MINISTRY of PUBLIC HEALTH UKRAINE

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

“It is ratified"

on meeting of department

Department of Accident Aid and Military Medicine

Manager of department
DMSc, Professor_________Shepitko K.V.
22.11.2017

METHODICAL INSTRUCTION

FOR INDEPENDENT WORK OF STUDENTS

DURING PREPARATION TO PRACTICAL SESSION

Emergency and Combat First Aid as

Academic Subject. Primary Examination of
an Injured
Class 2

Poltava-2016
 1. Topic relevance
We must have spiritual and psychological readiness to defend Ukrainian state
with weapons. «Emergency First Aid» subject lays the foundations of theoretical
knowledge and practical skills in organizing and conducting medical evacuation,
sanitary-hygienic and anti-epidemic measures, including provision with pre-
medical assistance in emergency situations of natural and anthropogenic origin and
in combat environment.

2. Concrete aims:

1. To be know main principals of «Emergency First Aid».

2. To be know relevance of «Emergency First Aid».
3. To be know the lawyer’s basis of «Emergency First Aid».
4. To be know the content of «Emergency First Aid».
5. To be able primary examination of an injured

3. Basic knowledge, abilities, practical skills required for studying of the

theme (interdisciplinary integration

Courses Practical skills

1.Lawyer’s basis 1. To know main laws about organization of

emergency medicine during natural, technical,
ecological and social-political disasters.

2.Safety of life 2. To use main rules of people behavior during

functions natural, technical, ecological and social-political
disasters and method of self-care and mutual
medical aid.

3. Latin language. 3. To use the Latin terminology in situations

emergency.

4.1Tasks for independent work during preparation to practical employment

Lawyer’s basis of Constitution of Ukraine and Law of Ukraine «On
«Emergency First Aid» emergency medical assistance», 05 of July, 2012 , №
5081-VI, etc.

The content of «Emergency First Aid» subject lays the foundations of

«Emergency First Aid» theoretical knowledge and practical skills in organizing
and conducting medical evacuation, sanitary-hygienic
and anti-epidemic measures, including provision with
pre-medical assistance in emergency situations of
natural and anthropogenic origin and in combat
environment.

Emergency Disruption of living conditions and human activity on

the site or area due to accident, disaster, natural
disaster or other dangerous event that resulted in death
or significant material damage.

The objectives of the To determine the severity degree of the injured and
study of «Emergency mastering the skills of provision pre-medical assistance
First Aid» to casualty in conditions of peace and war time.

4.2. Questions:
1. The amount of medical care in the red zone.
2. The amount of medical care in the yellow zone.
3. Protocol on tactical medicine CABCDE.
4. Protocol on tactical medicine «Wheel-bridge».
5. Algorithm AVPU.

4.3. Professional algorithms for forming practical skills and abilities:

1. To be know the amount of medical care in the red zone.
2. To be know the amount of medical care in the yellow zone.
3. To be know protocol on tactical medicine CABCDE.
4. To be know protocol on tactical medicine «Wheel-bridge».
5. To be know algorithm AVPU.

5. Detailed theme content:

Conventionally there are two places of first aid during the conduct of
hostilities:
 directly in the shelling sector (red zone) - in the line of fire with a significant
risk of a bullet wound;
Shelter sector (yellow zone) - place protected from direct enemy fire natural
elements (hills, slopes) or artificial (walls, buildings, safety engineering design).
The measure of first aid: in the shelling sector, transfer from the supine
position on his stomach; temporary stop external bleeding (neck, limbs);
In the shelter sector: primary inspection wounded (the definition of signs of
life), fast examination from head to toe (search for existing damage), if necessary -
a temporary stop bleeding (head, torso), cardiopulmonary resuscitation, overlay
dressings for wounds and limbs trunk, and fixation of fractures of the cervical
spine, preparing to transport the wounded to a safe area.
Conventionally distinguish the following stages of the first aid:
First aid in the shelling center.
Transportation (moving) the wounded from the battlefield in the shelter sector.
Assist in the shelter sector.
First aid in the shelling sector provide only fire on the orders of the
commander, as in the main battle is a combat mission. In some cases, when the
tactical situation allows, decisions are taken independently. Assistance is provided
in the form of self-help and mutual aid.
Approaching the wounded should try to get as much visual information about
him and the scene whether it happened before your eyes, in which the position is
that visible damage, foreign objects in the body or is a pool of blood where his
personal weapon, or you further is not threatened (hidden under the body of the
grenade removed linchpin and under.).
Signs of life in the shelling sector wounded determine only by oral appeals to
him, "You wounded? You need help? "The lack of response is interpreted as
fainting and necessary first aid. Detect breathing or pulse dangerous so don’t do it.
First aid in the shelling sector general terms.
Shoot with wounded protective equipment (helmet, body armor) can not, as
you put yourself thus additional risk of being affected by enemy fire. the
transportation of the wounded from the shelling sector should be only in the case
when the tactical situation allows. In the sector of attack can do stop external
bleeding wound in the localization in the neck, arms or legs (visible wound, from
which flows the blood stain on a garment or a pool of blood in the body part, hand
or foot) .In sector should stop shelling alone! life-threatening bleeding (heavy
leakage of blood from the wound, visible puddle of blood.
During the execution of any manipulation in the shelling sector wounded and
one who saves, are in danger, so everything must be done as quickly as possible in
compliance with the rules of personal safety (lifeguard does not rise above the
body injured, lying on the ground).
Transfer wounded in position on the abdomen is performed to reduce the risk
of airway obstruction due to retraction of the tongue or vomiting.
Wounded arm that is closest to you, place along its trunk in the direction of up.
Step 1 Transfer wounded in position on the side (belly)
Your head and shoulders while performing manipulation should not be above
the head and torso wounded.
Tightly pressed to the ground, grab an injured shoulder that away from you.
Step 2 Transfer wounded in position on the side (belly)
Sharp turn traffic over the wounded man on the side (belly).
Step 3 Leaving the wounded in position on the side (belly), continue to perform
combat mission, if not impossible
First aid in the shelter sector
In the sector of shelter wounded remove the protective elements. This must be
done quickly and smoothly: one of the men takes off the helmet, while the second
takes a bulletproof vest.
After removing the protective elements first fighter checks consciousness,
asking: "Do you hear me? You need help? ". In the absence of answers (injured
unconscious) he checks the breathing, the second examines quickly from head to
toe: head, neck, chest, abdomen, upper and lower limbs, back.
Initial review of the wounded, the definition of signs of life
• If not breathing - do cardiopulmonary resuscitation;
• If there is external bleeding - apply the tools to stop it;
• If you have wounds, burns - apply dressings;
• If you have chest wounds - apply
bandage;
• If there is penetrating chest wound when the wound is heard as the air goes
out or comes Bloody foam - need to close the opening material that is not
breathable (outer packaging of individual dressing package, oilcloth, cellophane)
• If you have a foreign object in the wound - fix it in the wound;
• fracture - fracture fixation.
Initial review of the wounded, the definition of signs of life
Provide assistance in accordance with the identified damages:
All unconscious wounded granted first aid, waiting for further transfer to the
medical center provide stable position on the side that they are not suffocated by
retraction of the tongue.
Wounded in the mind, but with a change in behavior (mental), should
immediately disarm because there is a risk of inappropriate use of their weapons
and wounding the other fighters. The reasons for behavior change (psyche) can be:
traumatic brain injury; shock; hypoxia; use of narcotic analgesics; psycho-
emotional stress.
The most characteristic symptoms of psychological disorders:
senseless and chaotic motor restlessness; exhaustion and feeling of unreality
surrounding the event; distance from the emotional environment; guilt;
hostile actions against people that surround; inadequate perception (ignore)
existing damage. Carry only CPR should be provided that this does not prevent the
implementation of tactical tasks and there is no danger for the soldiers providing
assistance. In the fire sector spending CPR prohibited. In penetrating wounds
success during CPR is extremely low. CPR should conduct the absence of injured
incompatible with life traumas: head with an open wound leaking brain matter;
open lacerations chest with damage to internal organs (lungs, heart); traumatic
limb amputations without stopping bleeding (overlay bundle) in the shelling sector;
burns III-IV levels (large, tense blisters or disclosed liquid or gelatinous saturated
yellow (bloody) color or coaling) skin and most of the body.
Implementation out cardiopulmonary resuscitation
Worldwide protocol is used on tactical medicine CABCDE: C (Catastrophic
haemmorhage) A (Airway) B (Breathing) C (Circulation) D (Disability) E
(Expose-Environment-Evaluate-Evacuate), developed by NATO, but a fight bad it
Add loader the.
Ukrainian algorithm and protocol on tactical medicine "Wheel-bridge" at the
NATO standards T3S.
Wheel - an abbreviation, the prototype of all steps in sequence protocol NATO
only Ukrainian: K (Bleeding massive critical), O (overview airways), L (light), E
(Efficiency breathing), C (heart), O (Browse all Body - Assessment of
consciousness-heated).
In accordance with NATO standards, sanitary losses account for a mere 3% - is
only wounded, incompatible with life, in all other cases, people are saving.
Protocol "Wheel-bridge" can significantly reduce the performance of sanitary
losses among men, as often assistance is provided quickly enough and in the wrong
sequence. Protocol "Wheel Bridge" allows people to better and faster to remember
the basic rules and algorithm first aid to the wounded. "Wheel-bridge" is designed
for people who came to the army with or without other specialties specialty at all.
Bridge The report - a summary of who provided first aid, the defeat suffered by
the people. This should be doctors who will continue to provide aid to speed up
and improve its quality. There is a common culture of documentation on the
battlefield.
Authors:
 Olga Omelchuk, sanitary instructor, medical service 12th separate infantry
battalion Armed Forces of Ukraine
Yuriy Marchenko, director of the charitable organization «Foundation for
Assistance Battalion" Donbass "tactical instructor of medicine
Andrew Porohnytskyy, doctor, medical instructor, Kyiv
Natalia Olyanyshyna, representative of the NGO "Free Ukraine - Estonia»
(Vaba Ukraina) in Ukraine.
When approaching the victim should first find out from the random witnesses,
police or rescue circumstances of the incident or the scene is safe, set the number
of victims.
If the scene requires the help of rescuers - reported in the ministry. In all cases
where the crime occurred or used violence, the police must first ensure the safety
for medical rescuers. If any information is not, and visually victim requires
emergency medical help should act independently, especially paying attention to
anything that might threaten personal safety: seat should fully explore.
If there is the slightest threat (containers, marked with special signs, spilled
liquid, smoke, fog, fire, and other natural gas, electric power wires, explosive
objects, objects that can fall from above, etc.) should decide whether there is a real
no opportunity to eliminate its own risk, but if not, you need to stop the movement
of the victim, causing rescuers. When a decision is yet to approach the victim in
the course need to find out for themselves what happened to predict, for example,
the mechanism of injury and tune in emergency medical technology and, if
necessary, intensive care. Must inspect all corners of the scene to discover other
people who may also need resuscitation or other assistance.
It is worth paying attention to all the details of the scene, constantly monitoring
the scene, because in the end may be additional hazard that will make not only
save the life of the victim, but also personal.
Uncontested, the priority remains his own life, then the patient's life, and all
others!
Initial inspection technology
To the victim if possible should be approached from the side of the head. First
visually assessed the patient as a whole (age, sex, morphology of body language,
color of skin, posture, presence movements (chest, limbs), facial expressions, eye
condition, visible lesions traumatic factor) is the primary conclusion of its severity
and algorithm further assistance.
To confirm or deny circulatory arrest
• The reaction of the patient
• Ensure airway
 • Evaluation of respiration and heart rate (less than 10 seconds) turns the state
of consciousness algorithm AVPU:
A - Alert (conscious, gives adequate answers to questions can perform
deliberate actions - at the request of the medical rescue);
V - Responds to Verbal stimuli - responsive to voice, precisely at a loud sound
at the two ears;
P- Responds to Pain - responds to pain (pinch on the skin in the area of
projection trapezius muscle, left pectoralis rotated 180 o);
U - Unresponsive - unconscious.
Evaluation of external signs of life one person:
If there is suspicion of simulation reveal faint 2 and 5 fingers forever. Patients
are conscious must strain the muscles of the eyelids and they submit themselves
with tension.
In addition, the patients (patients) who are in a coma for a full diagnosis of
degree should be applied scale com Glasgow. Monitoring the general condition of
the victim (evaluation of consciousness, breathing and heart activity)
Start initial examination by the method A, B, C (the optimal time performance
- 10 s).
Step A
Ensure airway:
evaluate whether to conduct an audit of the mouth. At present secretions
(blood, vomit, objects (depending on the mechanism of destruction) should reveal
the oral cavity (between the molars should put a spacer to prevent accidental
squeezing fingers), remove foreign bodies clamp with swab or suction to provide
toilet mouth and pharynx, free them from the discharge (if there are multiple
affected, the priority is their location on terrain head down), let down your head
and lift the chin, with suspected head injury head throw prohibited, should raise the
chin.
Step B.
Evaluation breathing victim. Counting the respiratory rate by 10 seconds.
Fashion for the tracheal intubation:
• apnea;
• risk of aspiration;
• threat or presence of respiratory failure (damage to the respiratory tract,
maxillo - facial trauma);
• closed head injury;
• hypoxemia, despite carrying oxygen therapy;
• respiratory rate less than 10 or more than 30 for 1 minute (in adults);
• threat respiratory arrest and cardiac (sepsis, severe burns).
 If breathing is abnormal, but not agonal (deep and noisy) and surface - shows
the affected oxygen therapy (10-15 l / min).
Objective criteria are data blood oxygen saturation <92% - indications for
oxygen therapy; saturation <90% - indications for intubation.
Step C.
Parallel to ascertain the presence of carotid pulse (within 10 seconds), if the
patient is unconscious.
When no pulsation - proceed to chest compressions at a rate of at least 100
times in 1 min. - 30 press on the chest and two air injection.
Inspect whether there is external bleeding. If it exists, stop the bleeding by
pressing his hand over the wound sterile cloth. If the bleeding stops - impose
clamp, pressure bandage or provide pressure vessel at a distance.
If the victim of traumatic amputees - along with assessments of respiratory rate
and arterial tourniquet impose clearly following the technical and time
requirements.
Pay attention to the temperature of the skin (rear brush), color, color after the
return pressure on the nail bed, skin moisture. These data point to the development
of shock. Pale, skin moisture, it is cold to the touch, and increased recovery time
color nail bed after compression than 2 s indicate severe shock. When signs of
shock, external bleeding, suspected internal bleeding establish blood products
transfusion through a catheter in a peripheral vein.
Establish presence in body victim pendants, bracelets, chains for tokens -
medical markers that can inform on the state of the patient's allergies, the need for
specific medicines (eg, diabetes, epilepsy, etc.), especially when the patient is no
consciousness.
On examination, give priority to:
• dangerous mechanism impression;
• reduction of consciousness;
• respiratory failure;
• violation during the initial review;
• Significant deviations in the overview (right we can conclude the severity of
the patient, his vitality tactics of examination and treatment).
Also, elements of the secondary examination at the ABCDE scheme for this is
to assess impairment of consciousness (Disability) and patient exposure
(Exposure)
D - violation of the state of consciousness (Disability)
By common causes of violations of the state of consciousness are severe
hypoxia, hypercapnia, ischemia or the use of sedative or analgesic medications.
 It is necessary to evaluate and treat these deviations scheme ABC, it should be
deleted (adjust) the likely hypoxic condition and hypotension. If possible drug card
checked the patient in order to exclude treatable causes, caused by drugs that
depressive effect on the activity of the CNS. If there are indications, it should
apply the antidote preparations (for example naloxone in case of overdose of
opioids).
The estimation of pupils (diameter, symmetry and reaction to light), fast
determine the state of consciousness of the patient in the scale AVPU.
Determine the level of glycemia via glucometers; if it is below 3 mmol / l.
necessary in / introduction 50-60 ml. 5% glucose solution.
A patient who is in a coma with respiratory failure (tongue retraction) is
translated in a stable position.
E - patient exposure (Exposure)
For comprehensive examination of the patient required inspection of all parts
of his body. It should respectfully refer to him with the rights and privacy, while
trying minimize heat loss.
Additional Information
1. The need to collect detailed history of the patient, in the case of coma - to his
family, friends, or others.
2. if possible, read the documentation of the patient, namely drugs had been
prescribed to the patient when and how and how much he took them.
3. checks vital parameters of the patient's values and their changes over time.
4. evaluated the results of laboratory and other examinations
5. The question of accommodation of the patient in the inpatient department
(general department, intensive care, etc.).
In the absence of any reaction to severe pain stimuli (Unresponsive) status of
the victim is regarded as a critical next step - providing airway He made using the
so-called triple reception P. Safar, namely throwing head (reception №1), the
nomination of the mandible down and forward (receiving №2), open mouth with
further revision (reception №3).
However, it should be remembered category of injured, which in this case is
probable head injury, so they tend to position №1 (throwing head) is performed.
Priori assume that brain injury occurs when traffic accidents, sports injuries, falls
from heights, injuries on the water, as well as injuries in children. The exceptions
are precisely those victims who are in a state of clinical death, prompting rescuers
to immediately start cardiopulmonary resuscitation.
Ensuring airways passability witch the previous head to perform mechanical
ventilation is a priority before additional damage likely in the area of cervical
spine!
 Monitoring the general condition of the victim
Further immediate preparations before resuscitation following steps: put the
victim on his back on a board, preferably with lowered upper part of the body. Not
involved in reanimation rescuer lifts the victim's feet to 50 - 60 cm, holding them
in this position for 10-20 seconds with a view to increased blood filling the cavities
of the heart.
At this time, the doctor evaluates external signs of life on the basis of the
victim's BC (where B rating breathing, circulation C-grade) performed during 8-
10 seconds. Their absence indicates a state of clinical death.

6. Materials of methodological and material support:

A. Tasks for self-control
1. In 30 minutes after a car accident the paramedics came on a place of accident. A
driver lied on the ground near the road. It is a man, about 30 years old. He is in
conscious. There is a bleeding from the left thigh. Dark red blood flows in a form
of a stream. What type of bleeding does a patient have?
A. venous
B. arterial
C. capillary
D. don’t have bleeding
E. all answers are correct

2.There is a man, about 30 years old on the road. He is in conscious. There is a

bleeding from the left thigh. Dark red blood flows in a form of a stream. What type
of bleeding does a patient have?
A. venous.
B. arterial
C. capillary
D. don’t have bleeding
E. all answers are correct

3.Military man, 20 years old, was founded by medic in “red zone”, who lied on the
floor in a pool of red bright blood. A patient is unconscious. It is the urgent case.
There is no history. Blood flows in a form of a fountain from the right thigh of a
patient. What type of bleeding does a patient have?
A. arterial.
B. venous
C. capillary
D. don’t have bleeding
E. all answers are correct
4. Military woman about 20 years old was found by medic in “yellow zone”, she
lied on the floor in a pool of dark red blood. It is the urgent case. There is no
history. She is in conscious. There is a bleeding from the right thigh. What type of
bleeding does a patient have?
A. venous.
B. arterial
C. capillary
D. don’t have bleeding
E. all answers are correct

5. In 30 minutes after a car accident the paramedics came on a place of accident. A

driver lied on the ground near the road. It is a man, about 30 years old. He is in
conscious. There is a bleeding from the left thigh. Dark red blood flows in a form
of a stream. What type of bleeding does a patient have?
A. venous.
B. arterial
C. capillary
D. don’t have bleeding
E. all answers are correct

6. The objectives of the study of «Emergency First Aid»:

A. to determine the severity degree of the injured and mastering the skills of
provision pre-medical assistance to casualty in conditions of peace and war
time.
B. to use the Latin terminology in medcine
C. to know chemical properties of acids and alkalis
D. no response is correct
E. all answers are correct

7. A special method of organization of medical assistance of wounded was

suggested?
A. Pirogov.
B. Wisniewski
C. Sklifosofskyy
D. Shevchenko
E. Mechnikov

8. What kind of accidents is war?

A. social-political.
B. natural
C. technic
D. this don’t accident
E. ecological

9. What kind of accidents is terrorism?

A. social-political.
B. technic
C. natural
D. ecological
E. this is don’t accident

10. What kinds of catastrophe is most old?

A. natural.
B. social-political
C. ecologic
D. technic
E. all kinds of catastrophes appear in one time

B. Tasks for final control of knowledge with answers:

Task № 1. There are several types of external bleeding?
A. arterial, venous, capillary.
B. strong, moderate, capillary
C. arterial, pulsating, venous
D. no response is correct
E. all answers are correct

Task № 2. Signs of arterial bleeding?

A. red, bright red blood that flows from a wound in a form of a fountain.
B. cherry color of blood that flows from the wounds in a form of a jet, but calmly,
no pushes
C. dark blood that flows in form of pushes
D. no response is correct
E. all answers are correct

Task № 3. Symptoms of venous bleeding?

A. dark-colored blood, flows in pushes.
B. red, bright red blood that flows from a wound in a form of a fountain
C. blood oozing across the surface of the wound as from a sponge
D. no response is correct
E. all answers are correct

Task № 4. Means of stopping capillary bleeding?

A. the imposition of the usual sterile dressings, in case of bleeding from the
wound limbs give it a while the raised position.
B. imposing a twist
C. imposition of a tourniquet
D. no response is correct
E. all answers are correct

Task № 5. What types of external bleeding do you know?

A. arterial, venous, capillary
B. strong, moderate, capillary
C. arterial, pulsating, venous
D. arterial, venous
E. venous, capillary

Task № 6. Means of stopping capillary bleeding?

A. the imposition of the usual sterile dressings, in case of bleeding from the
wound limbs give it a while the raised position.
B. imposing a twist of vessels
C. imposition of a tourniquet
D. may be stay without medical care.
E. must be necessary hospitalized to the surgery department

Task № 7. Symptoms of venous bleeding?

A. cherry color of blood, derived from a wound in a form of jet, but in a calm,
easy way, without pushes.
B. dark-colored blood, flows in pushes
C. blood oozing across the surface of the wound as from a sponge
D. red, bright red blood that flows from a wound in a form of a fountain
E. cherry color of blood that flows from the wounds in a form of a jet, but calmly,
no pushes

Task № 8. Maximum term of imposition of a tourniquet in summer?

A. 1.5 hour.
B. 3 hours
C. 2 hours
D. 24 hours
 E. 30 minutes

Task № 9. At what kind of bleeding foamy blood is observed?

A. pulmonary.
B. nasal
C. esophagus
D. gastric
E. intestinal

Task № 10. First medical aid during situation accidents include?

A. temporary stopping of an external bleeding.
B. degasation of a clothing
C. application or correcting of a wrong bandaging
D. warming of the victims
E. hot drink to patient

References literature

Basic references:
1. Medicine of emergency situations: textbook for students of higher medical
educational establishments of IV level of accreditation/ V.V. Chaplyk, P.V.
Oliynyk, S.T. Omelchuk, V.V. Humenyuk. - Vinnytsia: Nova Knuha, 2012. - 343
p.

Additional references:
1. Accident and emergency medicine: study guide/ O.M. Pronina, V.V. Shevchenko,
S.I. Danylchenko; Ministry of Public Health of Ukraine, Central Methodical
Office, UMSA. - Poltava: ASMI, 2015. - 143 p.

WEB-sources

1. http://www.umsa.edu.ua/kafhome/voennaya/kaf_voen.html
2. http://www.emergency.com.au/
3. http://firstaidforlife.org.uk/first-aid-courses/emergency-first-aid-all-ages/
4. https://www.redcrossfirstaidtraining.co.uk/Courses/First-aid-at-work-
courses-uk-mainland/Scheduled-courses/Emergency-first-aid-at-work.aspx

Guidelines prepared by:

PhD in Medical Sciences
Assistant Professor V.V. Shevchenko