what's in the bag can help when the adrenaline is pumping, or some people even color code what is what.
- Having gloves, pocket mask, and other protection readily available is very important.

Not only is the first aid kit itself important, it is how easily you can assemble all your resources.
Suggested Personal First Aid Kit List
1 - roll 1" cloth tape
4 - 4" x 4", or 3" x 3" general gauze pads
2 - non-adherent gauze pads
1 - 8" x 7" combine (bulk) dressing
8 - band-aid bandages
2 - 3" or 4" stretch roller gauze
3 - 3" or 4" occlusive dressings
2 - triangular bandages
1 - 4" ace wrap
1 - Sam Splint or wire splint
4pr - vinyl exam gloves
1 - CPR pocket mask w/ 1 way valve or shield
1 - Airways, nasal and/or airway
1 - blister kit (personal preference)
5 - povodine iodine packets
1 - trauma scissors
1 - splinter tweezers
1 - thermometer
1 - med kit (personal preference)
1 - blanket pin
2 - safety pins
1 - 12 to 60cc syringe
1 - 20-30' duct tape
-Medication

Carrying Device

One that works best in environment in which you travel.
o Dry Bag/Box, fanny pack, compartmentalized pouch, ziplock bags, etc.
Personal Protection
Must be easily accessible. Gloves can be placed in various places e.g in your pack, a lifejacket in a film canister, etc.
- Vinyl or Latex Gloves - 2 to 4 pairs per person*
- CPR Mask - or at the very least, a CPR Shield
- Airways - dependent on level of training
Wound Care
Bandages - narrow piece of cloth tie around wound or dressing :3" and/or 4" roller gauze that stretches and possibly self-adhering

Dressings – material used 2 cover and protect wound: carry multiple sizes of sterile gauze bandages or a 4" x 4". Different dressings may help make wound care much more manageable.

General Purpose Gauze Pads - uses for wound care, from padding to absorbency.

Combine and Trauma Dressing - used where high absorbency and/or padding are necessary. Larger sizes in these are usually recommended e.g Surgipad.

Occlusive Dressings - dressing to keep a wound dry in a wet environment. Care must be taken to remove these dressings during rest periods to help promote healing in a prolonged context. Examples include Bioclusive and Tegaderm.

Bandage Strips - a bandage with an attached dressing, better known as Band-Aids. It is important to change these regularly, so bring enough.

Tape – To secure bandages or closing wounds. 1" cloth tape is usually all that is needed in a basic first aid kit.

Duct, packaging and other tapes make great securing tools for bandages, splints, clothing, etc. Be careful to watch for constriction and other circulation problems. 20-30 ft.

Wound Cleansing
The risk of infection is greater when the wound is close, so prior wound cleansing is vital.

Clean water for washing off residue

Povidine Iodine (PI) used in a solution with water, to adequately irrigate the wound and surrounding area. Some people are allergic to iodine, so check their medical history first.

Soaps, as well as medical "scrubs" that can be used for cleansing around wounds.

Splinting
The most improvised skill there is. Lifejackets, packs, paddles, ski poles, etc. all make great splints.
- Use the injured’s person equipment first!
- Remember to watch for constriction, comfort, and compatibility.

Hardware
Tool that can expedite and assist during treatment:

Tweezers – to pull out splinter or hold cotton for wound cleaning

Pins - to secure materials such as using a sleeve as a improvised sling, or securing a tarp as a shelter.

Plastic bags - make great irrigators, improvised glove, or occlusive layer. Big trash bags are perfect for vapor barriers when wrapping up a patient, emergency shelter, and to put trash in.

Thermometer - A digital indoor/outdoor thermometer with a probe is a good resource to tell temp. variations of a patient who is either immobilized during or waiting for evac, although not as accurate as a medical version.

Trauma shears - for removing clothing, cutting improvised splints to size etc

Heat/Cold Packs - again usually carried in major med kits, these will help in short term context. Water bottles with warm water, cooled wet towels, filled ziplocks, can be improvised heat/cold packs.

Mirror/signal device - a compass with a mirror show a spruce speck in the eye, or help locate tick or leech. It can also be used to signal aircraft or other groups.

Whistle - can be use as signals.

Flashlight/headlamp - Select a light appropriate to your activity

Lighter/ waterproof matches- if traveling in wet, cold environments it is also good to carry a fire catalyst, such as fire ribbon, or fire gel.

Medications
Adequate training, written policies and procedures and medical control should all be considered.

- Topical antibiotic cream - such as Neosporin, has been proven to promote healing in shallow wounds and help maintain a good barrier.

- Analgesic, Antipyretic and Anti-inflammatory – pain killer such as Tylenol, Ibuprofen, and aspirin. It is personal preference to what has worked best for you.

- Antihistamine – for allergies: such as Benadryl and Sudafed for

- Antacid – for stomach discomfort/ burning feeling due to e.g overeating : Mylanta, Gelusil, Pepto Bismol, Maalox

- Antidiarrheal - Pepto, Keopectate, Immodium, Lomotil

- Anticonsptipation - Metmucil, glycerine suppositories

- Antifungal/yeast - Tinactin, Mystatin

- Dental Problems - pain relief from clove oil, Orabase

- Special Needs and Medications - such as prescription antibiotics, asthma inhalers, altitude meds, epineherine, etc

- Glucose - liquid glucose in a single use tube

- Oral Electrolyte Replacement Solution - such as Gookinaid, Gatorade, etc.

- Tincture of Benzoin - helps keep bandages attached

- Activated Charcoal – poisoning emergencies



BANDAGE, TRIANGULAR BANDAGE & CRAVAT
1. DEFINITION
Standard bandages are made of gauze or muslin and are used over a sterile dressing to secure the dressing in place, to close off its edge from dirt and germs, and to create pressure on the wound and control bleeding.

A bandage can also support an injured part or secure a splint. The most common types of bandages are the roller and triangular bandages.

2. General Application
- Applied evenly, firmly, but not too tightly. Excessive pressure may cause interference with the circulation and may lead to disastrous consequences e.g gangrene.
- It is safer to apply a large number of turns of a bandage, rather than to depend upon a few turns applied too firmly to secure a compress.
- In applying a wet bandage, or one that may become wet, you must allow for shrinkage.
- The turns of a bandage should completely cover the skin, as any uncovered areas of skin may become pinched between the turns, with resulting discomfort.
- The terminal end of the completed bandage is turned under and secured to the final turns by either a safety pin or adhesive tape. When these are not available, the end of the bandage may be split lengthwise for several inches, and the two resulting tails may be secured around the part by tying

Bandaging any extremity (arms or legs)
- leave the fingers or toes exposed so the circulation of these parts may be readily observed. (capillary refill)
- Include the whole member (arm or leg, excepting the fingers or toes) so that uniform pressure may be maintained throughout.
- It is also desirable in bandaging a limb that the part is placed in the position it will occupy when the dressing is finally completed, as variations in the flexion and extension of the part will cause changes in the pressure of certain parts of the bandage.
- The initial turns of a bandage on an extremity (including spica bandages of the hip and shoulder) should be applied securely, and, when possible, around the part of the limb that has the smallest circumference
- In bandaging the arm or hand the initial turns are usually applied around the wrist.
- in bandaging the leg or foot, the initial turns are applied immediately above the ankle.
- The final turns of a completed bandage are usually secured in the same manner as the initial turns, by employing two or more overlying circular turns.
- As both edges of the final circular turns are exposed, they should be folded under to present a neat, cuff like appearance.

3. Bandage Technique

ROLLER BANDAGE FOR HAND AND WRIST - Figure-eight bandage is ideal. - Anchor the dressing, whether it is on the hand or wrist, with several turns of a 2- or 3-inch bandage. - If on the hand, anchor the dressing with several turns and continue the bandage diagonally upward and around the wrist and back over the palm. - Make as many turns as necessary to secure the compress properly

ROLLER BANDAGE FOR ARM AND LEG - Use the spiral reverse bandage to cover wounds of the forearms and lower extremities - Make two or three circular turns around the lower and smaller part of the limb to anchor the bandage and start upward, going around making the reverse laps on each turning, overlapping about one-third to one-half the width of the previous turn. - Continue as long as each turn lies flat. - Continue the spiral and secure the end when completed

ROLLER BANDAGE FOR ANKLE AND FOOT - Use figure-eight bandage for dressings of the ankle, as well as for supporting a sprain. - While keeping the foot at a right angle, start a 3-inch bandage around the instep for several turns to anchor it. - Carry the bandage upward over the instep and around behind the ankle, forward, and again across the instep and down under the arch, thus completing one figures eight. - Continue the figure-eight turns, overlapping one-third to one-half the width of the bandage and with an occasional turn around the ankle, until the compress is secured or until adequate support is obtained

ROLLER BANDAGE FOR HEEL. - Place the free end of the bandage on the outer part of the ankle and bring the bandage under the foot and up. - Then carry the bandage over the instep, around the heel, and back over the instep to the starting point. - Overlap the lower border of the first loop around the heel and repeat the turn, overlapping the upper border of the loop around the heel. - Continue this procedure until the desired number of turns is obtained, and secure with several turns around the lower leg

TRIANGULAR BANDAGE



The longest side of the triangular bandage is called the base; the corner directly opposite the middle of the base is called the point; and the other two corners are called ends

The triangular bandage is useful because it can be folded in a variety of ways to fit almost any part of the body. Padding may be added to areas that may become uncomfortable.

TRIANGULAR BANDAGE FOR HEAD - This bandage is used to retain compresses on the forehead or scalp. - Folds back the base about 2 inches to make a hem. - Place the middle of the base on the forehead, just above the eyebrows, with the hem on the outside. - Let the point fall over the head and down over the back of the head. - Bring the ends of the triangle around the back of the head above the ears, cross them over the point, carry them around the forehead, and tie in a SQUARE KNOT. - Hold the compress firmly with one hand, and, with the other, gently pull down the point until the compress is snug; then bring the point up and tuck it over and in the bandage where it crosses the back part of the head.

TRIANGULAR BANDAGE FOR SHOULDER - Cut or tear the point, perpendicular to the base, about 10 inches. - Tie the two points loosely around the patient’s neck, allowing the base to drape down over the compress on the injured side. - Fold the base to the desired width, grasp the end, and fold or roll the sides toward the shoulder to store the excess bandage. - Wrap the ends snugly around the upper arm, and tie on the outside surface of the arm.

TRIANGULAR BANDAGE FOR CHEST - Cut or tear the point, perpendicular to the base, about 10 inches. - Tie the two points loosely around the patient’s neck, allowing the bandage to drape down over the chest. - Fold the bandage to the desired width, carry the ends around to the back, and secure by tying.

TRIANGULAR BANDAGE FOR HIP OR BUTTOCK - Cut or tear the point, perpendicular to the base, about 10 inches. - Tie the two points around the thigh on the injured side. - Lift the base up to the waistline, fold to the desired width, grasp the ends, fold or roll the sides to store the excess bandage, carry the ends around the waist, and tie on the opposite side of the body.

TRIANGULAR BANDAGE FOR FOOT OR HAND This bandage is used to retain large compresses and dressings on the foot or the hand. - For the foot: After the compresses are applied, place the foot in the center of a triangular bandage and carry the point over the ends of the toes and over the upper side of the foot to the ankle. Fold in excess bandage at the side of the foot, cross the ends, and tie in a square knot in front. - For the hand: After the dressings are applied, place the base of the triangle well up in the pal mar surface of the wrist. Carry the point over the ends of the fingers and back of the hand well up on the wrist. Fold the excess bandage at the side of the hand, cross the ends around the wrist, and tie a square knot in front

CRAVAT BANDAGE A triangular bandage can be folded into a strip for easy application during an emergency. - When folded as shown, the bandage is called a cravat. To make a cravat bandage, bring the point of the triangular bandage to the middle of the base and continue to fold until a 2-inch width is obtained. - The cravat may be tied, or it may be secured with safety pins (if the pins are available). - When necessary, a cravat can be improvised from common items such as T-shirts, bed linens, trouser legs, scarves, or any other item of pliable and durable material that can be folded, torn, or cut to the desired size.

Cravat Bandage for Temple, Cheek, or Ear After a compress is applied to the wound, place the center of the cravat over it and hold one end over the top of the head. - Carry the other end under the jaw and up the opposite side, over the top of the head, and cross the two ends at right angles over the temple on the injured side. - Continue one end around over the forehead and the other around the back of the head to meet over the temple on the uninjured side. - Tie the ends in a square knot. (This bandage is also called a Modified Barton.)

Cravat Bandage for Eye - After applying a compress to the affected eye, place the center of the cravat over the compress and on a slant so that the lower end is inclined downward. - Bring the lower end around under the ear on the opposite side. - Cross the ends in back of the head, bring them forward, and tie them over the compress.

Cravat Bandage for Elbow or Knee - After applying the compress, and if the injury or pain is not too severe, bend the - elbow or knee to a right-angle position before applying the bandage. - Put on middle of a rather wide cravat over the point of the elbow or knee, and carry the upper end around the upper part of the elbow or knee, bringing it back to the hollow, and the lower end entirely around the lower part, bringing it back to the hollow. - See that the bandage is smooth and fits snugly; then tie in a square knot outside of the hollow.

Cravat Bandage for Arm or Leg - The width of the cravat you use will depend upon the extent and area of the injury. - For a small area, place a compress over the wound, and center the cravat bandage over the compress. - Bring the ends around in back, cross them, and tie over the compress. - For a small extremity, it may be necessary to make several turns around to use all the bandage for tying. - If the wound covers a larger area, hold one end of the bandage above the compress and wind the other end spirally downward across the compress until it is secure, then upward and around again, and tie a knot where both ends meet.

Cravat Bandage for Axilla (Armpit) - This cravat is used to hold a compress in the axilla. - It is similar to the bandage used to control bleeding from the axilla. - Place the center of the bandage in the axilla over the compress and carry the ends up over the top of the shoulder and cross them. - Continue across the back and chest to the opposite axilla, and tie them.

Spiral Bandage Technique