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EMERGENCY AND DISASTER NURSING BY: Darran Earl Gowing, BSN, RN TERMS USE: Trauma Intentional or unintentional wounds/injuries on the human body from particular mechanical mechanism that exceeds the body s ability to protect itself from injury

Emergency Management Triage process of assessing patients to determine management priorities. traditionally refers to care given to patients with urgent and critical needs.

First Aid an immediate or emergency treatment given to a person who has been injured before complete medical and surgical treatment can be secured.

BLS ACLS Set of clinical interventions for the urgent treatment of cardiac arrest and often life threatening medical emergencies as well as the knowledge and skills to deploy those interventions. level of medical care which is used for patient with illness or injury until full medical care can be given.

Defibrillation Restoration of normal rhythm to the heart in ventricular or atrial fibrillation

Disaster Any catastrophic situation in which the normal patterns of life (or ecosystems) have been disrupted and extraordinary, emergency interventions are required to save and preserve human lives and/or the environment

Mass Casualty Incident situation in which the number of casualties exceeds the number of resources

Post Traumatic Stress Syndrome


characteristic of symptoms after a psychologically stressful event was out of range of an normal human experience

SCOPE AND PRACTICE OF EMERGENCY NURSING The emergency nurse has had specialized education, training, and experience. The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical, hands-on skills required to care for patients in an emergency situation. Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly. Although a patient may have several diagnosis at a given time, the focus is on the most life-threatening ones ISSUES IN EMERGENCY NURSING CARE Emergency nursing is demanding because of the diversity of conditions and situations which are unique in the ER. Issues include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. The emergency nurse must expand his or her knowledge base to encompass recognizing and treating patients and anticipate nursing care in the event of a mass casualty incident. Legal Issues Includes: Actual Consent Implied Consent Parental Consent

Good Samaritan Law Gives legal protection to the rescuer who act in good faith and are not guilty of gross negligence or willful misconduct.

Focus of Emergency Care

Preserve or Prolong Life Alleviate Suffering Do No Further Harm Restore to Optimal Function Golden Rules of Emergency Care Do s Don ts let the patient see his own injury Make any unrealistic promises Obtain Consent Think of the Worst Respect Victim s Modesty & Privacy

Guidelines in Giving Emergency Care A Ask for help I Intervene D Do no Further Harm Stages of Crisis 1. Anxiety and Denial encouraged to recognize and talk about their feelings. asking questions is encouraged. honest answers given prolonged denial is not encouraged or supported 2. Remorse and Guilt verbalize their feelings 3. Anger way of handling anxiety and fear allow the anger to be ventilated 4. Grief

help family members work through their grief letting them know that it is normal and acceptable Core Competencies in Emergency Nursing Assessment Priority Setting/Critical Thinking Skills Knowledge of Emergency Care Technical Skills Communication Assess and Intervene Check for ABCs of life A Airway B Breathing C - Circulation Team Members Rescuer Emergency Medical Technician Paramedics Emergency Medicine Physicians Incident Commander Support Staff Inpatient Unit Staff Emergency Action Principle I. Survey the Scene Is the Scene Safe? What Happened? Are there any bystanders who can help? Identify as a trained first aider! II. Do a Primary Survey

organization of approach so that immediate threats to life are rapidly identified and effectively manage. Primary Survey A - Airway/Cervical Spine - Establish Patent Airway - Maintain Alignment - GCS 8 = Prepare Intubation B Breathing - Assess Breath Sounds - Observe for Chest Wall Trauma - Prepare for chest decompression C Circulation - Monitor VS - Maintain Vascular Access - Direct Pressure Estimated Blood Pressure SITE Radial SBP 80

Femoral 70 Carotid 60

Control of Hemorrhage D Disability - Evaluate LOC - Re-evaluate clients LOC - Use AVPU mnemonics E Exposure - Remove clothing - Maintain Privacy - Prevent Hypothermia

III. Activate Medical Assistance Information to be Relayed: What Happened? Number of Persons Injured Extent of Injury and First Aid given Telephone number from where you re calling

IV. Do Secondary Survey Interview the Patient S Symptoms A Allergies M Medication P Previous/Present Illness L Last Meal Taken E Events Prior to Accident Check Vital Signs V. Triage comes from the French word trier , meaning to sort process of assessing patients to determine management priorities Categories: 1. Emergent -highest priority, conditions are life threatening and need immediate attention Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open fractures of long bones 2. Urgent have serious health problems but not immediately life threatening ones. Must be seen within 1 hour Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without evidence of significant hemorrhage, fractures 3. Non-urgent

patients have episodic illness than can be addressed within 24 hours without increased morbidity Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances. Field TRIAGE 1. Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. 2. Delayed: Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. 3. Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. 4. Expectant: Injuries are extensive and chances of survival are unlikely even with definitive care. 5. Fast-Track: Psychological support needed FIRST AID Role of First Aid Bridge the Gap Between the Victim and the Physician Immediately start giving interventions in pre-hospital setting Value of First Aid Training Self-help Health for Others Preparation for Disaster Safety Awareness BASIC LIFE SUPPORT Artificial Respiration a way of breathing air to person s lungs when breathing ceased or stopped function. Respiratory Arrest

a condition when the respiration or breathing pattern of an individual stops to function, while the pulse and circulation may continue. Causes: Choking, Electrocution, strangulation, drowning and suffocation. Methods: mouth to mouth mouth to nose mouth to stoma mouth to mouth and nose mouth to barrier device When to Stop AR:  when the patient has spontaneous breathing  when the first aider is too exhausted to continue  when another first aider takes over  when EMS arrives and takes over Cardiopulmonary Resuscitation (CPR) Cardiac Arrest a condition when the persons breathing and circulation/pulse stop at the same time Causes: Cardiovascular Disease, Management: External Chest Compression consist of rhythmic application of pressure over the lower portion of the sternum just in between the nipple Heart Attack, MI


COMPLICATIONS OF CPR: RIB FRACTURE STERNUM FRACTURE LACERATION OF THE LIVER OR SPLEEN PNEUMOTHORAX, HEMOTHORAX CHAIN OF SURVIVAL EARLY ACCESS early recognition of cardiac arrest, prompt activation of emergency services EARLY BLS prevent brain damage, buy time for the arrival of defibrillator EARLY DEFIBRILLATION 7-10% decrease per minute without defibrillation

EARLY ACLS technique that attempts to stabilize patient TRAUMA Head trauma Result of an external force applied to the head and brain causing disruption of physiologic stability locally, at the point of injury, as well as globally with elevations in ICP and potentially dramatic changes in blood flow within the brain. Trauma to the skull resulting in mild to extensive damage to the brain.


Causes: vehicular accidents, fall, acts of violence, sports Types of Head Injuries 1. Open Scalp lacerations Fractures in the skull Interruption of the dura mater 2. Closed Concussions a jarring of the brain within the skull with temporary loss of consciousness Contusions a bruising type of injury to the brain; may occur with subdural or extradural collections of blood. Contrecoup decelerative forces throwing the brain back and forth Fractures e.g. linear, depressed, compound comminuted

3. Hemorrhage causes hematoma or clot formation Types of Hemorrhage/Hematoma 1. epidural hematoma the most serious type of hematoma; forms rapidly and results from arterial bleeding forms between the dura and the skull from a tear int the meningeal area

2. Subdural hematoma

- forms slowly and results from a venous bleed - a surgical emergency

3. Intracerebral hemorrhage

- bleeding directly into the brain matter

Clinical manifestations: Altered level of consciousness Confusion Papillary abnormalities Altered or absent gag reflex or vomiting Absent corneal reflex Sudden onset of neurologic deficits Changes in vital signs Vision and hearing impairment CSF drainage from ears or nose Sensory dysfunction Spasticity Headache and vertigo Movement disorders or reflex activity changes Seizure activity Assessment What time did the injury occur?

What caused the injury? What was the direction and force of the blow? Was there a loss of consciousness? What was the duration of unconsciousness? Could the patient be aroused? Emergency interventions: Goal: maintain oxygen and nutrient rich cerebral blood flow Monitor respiratory status and maintain a patent airway monitor neurological status and vital signs (TPR,BP) monitor for increased ICP Head elevation 20 -30 degrees restrict fluids and monitor I & O immobilization of neck initiate normothermia measures assess cranial nerve function, reflexes and motor and sensory function initiate seizure precautions monitor for pain and restlessness avoid administration of morphine sulfate monitor for drainage from the nose or ears if there is CSF leak, monitor for nuchal rigidity do not attempt to clean the nose, suction or allow the client to blow the nose if drainage occurs do not clean te ear of drainage when noted but apply a loose, dry sterile dressing do not allow the client to cough Medical intervention: Osmotic diuretics pulling water out of the extracellular space of the edematous brain tissue Loop diuretic reduce incidence of rebound from osmotic diuretics Opioids decreased agitation Sedatives reduced anxiety and promote comfort and agitation

Antiepileptic drugs to prevent seizures Surgical intervention: Craniotomy a surgical procedure that involves an incision through the cranium to remove accumulated blood or tumor complications include increased ICP from cerebral edema, hemorrhage or obstruction of the normal flow of CSF DENTAL TRAUMA 1. Tooth Ache Rinse mouth vigorously with warm water to clear out debris Use dental floss to remove any food that might be wedged in between the teeth Use cold pack on the outside of the cheek to manage swelling Soak cotton with Oil of Cloves and place it on aching tooth 2. Knocked- out tooth 3. Broken tooth Gently clean dirt and blood from the injured area with the use of clean cloth and warm water Use cold compress to minimize swelling 4. Bitten Tongue or Lip Using a clean cloth, apply direct pressure to the bleeding area If swelling is present, apply cold compress 5. Objects wedged between the teeth Try to remove object with a dental floss Guide the floss carefully to prevent bleeding Do not remove the object with a sharp or pointed object 6. Orthodontic Problems If a wire is causing irritation, cover the end of the wire with the use of a cotton ball/ piece of gauze until you can get to a dentist Do not attempt to remove a wire embedded in the gums, cheek or tongue. Instead, go immediately to the dentist Place a sterile gauze pad or cotton ball into the tooth socket to prevent further bleeding

7. Possible fractured jaw Immobilize the jaw by any means Apply cold compress to prevent swelling CHEST TRAUMA Approximately a quarter of deaths due to trauma are attributed to thoracic injury. Immediate deaths are essentially due to major disruption of the heart or of great vessels. Early deaths due to thoracic trauma include airway obstruction, cardiac tamponade or aspiration. Classification of Chest Trauma: Blunt Trauma results from sudden compression or positive pressure inflicted to the chest wall. Penetrating Trauma occurs when foreign object penetrates the chest wall. Types of Chest Trauma A. Blunt Chest Trauma RIB FRACTURES - Fractured ribs may occur at the point of impact and damage to the underlying lung may produce lung bruising or puncture. - Commonly a result of crushing chest injuries Assessment: - Severe Pain - Tenderness - Shallow Respirations - Client splints chest Management: 1. Rest 2. Ice Compress then Local Heat 3. Analgesia 4. Splint the chest during coughing or deep breathing FLAIL CHEST - The unstable segment moves separately and in an opposite direction from the rest of the thoracic cage during the respiration cycle - Muscle spasm - Subcutaneous Crepitus - Reluctance to move

Assessment: Paradoxical respirations Severe chest pain Dyspnea/ Tachypnea Cyanosis Tachycardia

Management: 1. High Fowler s position 2. Humidified O2 3. Analgesia 4. Coughing & deep breathing 5. Prepare for intubation with mechanical ventilation with positive end-expiratory pressure ( PEEP ) for severe respiratory failure B. Penetrating Chest Trauma - occurs when a foreign object penetrates the chest wall 1.Pneumothorax - Accumulation of atmospheric air in the pleural space may lead to lung collapse Types: 1. Spontaneous Pneumothorax 2. Open Pneumothorax 3. Tension Pneumothorax Assessment: Dyspnea Tachypnea Absent breathe sounds Sucking sound Cyanosis Tachycardia Sharp chest pain

Tracheal deviation to the unaffected side with tension pneumothorax Management: 1. Apply dressing over an open chest wound 2. O2 as Rx 3. High Fowler s 4. Chest tube placement - Monitor for chest tube system - Monitor for subcutaneous emphysema Chest Tube Drainage System - returns (-) pressure to the intra-pleural space - remove abnormal accumulation of air & fluids serves as lungs while healing is going on Pulmonary Embolism - Dislodgement of thrombus to the pulmonary artery - Caused by thrombus & pulmonary emboli - Other risk factors: deep vein thrombosis, immobilization, surgery, obesity, pregnancy, CHF, advanced age, prior History of thromboembolism Assessment: Dyspnea Chest pain Tachypnea & tachycardia Hypotension Shallow respirations Rales on auscultation Cough Blood-tinged sputum Distended neck veins Cyanosis

Management: 1. O2 as Rx

2. High Fowler s 3. Maintain bed rest 4. Incentive spirometry as Rx 5. Pulse oximetry 6. Prepare for intubation & mechanical ventilation 7. IV heparin (bolus) 8. Warfarin (Coumadin) 9. Monitor PT & PTT closely 10. Prepare the client for embolectomy, vein ligation, or insertion of an umbrella filter as Rx ABDOMINAL TRAUMA A. Penetrating Abdominal Trauma Causes: - Gunshot wound - Stab wound - Embedded object from explosion Assessment: - Absence of bowel sound - Orthostatic hypotension Management: 1. Maintain hemodynamic status IVF & blood transfusion 2. Surgery- EXLAP 3. Peritoneal Lavage B. Blunt Abdominal Trauma Assessment: - Left upper quadrant pain (Spleen) - Right upper quadrant pain (liver) - Signs of hypovolemic shock Management: - Hypovolemic shock - Pain and tenderness

1. Maintain hemodynamic status 2. Monitor VS and oxygen supplements 3. Assess signs and symptoms of shock FOREIGN BODY AND AIRWAY OBSTRUCTION CAUSES: improper chewing of large pieces of food aspiraton of vomitus, or a foreign body position of head, the tongue resulting to difficulty of breathing or respiratory arrest Types of obstruction anatomical tongue and epiglottis mechanical coins, food, toy etc Assessment and clinical manifestations: Mild airway obstruction can talk, breath and cough with high pitch breath sound cough mechanism not effective to dislodge foreign body Severe airway obstruction can t talk, breath or cough Nasal flaring, cyanosis, excessive salivation Intervention: CONCIOUS PATIENT: ask the victim, are you choking? if the victim s airway is obstructed partially, a crowing sound is audible; encourage the victim to cough. relieve the obstruction by heimlick maneuver Heimlich maneuver: stand behind the victim place arms around the victim s waist make a fist

place the thumb side of the fist just above the umbilicus and well below the xyphoid process. Perform 5 quick in and up thrusts. Use chest thrusts for the obese or for the advanced pregnancy victims. continue abdominal thrusts until the object is dislodged or the victim becomes unconscious. UNCONSCIOUS PATIENT: assess LOC call for help check for ABCs open airway using jaw thrust technique finger sweep to remove object attempt ventilation reposition the head if unsuccessful; reattempt ventilation relieve the obstruction by the Heimlich maneuver with five thrust; then finger sweep the mouth reattempt ventilation repeat the sequence of jaw thrust, finger sweep, breaths and Heimlich maneuver until successful be sure to assess the victim s pulse and respirations perform CPR if required Choking child or infant: choking is suspected in infants and children experiencing acute respiratory distress associated with coughing, gagging, or stridor. allow the victim to continue to cough if the cough is forceful if cough is ineffective or if increase respiratory difficulty is still noted, perform CPR Foreign objects in the ear Don t probe the ear with a tool Remove the object if clearly visible Try using gravity and shake the head gently Try using oil for an insect Don t use oil to remove any other object than an insect Foreign objects in the eye


Flush eye clear with use of water Foreign objects in the nose Don t probe at the object with cotton ball or other tool Breathe thru your mouth until the object is removed Blow your nose gently to try to free the object POISONING Poison Any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body. Suspect poisoning if:

1. Someone suddenly becomes ill for no apparent reason and begins to act unusually 2. Is depressed and suddenly becomes ill 3. Is found near a toxic substance and is breathing any unusual fumes, or has stains, liquid or powder in his or her clothing, skin or lips Ingestion Poisoning Botulism Clostridium botulinum. From canned foods Note: Save the Vomitus Staphylococcus Aureus from unrefrigerated cram filled foods, fish Note: Save the Vomitus Petroleum Poisoning includes poisoning with a substance such as kerosene, fuel, insecticides and cleaning fluids Note: Never induce vomiting! May result in Chemical Pneumonia

Acetaminophen Poisoning most common drug accidentally ingested by children Antidote: Acetylcysteine Corrosive Chemical Poisoning strong detergents and dry cleaners results in drooling of saliva, painful burning sensation and pain and redness in the mouth Note: Never induce vomiting, may cause further injury Activated Charcoal, Milk of Magnesia Diagnostics:

Baseline ABG should be obtained periodically Baseline blood samples (CBC, BUN, electrolytes) ECG (since many toxic agents affect cardiac rhythm) Assessment: Headache Double vision Difficulty in swallowing, talking and breathing Dry sore throat Muscle incoordination Nausea and vomiting Management: Check victim s ABCs. Begin rescue breathing if necessary If ABCs are present but the victim is unconscious, place him in recovery position If victim starts having seizures, protect him from injury If victim vomits, clear the airway Calm and reassure the victim while calling for medical help P O IS ONPrevention. Child Proofing Oral fluids in large amount Ipecac Support respiration and circulation Oral Activated Charcoal Never induce vomiting if substance ingested is corrosive LAVAGE Inhalation Poisoning Carbon Monoxide Poisoning Carbon monoxide is a colorless, odorless & tasteless gas Assessment: - appears intoxicated

- Muscle weakness - Headache & dizziness - Pink or cherry red skin (not a reliable sign) - Confusion which may eventually lead to coma Management: 1. Check ABCs 2. Remove victim from exposure 3. Loosen tight clothing 4. Administer O2 (100% delivery) 5. Initiate CPR if required SPECIAL WOUNDS Human Bites staphylococcus and streptococcus infection Management: 1. Cleanse and irrigate the wound 2. Assist with wound exploration 3. Culture the wound site 4. Tetanus toxoid and vaccine to stimulate antibody production Animal bite dog and cat bite Management: 1. 2. 3. Wash wound with soap and water Tetanus toxoid and vaccine to stimulate antibodies Rabies Vaccine and immunoglobulin Snake Bite Infection can be neurotoxic or hemotoxic Assessment: Edema

Ecchymosis Petechiae Fever Nausea and Vomiting Possible hypotension Muscle fasciculation Hemorrhage, shock and pulmonary edema Management: 1. Establish ABCs 2. Immobilize bitten arm or extremity 3. Remove constricting items 4. Provide warmth 5. Cleanse the wound 6. Cover wound with light sterile dressing 7. Don t attempt to remove the venom 8. Anti venom therapy Insect Bites/ Bee stings Assessment: Itching, dyspnea Chest tightness, dizziness, urticaria Nausea, vomiting,diarrhea Abdominal cramps, flushing Laryngeal edema Respiratory arrest Management: 1. Remove stinger by scraping 2. Cleanse the site 3. If anaphylaxis occurs, give oxygen and medications

TRAUMA RELATED TO ENVIRONMENTAL EXPOSURE HEAT EXHAUSTION Assessment: Nausea and vomiting increased temperature Muscle cramps Tachypnea and Tachycardia Orthostatic hypotension Malaise Irritability and anxiety Management: Check ABCs Move to cool area Give salted water for vomiting periods Relieve cramps by firm pressure ECG and ABG monitoring FROSTBITE Assessment: Hard, cold extremities White or mottled blue extremity Extremity insensitive to touch Management: Remove constrictive clothing and jewelry Prevent ambulation if lower extremity is involved Institute rewarming measures Once rewarmed, elevate extremity to prevent swelling Apply sterile gauze or cotton in between digits to prevent maceration NEAR DROWNING

Four Methods of Water Rescue: 1. Reaching Assist 2. Throwing Assist 3. Rowing Assist 4. Wading Assist Assessment: Abdominal distention Confusion Irritability Lethargy Shallow gasping respirations Unconsciousness vomiting Absent breathing Management: Assess ABCs Give CPR and AR as necessary Check patient s temperature Administer rewarming measures as necessary Monitor lab results(electrolytes) and ECG BURN TRAUMA Is the damage caused to skin and deeper body structures by heat (flames, scald, contact with heat) , electrical, chemical or radiation FACTORS DETERMINING SEVERITY OF BURN: 1. age mortality rates are higher for children < 4 yrs of age and for clients > 65 yrs of age 2. Patient s medical condition debilitating disorders such as cardiac, respiratory, endocrine and renal disorders negatively influence the client s response to injury and treatment. mortality rate is higher when the client has a pre-existing disorder at the time of the burn injury 3. location

burns on the head, neck and chest are associated with pulmonary complications; burns on the face are associated with corneal abrasion; burns on the ear are associated with auricular chondritis; hands and joints require intensive therapy; the perineal area is prone to autocontamination by urine and feces; circumferential burns of the extremities can produce a tourniquet-like effect and lead to vascular compromise (compartment syndrome).

4. Depth
Classification 1st degree superficial 2nd degree partial thickness 2nd degree deep partial thickness Pediermis and part of the dermis Affected Part Epidermis Description of Wound Pin, painful sunburn Blisters form after 24 hours Red, wet blisters, bullae very painful What to Expect Discomfort last after 48 hrs; heals in 3-7 days

Heals in 2-3 weeks, in no complication

Only the skin appendages in the hair follicle remain

Waxy white, difficult to distinguish from 3rd degree except hair growth becomes apparent in 7-10 days, little or no pain

Slow to heal 94-8 weeks) surgical incision and grafting unless has complication

3rd degree Full thickness

Epidermis, dermis and subcutaneous tissue . no skin appendages


Dry, leathery, may be red or black May have thrombosed veins Marked edema Distal circulation may be decreased Painless

Requires excision and grafting. 10- 14 days for graft to revascularize


4th degree deep full thickness 5. Size: Rule of nine Skin, muscle, tendon, bonde

Dry, charred, bone may be visible

Requires excision, grafting and sometimes amputation

Assessment Head and neck 1 arm Posterior trunk Anterior trunk 1 leg Perineum

Child < 3 years old 18% 9% 18% 18% 14% 1%

Adult 9% 9% 18% 18% 18% 1%

6. Temperature determines the extent of injury 7. Exposure to the Source Thermal Burns caused by exposure to flames, hot liquids, steam or hot objects Chemical Burns caused by tissue contact with strong acids, alkalis or organic compounds Electrical Burns result in internal tissue damaging, alternating current is more dangerous than direct current for it is associated with cardiopulmonary arrest, ventricular fibrillation, titanic muscle contractions, and long bone and vertebral fractures. Radiation Burns are caused by exposure to ultraviolet light, x-rays or a radioactive source. Types of Burns and their Treatment: Scald burn caused by hot liquid immediately flush the burn area with water (under a tap or hose for up to 20 min) if no water is readily available, remove clothing immediately as clothing soaked with hot liquid retains heat Flame Smother the flames with a coat or blanket, get the victim on the floor or ground (stop, drop, and Roll) Prevent victim from running If water is available, immediately cool the burn area with water

If water is not available, remove clothing; avoid pulling clothing across the burnt face Cover the burn area with a loose, clean, dry cloth to prevent contamination Do not break blisters or apply lotions, ointments, creams or powder Airway if face or front of the trunk is burnt, there could be burns to the airway there is a risk of swelling or air passage, leading to difficulty in breathing Smoke inhalation Urgent treatment is required with care of the airway, breathing and circulation When 02 in the air is used up by fire, or replaced by other gases, the oxygen level in the air will be dangerously low Spasm in the air passages as a result of irritation by smoke or gases Severe burns to the air passages causing swelling and obstruction Victim will show signs and symptoms of lack of O2. He may also be confused or unconscious Electrical check for Danger turn of the electricity supply if possible avoid any direct contact with the skin of the victim or any conducting material touching the victim until he is disconnected once the area is safe, check the ABCs if necessary, perform rescue breathing or CPR Chemical Flood affected area with water for 20-30 min Remove contaminated clothing If possible, identify the chemical for possible subsequent neutralization Avoid contact with the chemical Sunburn Exposure to ultraviolet rays in natural sunlight is the main cause of sunburn General skin damage and eventually skin cancer develops The signs and symptoms of sunburn are pain, redness and fever

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