First Aid: Management of Life-Threatening Conditions

1. Systematic Assessment of the Casualty (DR C ABCDE)

Before touching any casualty, you must follow a strict algorithm. Life threats are treated immediately as they are FOUND before moving to the next step. The modern primary survey sequence is DR C ABCDE.

1.1 D — DANGER

Check for and control all scene hazards. Rule: If you die, no one is saved.

• Traffic: If a vehicle is still running, switch off the engine and apply the handbrake.
• Fire/Smoke/Heat: Assess the risk of explosion or toxic smoke inhalation.
• Live Electricity: Fallen wires must be assumed LIVE. Do not touch a casualty in contact with electricity until the main power is off. Use a non-conductive object (like dry wood or plastic pipe) to separate them from the source.
• Water (Drowning): Reach with a pole or throw a rope; don't jump in yourself unless you are a certified rescue swimmer.
• Toxic/Chemical/Gas Leaks: Always approach from upwind; cover your mouth and nose.
• Collapsing Structures: Unstable buildings or vehicles hanging on steep slopes.
• Blood/Body Fluids: Put on your Personal Protective Equipment (PPE) first!
• Action: Make the scene safe. Move the casualty ONLY if the danger is immediate, deadly, and unavoidable (e.g., a spreading fire, sinking ship, or speeding traffic). If you must move them, minimise movement and strictly support the head/neck if a spinal injury is possible.

1.2 R — RESPONSE (AVPU)

Approach from the front so the casualty sees you (this avoids startling them or triggering aggression). Introduce yourself and ask loudly: "Are you OK? Where do you feel pain?"

If there is no answer: shake their shoulders firmly (adult/child), tap the bottom of the foot (infant), and shout "Can you hear me?"

Action: If they score U (or P with abnormal breathing): shout for help NOW! Call 999/112 or 0800 211 088 (put on speakerphone if you are alone) before moving on.

1.3 C — CATASTROPHIC BLEEDING (2025 Update)

This step now comes BEFORE the airway. Why? A casualty can bleed to death from a severed major artery (like the femoral) in just 2 to 3 minutes; an airway problem usually allows slightly more time.

• Do a rapid 10-second whole-body scan for: spurting/pumping blood, massive blood pooling on the ground, deeply soaked clothes, or traumatic amputations.
• Action: Control IMMEDIATELY. Apply massive direct pressure → apply a tight pressure dressing → apply a Tourniquet immediately if it is a life-threatening limb bleed that won't stop.

1.4 A — AIRWAY

• Look in the mouth: Remove visible foreign material (use suction if available). Blind finger sweeps are strictly discouraged as they push objects deeper!
• Open the airway: Use the HEAD-TILT, CHIN-LIFT maneuver. One hand on the forehead tilting the head back, two fingers of the other hand under the bony part of the chin lifting up. This physically lifts the heavy tongue off the posterior pharyngeal wall (the #1 most common obstruction in unconscious patients).
• Suspected Cervical Spine Injury: (e.g., fall from a height, RTA, shallow diving). DO NOT tilt the head. Use the JAW THRUST instead — kneel at the head, place your fingers at the angles of the jaw, and push the jaw directly forward while maintaining strict manual in-line head stabilisation.
• Listen for airway noises:
  • Snoring (tongue obstruction)
  • Gurgling (fluids/blood — turn to side and suction)
  • Stridor (harsh, high-pitched upper airway obstruction)
  • Crowing (laryngeal spasm).

1.5 B — BREATHING

With the airway firmly open, assess for NO MORE THAN 10 SECONDS:

• LOOK: for chest/abdominal rise and fall.
• LISTEN: for breath sounds at the casualty's mouth.
• FEEL: for warm breath on your cheek.

Normal: Quiet, regular, 12–20 breaths/min (adult), effortless.

ABNORMAL (Treat as NOT breathing): Agonal gasps (occasional, slow, noisy, fish-like gulps), very fast/slow, very shallow, noisy, or silent with massive effort.

• Action if breathing normally but unresponsive: Place carefully in the RECOVERY POSITION to protect the airway from vomit/tongue fall-back, and monitor continuously.
• Action if NOT breathing (or agonal gasps): Start CPR immediately (30 compressions : 2 breaths). Send a bystander for an AED.

1.6 C — CIRCULATION

• Check pulse: Palpate the Carotid artery in adults/children (side of neck, 2 fingers, 5–10 seconds) or the Brachial artery in infants. Always palpate on YOUR side of the neck to avoid accidentally strangling the patient.
• No pulse (or unsure + not breathing) → Start CPR immediately.
• Check perfusion signs: Skin colour/temperature, capillary refill (<2 seconds normal), sweating, level of consciousness (this tells you if the brain is getting enough blood!).
• Look again: Find any non-catastrophic bleeding and control it. If there are signs of clinical shock, treat by lying them flat, raising the legs, and keeping them very warm.

1.7 D — DISABILITY & E — EXPOSURE

• D (Disability): Check conscious level again (ACVPU). Check pupil size/reaction (Equal? Pinpoint = opioid overdose; Dilated = hypoxia/brain injury; Fixed/dilated = severe brain death). Check for stroke signs (FAST: Face droop, Arm weakness, Speech slurred, Time to call) and paralysis.
• E (Exposure): Expose the casualty fully to find hidden injuries (a hidden stab wound under a thick jacket will bleed internally and kill!). However, deeply respect their dignity and prevent heat loss — "Examine then quickly cover." Look for medical alert bracelets, drug packets, needle marks, or impaled objects (STABILISE impaled objects — never, ever remove them).

2. Secondary Survey (History & Head-to-Toe)

This is only done AFTER all massive life threats in the primary survey are controlled.

Head-to-Toe Examination (Systematic Order)

• HEAD: Scalp wounds, skull depressions, pupils. Ears (blood/CSF leak — Battle's sign). Nose (bleed/CSF). Mouth (tongue bite, loose teeth).
• NECK: Is the trachea central? Neck veins distended? Cervical spine tenderness. Look for a stoma or medical necklace.
• CHEST: Symmetry of movement, wounds, tenderness. Listen to breath sounds if trained.
• ABDOMEN: Distension, tenderness, rigidity (sign of peritonitis), bruising (seat-belt sign indicates internal injury).
• PELVIS: Tenderness on compression (if you suspect a fracture, press gently ONCE only).
• LIMBS: Deformity, wounds. Check Circulation-Sensation-Movement (CSM) before and after applying any splint.
• BACK: Log-roll only if indicated (maintaining perfect spinal alignment), look for wounds.
• VITAL SIGNS: Pulse, respiration rate, BP, temperature, SpO2, blood glucose.
• RECORD EVERYTHING: Times are crucial (tourniquet time, seizure duration, CPR start time).

Paediatric Modifications of Primary Survey

• Responsive check: Tap the feet or shout; infants respond well to touch.
• Pulse check: Brachial artery (inner upper arm) because the neck pulse is very hard to feel in chubby infants.
• Breathing rate normal: Newborn 30–60; infant 25–40; child 20–30 breaths/min.
• CPR: 1 rescuer for child/infant = 30:2. 2 rescuers = 15:2. Depth is ~5 cm for a child, ~4 cm for an infant. Compress with 2 fingers (single rescuer infant) or 2-thumb encircling (2 rescuers).
• Airway: Neutral or slight "sniffing" position for infants. Because they have a large occiput (back of head), you may need a small towel roll under their shoulders. Avoid overextending the neck, as it collapses their soft, tiny airway.

3. HAEMORRHAGE (Severe Bleeding)

Definition: Loss of blood from the circulatory system — externally or internally — severe enough to threaten life.

Physiology (Why bleeding kills): An adult's blood volume is ≈ 7% of body weight (~5 Liters in a 70 kg adult); child ~8%; infant ~80–90 mL/kg. Loss of >15% volume triggers the body to compensate (tachycardia, vasoconstriction). Loss of >30–40% leads to decompensated shock. Loss >40% leads to death without rapid control and replacement. Every minute of uncontrolled arterial bleeding drastically reduces survival.

Classification A — By Vessel

Classification B — By Site

• External: Visible — wound bleeding, nose (epistaxis), mouth, etc.
• Internal: Concealed — into the chest (haemothorax), abdomen (liver/spleen rupture), pelvis, thigh (a femur fracture can lose 1.5 Liters of blood internally!), or skull (head injury). Have a high index of suspicion after blunt trauma!

Classification C — Classes of Haemorrhagic Shock (Adult)

★ EXAM PEARL: Notice that in Class II, the Blood Pressure is still NORMAL! Tachycardia and anxiety are the early warnings. Never wait for low BP to declare shock!

Signs of INTERNAL Bleeding (Memorise this list)

• Shock signs with no visible external wound.
• Pain, swelling, or tenderness over a body region; severe bruising (ecchymosis).
• Rigid, distended, board-like, tender abdomen (liver/spleen rupture).
• Vomiting bright red blood (haematemesis) or "coffee-ground" vomit.
• Black tarry stool (melaena) or fresh blood in stool.
• Blood in urine (haematuria).
• Femur fracture — massive thigh swelling, shortening, and unnatural rotation of the leg.

First Aid Management of External Bleeding (Step-by-Step)

• DANGER + Put your gloves on!
• Direct pressure: Press a sterile gauze or clean cloth firmly directly on the wound with your palm. Ask the casualty or a bystander to press it while you prepare a dressing.
• Elevate: Raise the bleeding limb ABOVE heart level. This reduces hydrostatic pressure at the wound. (Skip this if the limb is fractured or if moving it causes severe pain).
• Apply dressing + Firm bandage: Create a "pressure bandage" over the pad.
• If blood soaks through: ADD layers on top! Never remove the original dressing, because pulling it off rips off the blood clots and restarts the bleeding.
• Wound packing: For deep narrow wounds (groin, axilla, neck junctions where a tourniquet is impossible) — pack gauze deep into the wound and hold heavy pressure for a minimum of 3 minutes.
• Tourniquet: Used ONLY for life-threatening LIMB bleeding that direct pressure cannot stop.
  • Place 5–7 cm above the wound. NEVER place it over a joint (knee/elbow).
  • Tighten it until the bleeding completely stops (and the distal pulse is absent).
  • WRITE THE TIME of application on the casualty's forehead, bandage, or notebook.
  • Do NOT loosen it periodically. (Modern guidance says removal is only done by clinicians in the hospital).
• Splint the limb if a fracture is suspected.
• Treat for shock: Lie them flat, keep them warm, give NOTHING by mouth, and reassure them.
• Urgent Evacuation: Call 999/112 / 0800 211 088 immediately.

Special Bleeding Situations

• Internal Bleeding: Lie the casualty flat on their back (legs slightly raised if there is no pelvic/spinal injury). Give absolutely no food or drink. Keep warm. Nothing pressed on the abdomen. URGENT hospital transfer — surgery is the only cure; first aid only buys time.
• Nose Bleed (Epistaxis): Have the casualty sit down and lean FORWARD. Pinch the soft fleshy part of the nose for 10–15 mins. Spit blood out (swallowing blood causes vomiting). Apply a cold pack on the bridge of the nose. Do NOT tilt the head back, and do not pack the nose blindly.
• Amputation: Wrap the stump in a tight pressure dressing. Send the amputated part to the hospital with the casualty. Wrap the severed part in a clean, moist cloth, place it inside a sealed plastic bag, and float that bag in ice/cold water. (Never let the amputated tissue touch ice directly, it causes frostbite and ruins replantation chances).
• Impaled Object: NEVER pull it out! Stabilise it heavily with bulky dressings, cut around the object to expose it, and transport the casualty carefully.

4. SHOCK

Definition: Shock is a clinical state of inadequate tissue perfusion and cellular oxygenation resulting from circulatory failure, leading to cellular hypoxia, organ dysfunction, and death if uncorrected. (Note: Do not confuse this with "emotional shock" in exams!)

Pathophysiology (The simple 3-stage story)

• 1. The Trigger: Something drastically reduces effective circulation (massive blood loss, heart pump failure, severe vasodilation, or obstruction).
• 2. The Body Compensates: The heart speeds up (tachycardia) to pump harder, and blood vessels constrict to push blood away from the skin, kidneys, and gut toward the brain and heart. BP is maintained early on. Adrenaline causes anxiety, thirst, and sweating.
• 3. Compensation Fails: The body runs out of energy. BP crashes. Organs fail (kidneys stop making urine; brain becomes confused; heart develops arrhythmias) leading to the irreversible stage, and finally death.

Types of Shock

• 1. HYPOVOLAEMIC SHOCK: (Most common in first aid). Causes: Haemorrhage (wounds, internal), plasma loss from severe burns, massive vomiting/diarrhoea (Cholera!), dehydration. Clue: History of fluid loss + flat neck veins. First aid: Stop the loss (pressure on bleeding), lie flat with legs raised, warmth, ORS (only if fully conscious, mild loss, and no abdominal injury), urgent referral.
• 2. CARDIOGENIC SHOCK: Causes: Heart attack, severe arrhythmias, heart failure. Clue: Chest pain, severe breathlessness, pink frothy sputum, history of heart disease. First aid: Rest semi-reclined (they cannot breathe lying flat!), loosen clothing, reassurance, Aspirin 300 mg chewed (if conscious/not allergic), urgent transfer. Do NOT raise their legs high (it dumps blood onto a failing heart).
• 3. ANAPHYLACTIC SHOCK: (Severe allergy). Causes: Drugs (Penicillin), foods (peanuts, eggs), insect stings, vaccines. Clue: Rapidly progressing itching/hives, facial/tongue/lip swelling, wheeze/stridor, hoarse voice, breathing difficulty, sense of doom. Can kill in minutes! First aid: Lie flat with legs raised (EXCEPTION: if breathing difficulty is severe, semi-sit). Remove the trigger (scrape out bee stings). Maintain airway. Administer Adrenaline IM into the anterolateral thigh if trained (0.5 mg adult; repeat every 5 min if no response). Urgent transfer even if improved (biphasic reactions occur).
• 4. SEPTIC SHOCK: Causes: Severe overwhelming infections (pneumonia, meningitis, peritonitis, severe malaria in children). Clue: High fever (or hypothermia), infection source, confusion, fast breathing. First aid: Refer urgently; do not use cold cooling baths; monitor vitals.
• 5. NEUROGENIC SHOCK: Causes: Spinal cord injury, severe pain, emotional shock (vasovagal faint — which is brief and self-limiting, but rule out injury first). Clue: Warm, dry, pink skin (unlike cold/clammy in hypovolaemia!), extremely slow pulse with low BP. First aid: Spinal immobilisation, flat, warmth, urgent transfer.
• 6. OBSTRUCTIVE SHOCK: Causes: Tension pneumothorax, cardiac tamponade, massive pulmonary embolism. First aid: You cannot fix this in the field. Fastest possible evacuation.

5. CARDIAC ARREST

Definition: Abrupt loss of heart function resulting in no effective circulation, no pulse, and no normal breathing.

Note: A "Heart Attack" (myocardial infarction) is a blockage of a coronary artery. The casualty is usually CONSCIOUS with severe chest pain. A heart attack can LEAD to cardiac arrest. Do not confuse them in exams!

Recognition (The 3 Key Signs)

• Unresponsive (no response to voice or pain).
• Absent or abnormal breathing (agonal gasps only).
• No carotid pulse (checked for ≤10 seconds). If you are unsure and they are not breathing, treat it as an arrest!

CPR Technique (Adult)

• Position casualty on a firm, flat surface (floor or hard board). Kneel beside the chest.
• Hand position: Heel of one hand on the centre of the chest (lower half of the sternum). Second hand on top, interlock the fingers. Keep your arms completely straight, with your shoulders directly over your hands.
• Compressions: Rate of 100–120/min. Depth of 5–6 cm. Allow FULL chest recoil between pushes. Minimize interruptions to less than 10 seconds.
• Breaths: 30 compressions : 2 breaths. Use head-tilt chin-lift, pinch the nose, seal lips, give 1 second per breath watching the chest rise. (Hands-only CPR is acceptable if you are unwilling/unable to give breaths without a mask).
• Swap compressors every 2 minutes to avoid exhaustion (with a <5s swap time).
• Reassess signs of life ONLY briefly every 2 minutes or when the AED is analyzing. Do NOT stop for long pulse checks.

AED (Automated External Defibrillator) Use Steps

• Switch on the AED and follow the voice prompts.
• Expose the chest; wipe it dry; shave excessive hair rapidly if the pad won't stick.
• Attach pads: One on the upper right chest below the clavicle, the second on the left side below the armpit ("Right shoulder, left ribs").
• CLEAR! Ensure nobody is touching the casualty while the AED analyses the heart rhythm.
• If SHOCK advised → ensure everyone is clear → press the shock button.
• If NO shock advised → resume CPR compressions immediately.
• Continue 2-minute cycles until the casualty breathes normally, EMS takes over, or the scene becomes unsafe.

CPR in Special Situations

• CHILD (1 yr to puberty): Depth is ~5 cm (⅓ of the chest). 2 rescuers use a 15:2 ratio. Start with 5 rescue breaths if it is DROWNING/ASPHYXIA.
• INFANT (<1 yr): Use 2 fingers or the 2-thumb encircling technique. Depth is ~4 cm. Check the brachial pulse.
• DROWNING: Always give 5 initial rescue breaths BEFORE starting compressions (because they arrested due to lack of oxygen!).
• PREGNANT: Hand position is slightly higher on the sternum. Apply LEFT TILT (wedge a coat under her right hip) or perform manual uterine displacement to move the baby off the vena cava, improving blood return to the heart.
• HYPOTHERMIA: Check the pulse for up to 1 MINUTE (a freezing heart beats very slowly). Do not stop CPR until rewarmed in the hospital ("They are not dead until they are warm and dead").

When to STOP CPR: Signs of life return (normal breathing/movement), an EMS/clinician of equal or higher skill takes over, you are completely physically exhausted and alone, the scene becomes unsafe, or a valid DNAR (Do Not Attempt Resuscitation) order is presented.

6. CHOKING

Definition: Obstruction of the airway by a foreign object preventing airflow, leading to asphyxia if not relieved. Common causes: Meat chunks, bones, groundnuts, coins, sweets, vomit.

Recognition — Graded Severity

• MILD obstruction: Coughing effectively, able to speak/cry, may wheeze. Action: ENCOURAGE coughing; monitor closely. Do not interfere physically yet.
• SEVERE obstruction: Weak/ineffective or no cough, cannot speak or breathe, clutching the throat (the universal choking sign), silent or high-pitched stridor sounds, cyanosis, severe panic. Action: Act IMMEDIATELY.
• UNCONSCIOUS: Found collapsed, not breathing, may have food/vomit in mouth.

Management — Conscious Adult/Child (>1 yr)

• Ask: "Are you choking? Can you cough?"
• Lean the casualty well forward (let gravity help).
• Give 5 BACK BLOWS: using the heel of your hand directly between their shoulder blades. Give sharp, hard blows.
• If ineffective, give 5 ABDOMINAL THRUSTS (Heimlich Maneuver): Stand behind them, make a fist (thumb side in) and place it slightly above the navel and strictly BELOW the xiphisternum. Grasp your fist with your other hand, and pull IN and UP sharply.
• Alternate 5 back blows : 5 abdominal thrusts. Continue until the object is expelled or the casualty collapses.
• Aftercare: All choking casualties who received abdominal thrusts must go to the hospital for review (internal organ injury from the thrusts is very possible).

Special Choking Scenarios

• INFANT (<1 yr): Sit them on your thigh, head DOWN. Give 5 back blows (supporting the head/jaw) → turn them over → give 5 CHEST THRUSTS (using 2 fingers on the lower sternum, 4 cm deep). Alternate these. NO abdominal thrusts for infants (massive risk of liver rupture).
• PREGNANT / OBESE: Use chest thrusts instead of abdominal thrusts.
• ALONE & CHOKING: Perform a self-thrust with your fist above the navel by pressing against the hard edge of a chair back or counter, or press your own fist violently inward and upward.
• UNCONSCIOUS after choking: Lower them to the ground. Call 999/112 / 0800 211 088. Start CPR (30:2). Before giving each breath, OPEN THE MOUTH and look for the object. Remove it only if it is clearly visible using a finger sweep with a hooked finger. Do NO blind sweeps. Do NO abdominal thrusts on an unconscious person.

7. EPILEPSY / SEIZURES

Definitions:

• Seizure: Sudden, excessive, abnormal electrical discharge of brain neurons causing transient altered consciousness, behaviour, or movement.
• Epilepsy: A neurological tendency to have recurrent unprovoked seizures.
• Convulsion: A seizure presenting WITH motor (jerking) features.

Phases of a Tonic-Clonic Seizure (Grand Mal)

• AURA: A warning sign (strange smell/taste, fear) before the seizure.
• TONIC Phase: Sudden loss of consciousness, body rigidity, back arched, eyes rolled up. May cry out as air is forced past vocal cords. Lasts ~10–30s. Breathing may pause causing cyanosis.
• CLONIC Phase: Rhythmic, violent jerking of limbs and body. Jaw clenching (biting the tongue), frothing at the mouth, possible incontinence of urine/stool. Lasts 1–2 mins.
• POSTICTAL Phase: The body goes limp. Deep, loud breathing. Casualty is extremely drowsy, confused, has a headache, and wants to sleep.

First Aid — During the Seizure (DOs)

• Stay calm; note the START TIME (announce it out loud).
• Protect from injury: move furniture/hard objects away, cushion the head with a folded cloth or your hands. Loosen tight collars.
• Turn the casualty onto their SIDE as soon as it is safe to do so (maintains airway; allows saliva/blood/vomit to drain out).
• Protect their dignity: shield them from the crowd, stop people from staring or taking videos.
• Stay with them until they are fully awake. Orient them calmly ("You had a seizure; you're safe; I'm a nurse").

When is a Seizure a Medical Emergency? (Call 999/112): It is their first-ever seizure. The seizure lasts >5 minutes (Status Epilepticus - brain damage risk). They have repeated seizures without waking up in between. They do not start breathing normally after the jerking stops. They are injured, pregnant, diabetic, or the seizure happened in water. It occurs with a high fever + stiff neck (suspect Meningitis).

8. ASPHYXIA

Definition: Deficient oxygenation of blood and tissues with retention of carbon dioxide (hypoxia + hypercapnia) — effectively, suffocation. Ends in unconsciousness, brain damage (within 4–6 mins), and cardiac arrest.

Mechanisms (Causes)

• Obstruction: Foreign body, tongue fall-back, asthma swelling, vomit.
• External compression of neck: Strangulation, hanging.
• Smothering: Pillow, plastic bag over the head.
• Chest crush: Buried in a trench collapse, severe crush injury.
• Poison Gas: Carbon Monoxide (fires, leaving a charcoal jiko burning in a closed room, generator exhaust — VERY common in Uganda!), chemicals (H2S in latrines), Carbon dioxide accumulation in deep wells.

First Aid Management (General Asphyxia)

• REMOVE THE CAUSE: Bring them to fresh air, cut the hanging ligature, clear the airway, or drag them from the gas area (ONLY with protection/ventilation).
• Open the airway (head-tilt chin-lift); suction any vomit; remove dentures.
• If breathing is absent → start rescue breaths (use a barrier). If pulse is absent → full CPR.
• If unconscious but breathing → put in the Recovery Position.
• Loosen clothing and keep warm to prevent hypothermia.
• OXYGEN 100%: Absolutely essential in Carbon Monoxide poisoning. It physically displaces the CO from the haemoglobin.
• Refer ALL asphyxia cases to the hospital (brain/lung injury can be delayed by hours).

9. DROWNING

Definition: Respiratory impairment from submersion/immersion in liquid, leading to hypoxia (may be fatal or non-fatal). The lethal problem is the LACK OF OXYGEN, not necessarily the amount of water in the lungs.

First Aid Management (Sequence)

• SHOUT for help; call 999/112 / 0800 211 088; send for an AED.
• RESCUE FROM SAFETY:
  • REACH with a pole/branch/oar.
  • THROW a rope/buoy/life ring/jerrycan.
  • ROW a boat to them.
  • GO (Swim) ONLY if you are a highly trained rescue swimmer, and take a flotation device with you. Always approach a struggling drowning victim from BEHIND (they will panic, climb on you, and drown you).
• Remove them from the water, supporting the head/neck if a spinal injury is possible (diving/surfing/falling).
• Check response → open airway → check breathing (≤10 s).
• NOT breathing → give 5 INITIAL RESCUE BREATHS immediately. (Drowning is a hypoxic arrest; they desperately need oxygen first!). Then proceed to 30:2 CPR. Use an AED when available (dry the chest first).
• Vomiting is incredibly common during drowning rescue breaths: turn them to the side quickly, clear the mouth, and continue.
• ALL casualties must go to the hospital for observation even if they wake up and feel fine. Even a tiny bit of aspirated water damages lung surfactant, causing Secondary Drowning (fatal pulmonary oedema hours later).

10. Clinical Scenarios (OSCE Prep)