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Essential first aid skills

e are going to limit the discussion here to dealing with life-threatening injuries, major bleeding, shock and broken bones. Most people can deal with minor scrapes, blisters and the like. The following discussion is no substitute for taking a proper first aid course and practising until your approach to a victim becomes instinctive. In short, your approach to a victim (or victims) should encompass:

Ensuring your own safety first - there is no point wading in to a situation only to become another victim yourself,
Being able to perform triage at the scene (see below), and
Being able to asses the victim for ABCDE (airway, breathing, circulation, disability, expose and search for minor injuries).

The concept of triage is very useful. Triage is about categorizing multiple casualties (like you might get in a major avalanche) into three groups:

The obviously dead or those who are beyond help because of their condition,
Those who will die unless you act quickly, and
The walking wounded.

What constitutes “obviously dead”? Some injuries are obviously incompatible with life, such as a decapitation. It’s a bit trickier to ascertain if someone is dead who is very battered and bloody and not responsive (i.e. unconscious). In some situations the mechanism of injury (how they got injured) can be suggestive of underlying injuries incompatible with life, such as a major fall onto rocks. Even if this person is not already dead, chances are they will be shortly from shock (blood loss), a head injury or a chest injury so there’s little point in expending resources treating Group 1 victims, at the expense of those who might survive with prompt attention. Therefore, in cases of multiple victims, once we’ve quickly sorted who’s in Group 1 our attention should readily turn to identifying the Group 2 victims. This is easy – they’re the victims NOT running around moaning and screaming about their broken arm, cut head etc. These are Group 3 victims, the walking wounded who have non-life threatening (even if they are painful) injuries. Nobody died of a broken arm. Don’t be distracted by the loudest voice crying for attention. It’s the quiet victims who need your attention first (unless they’re obviously dead!).

The Group 2 victim faces imminent death possibly from a combination of causes (usually from low blood oxygen or shock), some of which we can do nothing about. Where we can possibly avert death is in rapid action to manage the victim’s ABC’s – Airway, Breathing and Circulation. Once ABC is under control we can assess D-Disability and then comes E, which is the Cold injury of the patient and search for other injuries whilst maintaining Environmental control (so the patient doesn’t get hypothermic).

Airway

If the airway is obstructed (with foreign matter – snow, vegetation, soil) the victim will be brain dead in minutes and plain dead shortly thereafter. We must deal with this before dealing with bleeding or broken bones – no matter how horrific their injuries might be.

If the airway is obstructed in a conscious person they will have a wild look in their eyes, they will be clutching their throat and they won’t be making any sound or if anything, you’ll hear minor gasps and wheezes as they struggle to move air in and out of their lungs. They will shortly go blue in the face then pass out. The likely reality is your victim will already be unconscious so unless your approach is to automatically move in rapidly to assess and, if need be, open their airway, by the time you fully dig them out of the avalanche, they will be dead. As soon as you have access to the head and mouth assess the airway. If there’s no sound or movement of air, open the airway first by simply opening the mouth and inspecting for foreign material. If you see something that shouldn’t be there, scoop it out carefully and swiftly but be careful not to jam your fingers down their throat, which will drive the foreign object deeper and/or possibly induce a gag reflex and make the victim vomit. Airway management takes priority over everything else until the airway is clear and open. To open the airway we have three options:

Tilt the head back,
Lift the chin forward, and
Do a jaw thrust by putting your fingers behind the angle of the jaw and pushing forward. Options 2 and 3 are best used if you suspect a neck injury.

Breathing

Once we’re sure the airway is clear, we need to assess breathing. Is the victim breathing? Can we see and feel the chest rise and fall and can we feel and hear their breath on our face as we get close to listen? Look, listen and feel for signs of respiratory effort for AT LEAST 10 SECONDS. If there’s no breathing, we need to give two rescue breaths then assess ...

Circulation

Does this victim have a pulse – is their heart still beating? Feel for the pulse at the neck and look for signs of returning circulation – coughing, swallowing, movement, return of colour. If there’s no pulse then technically, by the first aid book, we should start CPR (cardiopulmonary resuscitation), which is combined expired air resuscitation (EAR) and chest compressions – but read below first. In C, we also need to control major bleeding by direct pressure.

The dilemma with a NOT BREATHING/NO PULSE victim scenario in a cold setting is distinguishing between the hypothermic victim who may have a slow, weak and undetectable heartbeat and the victim whose heart has stopped due to asphyxiation. In the case of cold-water immersion a rule of thumb is if the victim has been immersed for less than 30 minutes and has no pulse, then we treat as a drowning with an emphasis on full CPR. If the immersion is greater than 30 minutes, we treat as a hypothermic patient where the emphasis is on rescue breathing, rewarming and very gentle handling of the patient to avoid “bumping” the heart into VF (ventricular fibrillation, where the heart is like a quivering bowl of jelly and doesn’t pump properly.) Rescue breathing is unlikely to provoke VF, unlike chest compressions. If we equate our cold water immersed victim with a buried avalanche victim then this rule of thumb might be useful, although water is a much greater conductor of heat than snow so the rate of cooling of the victim buried in snow will be slower. Of course it’s likely that this victim has been asphyxiated AND is hypothermic. Either way we have to make a guess about how to treat what is effectively already a dead person. If we are hours or days away from help, remember that our victim should not be abandoned and considered dead until WARM and dead. This means that we must continue to provide first aid until we are sure the victim has been rewarmed but there’s still no breathing effort or pulse. You may feel uncomfortable not initiating CPR when there’s no pulse but remember, they have no pulse and are therefore already dead. CPR alone will not “restart” a heart. You need a defibrillator (electric shock paddles) to do this and you clearly won’t have one with you.

Disability

In the conscious patient we can ask if they can feel and move their toes and fingers. Can they feel you touching them? Do they have neck or back pain? This gives us an idea of how intact their spinal cord is. We can feel the neck and down the back for “steps”, swelling, and ask if this causes pain. Remember that in the UK 10-15% of people attending A&E with a head injury resulting in unconsciousness also have an associated neck injury. So anyone with a cracked head (or helmet!), especially if they’ve been unconscious for any length of time should be managed cautiously with regard to a suspected neck/spinal injury, even if they have full movement and feeling of their arms and legs. Disability also encompasses an assessment of conscious level. A simple system to know is AVPU:

A – is alert

V – responds to verbal stimulus (can answer questions)

P – only responds to a painful stimulus (a rub over the eyebrow is best)

U – is unresponsive

It’s obviously more difficult to assess D in the unconscious patient, who may be P or U on our scale above and we have to be very prudent about aggravating any neck or spinal injury (but not at the expense of managing their ABC’s we must emphasize). Once the situation as far as A to D is under control, we can take the time expose the patient as far as this is practical without making them hypothermic, to search for other less life threatening injuries which we can then go on to treat.

Bleeding

Stopping bleeding is the priority. In a snowy wilderness we can worry less about wound infections than say in the jungle. However, clean the wound as best you can, apply direct pressure (carefully on the scalp) and elevate the wounded area if possible. Bandage and splint the affected limb, which will help control the pain of wounds (and breaks). If blood loss (internal or external) is severe then shock (low blood volume) is life threatening (shock is formally defined as inadequate tissue perfusion to the vital organs). Shock is worsened by cold, pain and fear – so also do what you can to alleviate these aggravating factors whilst dealing with the source of blood loss, if it’s external.

Recognising shock: the signs and symptoms

Fast pulse rate - above 100 beats per minute. (60-80/min would be normal for the average adult)
Cold, clammy, grey skin, sweating.
Loss of co-ordination, speech difficulties, reduced conscious level and eventually coma (sounds like hypothermia doesn’t it!)
Increased breathing rate - over 30 breaths per minute would be worrying. (12-15 is normal for the average adult).
Low blood pressure (difficult to measure accurately without a blood pressure cuff)

The first aid treatment for shock is simple:

Lie flat, raise legs and keep the victim warm.
Reassure.
Treat the underlying cause.

Broken bones

This includes breaks and dislocations since we might not be able to distinguish between the two in the field. Either injury will be characterised by any or all of: pain, deformity, crepitus (bone grating), limb shortening, overlying soft-tissue injury, swelling and bruising. We will want to straighten and splint the limb but we must first assess that the affected limb’s nerve and blood supply hasn’t been interrupted. Check this by feeling for pulses below the injury (blood supply) and asking the patient if they can feel your touch (normal sensation). Note the absence or presence of normal sensation and a blood supply. Then straighten the limb using a gentle but steady pull until the break is “reduced” and the limb is straight. Check again that the relevant pulses are palpable and that sensation is normal. If not, continue to apply traction until pulses and sensation return. Then splint the limb in the position of function, using lots of improvised padding alongside bony areas to prevent discomfort and pressure sores from forming. The downhill skier is posed in the position of function – don’t splint limbs, hands, fingers or legs completely straight.

Altitude sickness

Altitude sickness is common when people travel to altitudes above 3,000m, particularly if the ascent is rapid – like at the start of a big ski tour. Above 4,000m there is a significant risk of the more serious High Altitude Pulmonary Oedema (HAPE) or High Altitude Cerebral Oedema (HACE). Sleeping at high altitude (for example in a mountain hut) is a particular risk. Common symptoms are headaches, fatigue, breathlessness on exertion, loss of appetite, nausea, dizziness and difficulty sleeping. Most symptoms disappear after a night’s rest or a couple of days of acclimatisation, but if symptoms worsen or fail to improve the victim must descend.

Pain relief

Use paracetamol, or paracetamol in combination with ibuprofen to provide some pain relief for injuries. Ask about allergies and never attempt to give an unconscious casualty ANYTHING by mouth. Your first aid kit should contain:

Some bulky dressings to stem the bleeding,

A few sterile gauze pads,

Something for pain relief,

A few large safety pins,

A roll of surgical tape,

A couple of triangular bandages, and

Adhesive plasters.

Rescue

Think about how you might summon help in the backcountry. Being able to succinctly communicate a history of what’s happened to your casualties and what treatment you’ve instigated will be immensely useful to your rescuers.

In summary:

Never endanger yourself to render aid.
Keep a cool head and conduct a rapid triage assessment if there are multiple victims.
Our priorities are ABC – a blocked airway can kill in minutes – don’t be distracted into forgetting to manage the airway.
The buried avalanche victim may not be breathing or have a pulse.
If they are not breathing and have no pulse and have only been buried for a short time, begin CPR, keep the victim from getting hypothermic and arrange evacuation.

If they are not breathing and have no pulse and have been buried for a longer time, the emphasis should be on clearing and managing their airway, giving EAR but not chest compressions, handling them very carefully and gentle re-warming if a hospital is not within easy reach, and arranging evacuation.

Don’t give up unless your patient is warm and dead.