Anatomy of First Aid

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Anatomy of First Aid - A Case Study ApproachEditor:

Ronald A. Bergman, PhDEmeritus Professor

Department of Anatomy and Cell Biology

The University of Iowa

Contributing Computer and Graphics Specialists:

Michelle LeveilleNola J. Riley, B.A.

Peer Review Status: Internally Peer Reviewed

First Published: November 2004

Last Revised: November 2004

Table of Contents

Preface

Drawing Blood and Transfusion Closing Cuts of the Skin and Underlying Tissue Stitching a Cut The Eye Fracture of the Jaw The External Ear Bladder Catheterization Choking Sucking Chest Wound Injury to Thigh, Compound Fracture of Femur, Use of Tourniquet Abdominal Wound with Protruding Viscera Amputation Burns Smoke, Gas and Chemical fumes


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Anatomy of First Aid: A Case Study Approach

Drawing Blood and TransfusionRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A hospital corpsman consulted her list of blood donor volunteers and asked one to donate a pint

of O+

blood. It was possible that it might be needed for an emergency appendectomy being

undertaken by the ship's surgeon while at sea. The volunteer Sailor was brought to sickbay andasked to lie down on the bed. The corpsman determined that the Sailor was healthy; his pulse,

temperature and blood pressure were of normal values. She then tied a rubber band around the

Sailor's arm, above the elbow, tight enough to stop superficial venous blood flow but not enough

to prevent arterial blood flow.

The cubital fossa (anterior surface of the elbow) was palpated and the median cubital vein wasreadily located (see illustrations), facilitated by the Sailor repeatedly making a fist. The

corpsman knew that there were several large veins available in the region of the cubital fossa that

she could use for venipuncture. She was aware that there is considerable normal variation in thepattern of veins in the arm and this is usually of no consequence. The corpsman then sponged

clean the cubital fossa with alcohol and dried it with a sterile gauze pad.

She inserted the IV catheter through the skin at an angle of about 45 degrees until she felt the

needle enter the vein (by a slight decrease of resistance), then she decreased the angle of the

syringe to about 10 to 20 degrees and advanced it slightly. Blood filled the lower part of thecatheter reassuring the corpsman that she was indeed inside the vein. The plastic sleeve of the IV

catheter was advanced over the catheter needle into the vein.

The pressure band was then released. A blood collection bag was connected to the hypodermic

needle and the hypodermic needle was carefully taped to the skin to prevent it from becoming

dislodged. The corpsman had several types of catheter needles to select from but used thesimplest one in this case.


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The back of the hand (the dorsum of the hand) is also available for venipuncture or IV insertion

and here the veins are usually clearly seen. They are not tightly bound to surrounding tissues,

hence they move and are deceptively easy to penetrate. If they are held in place by a finger,penetration is facilitated. Instead of the rubber band being applied around the arm when the back

of the hand is selected for venipuncture, it is placed around the lower forearm above the wrist.


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Closing Cuts of the Skin and Underlying TissuesRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

Minor or even deep wounds to the skin and underlying tissues can be closed by using Butterfly

tape or by suturing. Taping or suturing should be done when the wound is large, clean and non-

jagged. Wounds of the chest and abdomen will be considered later in this booklet.

Do not close a wound if the area of the wound is dirty (contaminated), is very deep (into fatty

fascia or even deeper, into muscle), or is over 12 hours old. Bleeding is to be controlled, by

pressure or by tourniquet if necessary. If the wound cannot be closed, tape a sterile or clean,moistened bandage over the entire wound and seek medical assistance immediately.

Things to remember: Skin thickness varies. It is thinnest over the eyelids and face and thickest

on the palms of the hand and soles of the feet, the back and scalp. It is usually thinner over

ventral (anterior) surfaces and in older people.

Bringing the edges of the skin together by suturing will be shown.

First review the anatomy of the skin and underlying tissues of the limbs in the following

illustration:


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Stitching a CutRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A cook on his first deployment, was preparing some meat for a stew when he lost control of the

knife and cut his hand. He stemmed the blood flow by placing a clean cloth over the cut and

applying pressure above the cut. He hurried over to the sickbay to find a hospital corpsman.

The corpsman cleaned the hand with antiseptic and decided to use sutures to close the wound.

The size of the cut was too large to use a butterfly tape as a skin closer. The corpsman had

several types of stitching to choose from (see illustrations):

Sutures A: a lock-stitch

Sutures B: an interrupted stitch

Sutures C: a continuous stitch.


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An interrupted stitch (B) was thought to be the best to close this cut.

The corpsman used a sterilized needle and suture. A stitch was made through the skin (avoiding

the superficial fatty fascia as much as possible) at the midpoint of the wound and the edges of the

wound drawn closely together. The thread was knotted (square knot) and cut. The corpsmancontinued until he completed the closure and covered the wound with sterile gauze. The gauze

was taped to keep the injured area clean. The corpsman advised the cook to inspect his hand

daily for signs of infection (inflammation, heat, pus and no sign of healing). A serious infection

may require stitches to be removed to drain the infected site.

Sutures D: remove stitches

After 7 days, the corpsman had the cook return to sickbay to remove the stitches using the

technique shown in the last illustration (Sutures D). It is important to cut the sutures as shown to

reduce the possibility of infection. Before removing the stitches however, the injured hand wasagain cleaned with antiseptic. Pull up on the knot. Slide scissors under one end with the blades

parallel to the skin. Cut suture and pull knot and suture out of skin completely.

A corpsman may use the following guideline for the number of days for healing to occur before

removing stitches: 5 days for face wounds, 7 days for body wounds and arm and hand wounds,and 8-10 days for leg and foot wounds.


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The EyeRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A Machinist Mate is finishing work on a metal object when he suddenly feels scratchy, sharp

pain in his eye and hurries to the medical corpsman for help.

The corpsman first, tries to wash out the offending object with lukewarm water by splashing or

flooding the eye with water, until blinking is not painful.

If this does not succeed in removing the object, blinking alone may flush the object from the eye.This may be very painful because the conjunctiva is richly supplied with pain nerve receptors.

If this simple procedure also fails, the corpsman will examine the eye by lifting the eyelid from

the eyeball. Several methods are shown in the illustrations.


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If the corpsman cannot find any object on the conjunctiva or cornea that would cause irritation,

the object may be embedded in the eye. If this is the diagnosis, both eyes are covered with sterile

or clean pads and taped in place. Medical advice or assistance will be sought.

The eyelids and eye will be examined and if a foreign object is seen, it will be flushed directly to

dislodge it or, with a clean moistened soft swab, the object is loosened and flushed, to removethe offending object. See illustrations.


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If pain, tearing, or vision defects occur after removal of the foreign object or if the corpsman

fails to find the cause of the problem he will seek medical advice and / or assistance.

Note: If any damage occurs to the eyeball, both eyes must be covered by sterile moist pads, and

taped in place. Remember that the eyes are extensions of the brain and infections may ultimatelyinvolve the brain; this is to be avoided at all cost. A physician must treat a damaged eye, as soon

as possible.


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The anterior eye and eyelids.

EYE A. The eyeball is covered and protected anteriorly by two thin , movable eyelids (or

palpebrae). The eyeball is also covered by a transparent mucous membrane (the conjunctiva),

which is continuous along the inner surface of both eyelids (the palpebral conjunctiva).

At the medial angle of the eye a small piece of skin (the caruncula lacrimalis) is located thatcontains sebaceous and sweat glands.

The pupil is the circular opening in the iris. The size of the opening is controlled by the nervoussystem: at rest, the parasympathetic nervous system constricts the pupil and in danger, the

sympathetic nervous system supplies the pupillary dilator muscle to enlarge the pupil.


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The lower eyelid and medial angle

EYE B. The lower eye lid has been pulled downward in order to expose its inner surface (i.e., thepalpebral conjunctiva), as well as the medial angle (or medial canthus). The gaze is upward

(superiorly) and outward (laterally).

The conjunctiva is very vascular and very sensitive. The inferior palpebral part and the bulbar

part are continuous along a line of reflection (inferior conjunctival fornix). The line of reflectionis also found between the eyeball and the upper eyelid (superior conjunctival fornix).

When the medial angle is enlarged, a pair of small openings (punctae lacrimali) are visible,located above and below the caruncula lacrimalis. These openings enter the lacrimal canals

leading to the nasolacrimal duct and further, to the nose.


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Fracture of the JawRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A petty officer was carrying an iron rod on his shoulder. He heard his name being called and

swung around. The iron rod accidentally hit a Sailor in the face with great force. He fell to the

floor and broken teeth and bloody saliva came from his mouth; he was unconscious. The face ofthe Sailor began to swell and extensive bruising became evident. A corpsman was called

immediately. (It is important for the person providing first-aid to know the anatomical basis of

the injured region before treatment starts. This information is provided in the first illustration).


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The Sailor was coughing and choking and it was not certain if there was any neck damage. The

corpsman, with additional aid from other Sailors, carefully rolled the patient to his side.Particular attention was paid to the position of the head and neck so that it remained facing

forward in its usual position with the body lying on its side. The Sailor's mouth was inspected

and cleared of broken teeth and foreign bodies; the choking ceased. Whole teeth were wrapped ina sterile or clean cloth. The patient gradually became conscious but was in great pain, which the

corpsman medicated. A neck brace was applied until the extent of the injuries could be

accurately determined. The patient was turned on his side so that blood and saliva could drain

from his mouth. Bleeding from a small cut on the Sailor's face was cleaned with a moist sterilecloth and controlled by gentle pressure. A cold bandage or package was applied to help reduce

swelling of the tissues associated with the jaw.

The following clues were sufficient for the corpsman to diagnose a broken jaw: facial tenderness,

swelling, a change in symmetry of the face, pain on moving the jaw, inability to speak and open

or close the jaw. The possibility of other damage, e.g., to the zygomatic arch, the orbit and eyemust also be carefully considered (second illustration).

The corpsman also determined that the airway was clear, controlled bleeding and supervised thetransfer of the Sailor to sickbay for definitive medical attention.


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The External EarRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A petty officer second class took a boat full of supplies to a Marine base located on an island in

the South China Sea. While waiting for his boat to be unloaded he found an isolated place to takea nap. When he awakened he heard a buzzing in his ear and became panicked and tried to

remove the insect with his little finger to no avail - but the buzzing stopped. A corpsman,

assigned to the Marines and who was on the island at the time, told the Sailor the followingimportant things to remember when there are problems with the ears. If there are foreign objects

in the ear do not use any liquid to flush the offending object from the ear. Do not place any

instrument or tool in the ear canal. Do not hit or thump the head to free and dislodge theoffending object. The corpsman suspected that an insect became trapped in the ear. The

corpsman had an otoscope in his medical kit and was able see, and to remove, the crushed insect.The corpsman suggested several things that could be done in the absence of immediate medical

care. If a live insect is in the external auditory canal one can safely kill the insect with a fewdrops of alcohol. However, seek medical assistance as soon as possible to remove the insect. The

rationale for not putting water in the ear is that some objects swell in water, leading to significant

pain and greater difficulty in removal of object.


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Objects that are clearly visible and easily accessible at the entrance of the canal may be removed

with a tweezers. A physician should be consulted to confirm the removal of the object(s). To theinexperienced, trying to remove objects with a tweezers can result in damage to the eardrum.

One additional method, short of medical treatment, is for the individual to turn his head, with the

affected ear down, and to shake his head. Do not try any other procedure -- no oil, water or

hitting the head. The corpsman will safely remove the object.

Drainage from the ear is another serious event. If there is bleeding from the ears consider a skullfracture; immediate medical attention is essential. If bleeding is from the external ear, it may be

controlled by direct pressure with a sterile or clean cloth. Do not try to stop drainage or bleeding

from inside the ear. Do not allow the patient to thump his head to restore lost hearing. Have thepatient lie on the side of the head that is affected to promote drainage.


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Ear drum

Ear emergencies requiring medical care may include the following: swimmer's ear usually

caused by bacteria; varieties of ear pain from middle ear infections, toothache, and mandibularjoint pain; excess wax in the ear and perforation of the ear drum resulting in a loss of hearing;

poking irritating hard objects into the ear and the introduction of foreign objects.

Swimmer's ear may result in disturbing sensations from retention of water in the ear. This can be

avoided by placing a few drops of a solution containing 20% white vinegar or dilute 20%

rubbing alcohol in the external acoustic canal.


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Bladder CatheterizationRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A Sailor aboard a supply ship in the Red Sea reported to sickbay and told the hospital corpsman

on duty that he was having great difficulty urinating and that his bladder was full and he could

not adequately relieve himself. His distress was obvious. The corpsman donned sterile glovesand then tapped the Sailor's lower abdomen verifying the full bladder. He told the Sailor that he

would empty his bladder by catheterization (see accompanying illustrations). Hearing this, the

Sailor became very anxious. His anxiety was greatly lessened when the corpsman explained to

him that the procedure might look painful but actually was not. In addition, the relief he wouldfeel would worth any discomfort he might feel.


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Anaseptic wash of urethral opening of penis.

Insertion of catheter.


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In order to catheterize the Sailor the corpsman swabbed the urethral opening of his penis with a

non-irritating antiseptic. Taking a sterile catheter lubricated for about two inches he inserted it

slowly into the urethral meatus (opening), he encountered a slight resistance at the sphincterlocated in the urogenital diaphragm, then it moved easily through the prostatic urethra into the

bladder. A flood of urine entered the collection bag. The corpsman taped the catheter tube to the

Sailor's abdomen to secure the collection bag. The corpsman told the Sailor that a physician

would take over his case and prescribe a course of treatment for his problem.

Recovery of urine.

Catheterization is essentially the same in both male and female; the catheter, by traversing the

urethra, enters and drains the bladder. The anatomical route is shorter in the female patient but

must be understood in order to effectively perform the catheterization procedure.


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ChokingRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A squad of Marines was celebrating the end of prolonged and strenuous maneuvers with a steakdinner. During the meal, one of the Marines stood up clutching his throat, his face turning red.

The choking sign was clearly understood; he was unable to speak and he had severe difficulty

breathing. The treatment to follow will be considered in 5 scenarios:

Immediately the Marine began coughing. A piece of meat flew out of his mouth and the Marine

began to breathe normally. This ends the 1st scenario.

Immediately the Marine thrust his abdomen on the top of a chair back. A piece of meat flew outof his mouth and the Marine began to breathe normally. This ends the 2nd scenario.


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Standing thumper

Immediately a corpsman assigned to the squad asked, "Are you choking?" The Marine nodded.

The corpsman gave 3 backblows between the shoulder blades to the Marine with the man in abent over position. A piece of meat flew out of his mouth and the Marine began to breathe

normally. This ends the 3rd scenario.

Standing Hemilich If pregnant


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Immediately a corpsman assigned to the squad grabbed the Marine from behind, between the ribs

and the umbilicus (belly button), and gave several strong thrusts or squeezes to the Marine's

abdomen (Heimlich maneuver). A piece of meat flew out of his mouth and the Marine began tobreathe normally, the red skin color decreased, the heart rate decreased and the panic subsided. If

pregnant, the corpsman would give the thrusts mid-sternum. This ends the 4th scenario.

The methods outlined above, coughing, backblows, and abdominal thrusts (Heimlich maneuver)have a very high rate of success. In the event, however, that these methods fail to dislodge the

obstructing material from the air pipe (trachea), a tracheotomy must be considered.


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If the choking victim is without oxygen for 4 to 5 minutes he may die or have severe brain

damage, if he survives. Tracheotomy is the last resort - the very last resort - a matter of life or

death. In order to be successful, several common sense things must be kept in mind.


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Immediately a corpsman that was present for dinner asked one of the Marines to keep time for

him and call out the time by the minute. He tried the Heimlich maneuver several times and afterthis failed to dislodge the obstruction the choking victim became unconscious. The corpsman

then palpated the thyroid cartilage and found the "Adam's apple" or laryngeal prominence. The

corpsman then traced the cartilage distally in the midline straight down until it ended (about 2.5cm. or 1 inch). The hard cartilage gave way to a membrane (soft spot), the cricothyroid

membrane. It is this membrane that must be opened (see diagrams). (Elapsed time - one minute)

The skin was opened with a sharp knife in the sagittal plane (up/down). Pulling the cut surfaces

apart (right/left) he quickly examined the exposed area for blood vessels and parts of the thyroidgland. (Elapsed time - two minutes) Avoiding blood vessels and glandular tissue he puncturedthe cricothyroid membrane with a knife (very carefully and never transversely) (or he could have

used a sharp pencil or ball point pen), to enter the trachea. The depth of the puncture should be

just sufficient to gain access to the airway. No more than a half-inch or about 1.25 cm. To

maintain the opening to facilitate breathing, a soda straw or tube was placed in the opening.(Elapsed time - three minutes) The duty corpsman said he was told by a physician about "the rule

of three" - something easy to remember and to be on the safe side - three weeks without food and


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you die; three days without water and you die; but only three minutes without air and you die.

The Marine was then taken to sickbay for further treatment. The entire procedure took less than 4

minutes. The opening of the airway allowed the Marine to get the oxygen needed to survive. Thisends the 5th scenario. Remember that tracheotomy is the last resort to restore respiration but; the

alternative is death.

Dangers of anatomic variations covering the cricothyroid ligament

Knowledge, and confidence in that knowledge, makes this procedure as safe as is possible in anemergency situation.


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Sucking Chest WoundRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A Marine on patrol in the desert felt a sharp pain in his chest and had difficulty breathing; he

called for a corpsman and then collapsed. He had sustained a penetrating bullet wound to his

chest on the right side. Air had rushed into his chest and his right lung collapsed. The corpsmanrecognized the seriousness of this life-threatening wound and knew that the Marine was

breathing with one lung. He cut away the Marine's shirt and looked for entrance and exit

wounds; he found only an entrance wound. Bleeding was minimal but uncontrollable. The

corpsman recognized that on inspiration air entered the opening in the chest caused by the bulletand, on expiration, air was forced out of the thoracic cavity (see illustrations). He prepared a

sterile occlusive dressing that was taped securely to the chest over the wound on 3 sides. One

edge was not taped leaving an opening to the dressing. He knew that this would act as a "valve"and on inspiration the occlusive dressing would be drawn tightly to the chest by the negative

pressure (hence the name "sucking wound"). External air is excluded. On expiration, the airforced out of the thorax escapes at the unsealed edge of the occlusive dressing. Had thecorpsman found an exit wound he would have dressed the wound in the same way. As soon as

the corpsman finished with the dressing he covered the Marine with a jacket to reduce shock. He

called for a stretcher and because of the life-threatening nature of the wound, he had the Marine

airlifted by helicopter to a hospital ship lying off shore. He was immediately taken to a navy

surgeon for the definitive treatment that is only available in the hospital.


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Injury to ThighCompound (Open) Fracture of Femur

Use of Tourniquet

Ronald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

On an aircraft carrier in the Persian Gulf, flight deck personnel were readying fighter aircraft fora strike at enemy ground forces. One of the Sailors had a problem with ordinance and one rocket

accidentally discharged. The rocket flew into and past another Sailor causing severe injury to his

thigh and fracturing his femur. Ruptured femoral vessels poured forth blood and the injuredSailor fell to the deck unconscious. An alert Sailor called for someone to summon the corpsman

and then he dropped to the deck to close off the blood loss by use of a tourniquet. Very shortly

afterwards the corpsmen arrived. The corpsman checked the tourniquet (see accompanying

illustrations), and wrote on the forehead of the victim the time of application of the tourniquet.The Sailor was covered with a blanket to reduce the possibility of severe shock and the wound

was covered with sterile, moist gauze. The injured Sailor's vital signs were taken (pulse, blood

pressure and respiratory rate) as he was taken rapidly to the sickbay. In the meantime, the navalsurgeon was summoned to sickbay, which was readied for treatment of the injured Sailor. If this

accident had happened on shore, the corpsman would have followed the same procedures but


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would have had to immobilize the leg with a splint. The splint, in combat, might include a branch

of a tree or any other inflexible object (preferably clean) a pillow, magazine or newspaper as the

supporting structure. The two legs can be merely bound together. The rationale is to avoidcausing further damage by the sharp edges of the fractured bones moving about while the patient

is being evacuated.

The following are useful guidelines when one considers the possibility of broken bones. A

corpsman may use the following signs as indicators of broken bones:

1. Pain or soreness over a joint or bone.2. The victim tells the corpsman that he heard or felt a break.3. The victim can't move an injured part or that a move is painful.4. The victim tells the corpsman that there is numbness or tingling in the injured limb. This

is also an indicator of possible nerve injury.

5. An arterial pulse cannot be found in the injured part or limb. This is an indicator of bloodvessel injury.

6. The corpsman sees swelling or bruising in the injury site. This an indicator ofextravasated blood.

7. The injured part is in an unusual or abnormal position and any possible movement isabnormal.

How to provide first aid to victims with bone or joint injuries? Without x-rays or MR imaging it

is not always possible to know if a bone is broken, a joint is dislocated or damaged, or if

ligaments are stretched or torn. The rule-of-thumb therefore, is not to guess, but to immobilizethe injured part. However, this is not the first step in the first aid of these victims.

1. Treat for any life-threatening condition first: check breathing, pulse and for any bleeding.Finally stabilize the fractured bone or injured joint.

2. It is essential to keep movement of the individual and the injured part to a minimum. Therational for minimal movement is to reduce the possibility of additional damage to bone,muscle, blood vessels and nerves and the production of additional pain.

3. Immobilize the injured part with bandages, slings and splints.


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4. If there is torn skin avoid contamination of exposed underlying structures using sterilecompresses. Infections of bone are very serious and difficult to treat. If there is a

compound or open fracture (bone sticking through the surface of the skin) never try to

push the bone inside the torn muscle.5. Swelling of joints can be avoided by cooling the injured part using ice wrapped in a cloth

or towel.

6. Treat for shock and secure the aid of a medical corpsman and physician as soon aspossible.


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Colle's fracture


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Comminuted

fracture

Green-stick


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Impacted

Incomplete


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Linear

Oblique


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Pott's fracture

Spiral fracture


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Transverse

fracture


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Abdominal Wound with Protruding VisceraRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A Sailor, on liberty in a foreign port, was returning to his ship when a knife-wielding assassin

attacked him. He later remembered that he was slashed, but was able to chase his assailant away,

before he collapsed. Two of his shipmates found him, and when it was clear that the injury wassevere, one of the shipmates was sent to get the ship's corpsman.

The attending shipmate was familiar with "first aid" and set about initial care to reduce the

possibility of severe shock. The injured Sailor had regained consciousness and was rational andwas told not to stand up. He was covered with his shipmate's jacket and his feet and legs were

elevated. His vital signs were satisfactory; pulse was regular (between 60 and 90 beats persecond); breathing rate acceptable (about 15 to 20 per minute), and his blood pressure pulse was

judged, in the absence of a pressure cuff, to be strong.

The corpsman on duty and the other shipmate quickly returned from the ship. The corpsman took

over responsibility for first aid and examined the wound. He cut away the Sailor's shirt to expose

the abdominal wound and found that his intestines were protruding from the wound. Althoughbits of the Sailor's shirt were adhering to the intestines they were not removed. The corpsman

told his shipmates that the intestines must not be touched and no attempt must be made to replace

the intestines back into the abdominal cavity as part of first aid. This is to be performed insickbay by the naval surgeon. The corpsman carefully covered the wound with a sterile moist

gauze bandage taped to the abdomen.

The corpsman contacted the ship's duty officer to obtain a stretcher and to alert the medical

officer that a severe abdominal wound was on the way to the ship for surgical treatment. When

the stretcher arrived, the four Sailors carefully placed the injured Sailor on the stretcher andtransported him safely to sickbay for definitive medical care aboard ship.


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AmputationRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A Sailor aboard a destroyer in the Atlantic Ocean

lost her hand in an engineering accident. A nearbySailor called out for someone to summon the

corpsman and he immediately applied a tourniquet

(see section on Injury to Thigh) on the injured arm.

He was able to stop the bleeding and had the Sailorlie down. She was covered with a blanket to reduce

the possibility of severe shock. The Sailor alsorecognized the necessity to elevate her feet by about

8 to 12 inches. He remembered that shock is

essentially a sudden drop in blood pressure, whichmay be so severe that the brain and other vital

organs do not have adequate blood flow. These few,

simple, things help prevent additional

cardiorespiratory complications.


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By now the corpsman arrived on the scene and took charge of first aid. He checked her vital

signs (pulse rate, blood pressure, and respiratory rate), which were found to be at satisfactory andstable levels. He located the severed hand, wrapped it in sterile bandages and placed the hand in

a plastic bag and then into a carrier he brought with him. It was filled with ice to chill (not

freeze) the amputated part. The corpsman then returned to the patient and recorded the time ofapplication of the tourniquet on the patient's forehead with a waterproof marker in large

numbers. Ascertaining once again that the bleeding had stopped, he taped a loose, sterile, moist

bandage over the stump of the forearm but was very careful not to cover the tourniquet. He then

supervised the movement of the patient to his sickbay. Not equipped to handle amputations, hecommunicated with the medical officer on a nearby ship for further instructions. He then made

preparation for ship-to-ship transfer of the injured patient.


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Burns (by degree)Ronald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

A submarine rendezvoused with its submarine tender and an electrical power line was

requisitioned by the submarine to service the submarine while it took on supplies and the crew

worked on its nuclear power plant. One of the submariners handling the power line wasaccidentally electrocuted. Immediately another crewmen moved the Sailor from the power line

with a non-conducting wooden pole. A corpsman had been summoned and arrived in time to take

over the first aid treatment.

Before discussing first aid given to the submariner, burns, whether caused by flames, electricity,

scalding water, friction, radiation or chemicals are described as first-, second- or third-degree


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burns. The first illustration depicts the tissues effected. A first-degree burn is one involving the

epidermis causing erythema (redness) and edema (swelling) but no blisters. A second-degree

burn involves the epidermis, the dermis and usually forms blisters that may be the result ofsuperficial or deep dermal necrosis. Burns of this type have epithelial regeneration extending

from skin appendages (sweat glands, hair follicles, etc.). A third-degree burn results in the

destruction of skin, and may extend into the superficial (fatty) fascia, muscle and bone. Scarringis a consequence of this type of burn.


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Returning now to the Sailor with the electric shock; the corpsman knew that electrical burns,

even the smallest, are considered third-degree and both an entry and exit burn was possible. The

clothing was removed from the areas of both burns, which were quickly, but briefly, cooled withwater. A cold wet compress was placed on the wounds followed by clean dry (sterile) dressings.

The patient was breathing rapidly, but denied the presence of pain. The absence of pain is typical

because nerves are destroyed in the path of the burn. The burns were seen as charred areas abouttwo inches across. The corpsman asked for a blanket to keep the Sailor warm to reduce the

possibility of severe shock; his feet were elevated and his vital signs (respiration rate, blood

pressure and temperature) were monitored. The corpsman covered the burns with sterile

dressings, and the patient was taken to the subtender's sickbay where a naval surgeon tookcharge of treatment of the burn victim.

Before he left, the corpsman told several interested crewmen that blisters and charred skin would

be treated at a later time. In addition he said that butter, household remedies, pain relief

medication, ointments or sprays were not to be used for burns of this type and further, if used,may even delay proper healing. The corpsman said that a small third-degree burn might be

difficult to recognize if it is located in an area of second- or even first-degree burn skin damage.

If there is any doubt, the whole area is treated as a third-degree burn. In addition, because of

nerve damage in third-degree burns, a patient must not be allowed to use or put weight on aburned limb, foot or hand.

The knowledgeable medical corpsman continued by explaining to the assembled group thedifferences between, and treatment for, second- and first-degree burns. First-degree burns are

characterized by red skin, mild swelling with or without pain. Second-degree burns are deeper,

with red coloration and other skin damage, such as swelling, blisters, oozing or leaking skin, paingreater than 1st degree burns and the possibility of shock . See the first illustration to gain an

understanding of the depth of tissue damage in various types of burns. As with other first aid

treatments, rapid and proper treatment will reduce the severity of the problem for the patient.With burns of the face, or hot air or hot smoke inhalation assume the possibility of respiratory

burns; these require immediate medical attention. Do not remove dead burned tissue and do not

open blisters that may form, particularly in second-degree burns. Do not remove clothing thatmay adhere to the burned area. Do not use home remedies, margarine or butter, ointments or

sprays except on the advice of a physician or senior corpsman. Pain relief sprays and ointments

can be used on minor or small first-degree burns. Seek the advice of the corpsman for any burns

but particularly those of the face, second-degree and extensive first-degree burns. Minor second-degree burns are those small enough to be covered by a small, 3" X 3," sterile dressing but do not

involve the face, hands or feet. First aid includes immersion of the burned part under coldrunning water or if this is impractical, by using cold wet compresses. Continue the cool watertreatment until the pain disappears. For second-degree burns of hands, feet, face and/or

perineum, e.g., the entire arm or 10 to 15 % of the body, and burns that blister, see the corpsman

for advice and additional treatment. Second-degree burns involve deeper areas of the skin thatmay release fluid from damaged blood vessels that cause blisters. Usual causes are: deep

sunburns resulting from prolonged exposure to the sun by Sailors not wearing shirts on outdoor

work details, prolonged exposure with hot objects, scalding by hot water or steam, and by flash-


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burns from inflammable liquids. First-degree burns involve the superficial layers of the skin,

which becomes red but not broken or blistered. Pain receptors in the superficial layers of the skin

become irritated and produce the perception of pain, which may be intense. Recovery of the skinfrom the burn is usually quick and complete. Treatment may include cooling with water, aspirin

or other analgesics.

The corpsman said he used the "rule of nines" to describe the extent of the burn or area of the

burn expressed in percent of the total body surface for an adult. The rule of nines allows that

each upper limb is 9%, head and neck is 9%, anterior trunk (chest and abdomen) is 18%, the

posterior trunk (back) is 18%, each thigh is 9%, and each leg (not including thigh) is 9%, and theperineum is 1%. Burns need to be treated in the hospital if they are more than 20% of body area,

involving a critical area such as face, hands, feet, genitalia, perineum, and major joints, all

electrical and chemical burns regardless of size, and smoke inhalation or carbon monoxidepoisoning.

The corpsman also discussed chemical burns and stated that exposure to dangerous chemicalsmust be rinsed from the skin and that contaminated clothing is removed. Water dilutes these

substances and flushes them away. No attempts to neutralize the substance should be attempted

because greater damage may occur by chemical reaction resulting in additional burning.Frequently encountered products that cause third-degree chemical burns include hydrofluoric

acid (rust removers) nitric, sulfuric, phosphoric acids (commercial grade acids) hydrochloric acid

(cement and drain cleaners); these chemicals must be used with great care.


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Treatment includes removal of contaminated clothes, flushing the affected area with running

water for at least 5 minutes. Relieve pain with cool, wet compresses until the corpsman arrives.The corpsman will decide if a naval surgeon is required. He also said that in burns to the face or

the inhalation of toxic chemicals; assume a condition of respiratory burns, which require the

immediate attention of a physician.


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Smoke, Gas, and Chemical FumesRonald Bergman, Ph.D.Peer Review Status: Internally Peer Reviewed

Fumes from any unknown source may be flammable! Before proceeding to assist a shipmate in a

"smoke-filled" room do not light a match, use a candle, or even turn on a light switch. Do not

produce a flame or spark in the presence of gas or unknown sources of fumes.

The cruiser returned to port for refitting and the Executive officer was told to have the deck crew

remove the rust on the ship, to chip loose paint and to repaint those areas. The Chief went with a

crewman to the paint locker to inventory existing supplies. On entering the locker theyencountered overwhelming fumes, were quickly overcome, and collapsed before they could

escape the room. Because the Chief was needed for another problem another crewman went to

the paint locker to find him. He smelled the fumes and remembered that he might need moreassistance when he got to the locker. He also remembered the admonition about sparks and

flames and also the need for a hospital corpsman. The Sailor told these things to anothershipmate to get help and he and still another Sailor proceeded to the locker. Although dark, hecould make out two bodies on the deck. The two Sailors took several deep breaths of fresh air,

inhaled and then held their breath. In cases where smoke and fumes are visible above the floor

they would stay below them but in this case the paint fumes were evenly dispersed in the entire

room. They removed the two men into an area with fresh air and examined the two men forbreathing. One was still breathing but the Chief was not. The prompt arrival of the corpsman

began with attempts at artificial respiration to restore breathing. Eventually the corpsman was


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successful and the Chief began to breathe on his own. The corpsman made a quick check of the

victim's eyes and skin to see if the fumes were toxic enough cause visual problems. The eyes

were clear but were flushed with clean (or sterile) water. Before the Sailors could be moved theywere treated for shock. Their vital signs were assessed and found satisfactory but weak. The

Chief was placed on his back with his head and chest slightly elevated. The Chief was

unconscious and vomited. He was placed on his side and his knee of his top leg was bent to helphim from rolling forward. Both Sailors were covered with blankets to lessen shock and were

finally taken to sickbay for observation.

The corpsman provided additional information. The effects of inhaled smoke, gas, and fumes

from other sources may not be totally evident immediately. A thorough medical examination is

necessary, and a period of observation in sickbay may be beneficial should other symptoms orsigns appear subsequently.

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Anatomy of First Aid