updated for 2011 precert package - antonssports.netlifeguard/downloads/resources/precert... · 2010...

NLS

Precert

Package

Created by: RYAN RADFORD

THE

LIFEGUARDHOME® www.lifeguardhome.com

ver 6.1

Updated For

2011

NLS Precert Package 2011

Ryan Radford www.lifeguardhome.com -2-

Table of Contents

GENERAL LIFEGUARDING INFORMATION Introduction ................................................................................................................................................... 3 Evaluation Items ............................................................................................................................................. 3 Evaluation Criteria and Simulations ................................................................................................................ 4 Lifeguarding Principles ................................................................................................................................... 6 Scanning ........................................................................................................................................................ 7 NLS Procedural Update .................................................................................................................................. 8 Lifeguarding Techniques ................................................................................................................................ 9 Public Relations ............................................................................................................................................. 9 Drowning Physiology ................................................................................................................................... 10 EMS ............................................................................................................................................................. 11 Lifeguard & the Law ..................................................................................................................................... 11 Pool Chemistry............................................................................................................................................. 12 BC Pool Regulations (2010) .......................................................................................................................... 13 Respiratory/Circulatory System Anatomy....................................................................................................... 14

FIRST AID & RESUSCITATION ABC’s (The Priority Action Approach) ........................................................................................................... 14 2010 AHA CPR Standards ............................................................................................................................ 16 Primary Survey ............................................................................................................................................. 17 Automated External Defibrillator .................................................................................................................. 17 Secondary Survey ......................................................................................................................................... 19 Oxygen Therapy and Oropharyngeal Airways ............................................................................................... 20 Anaphylaxis ................................................................................................................................................. 21 Auto-injectors (Twinject® and Epi-Pen®) ........................................................................................................ 22 Bleeding Management .................................................................................................................................. 23 Burn Management ........................................................................................................................................ 24 Breathing Emergencies ................................................................................................................................. 25 Cardiovascular Emergencies ......................................................................................................................... 26 Diabetic Emergencies ................................................................................................................................... 27 Fractures/Joint Injuries .................................................................................................................................. 28 Head Injuries ............................................................................................................................................... 29 Heat-Related Disorders ................................................................................................................................ 30 Seizures (and Epilepsy) ................................................................................................................................. 31 Spinal Injuries .............................................................................................................................................. 32 Frequently Asked Questions ......................................................................................................................... 33

Q: What does the “initial 5 breaths” mean? I’ve never heard of this before. ............................................................................................................ 33 Q: How long should a “breath” take when ventilating? .......................................................................................................................................... 33 Q: Can we demonstrate 2 breaths in the water, then 3 breaths out of the water? .................................................................................................... 33 Q: What is a “Sign of Life” ..................................................................................................................................................................................... 33 Q: What is the difference between vomit and regurgitation? ................................................................................................................................... 34 Q: What are agonal respirations? ........................................................................................................................................................................... 34 Q: What is a “Guppy Breather” Spinal? ................................................................................................................................................................. 34 Q: What is the difference between “Lateral”, “3/4 Prone”, Recovery, Drainage, and Semi-Prone Position? .............................................................. 35 Q: Can I administer sugar to an unconscious, diabetic patient? .............................................................................................................................. 35 Q: What are some simple tests to help check for signs of a stroke/TIA? ................................................................................................................... 35 Q: Can a patient who has taken Viagra or Cialis safely take nitroglycerine? ............................................................................................................. 35 Q: Can a patient suffering from angina take both nitroglycerine and ASA? Which should be taken first? How long between medications? ................ 35 Q: Is it true we’re doing Back Blows for obstructions now? .................................................................................................................................... 36 Q: Can I administer an expired EpiPen or TwinJect? ............................................................................................................................................... 36 Q: How do I remove a bee stinger? ....................................................................................................................................................................... 36 Q: What do I do if someone steps on a hypodermic needle? .................................................................................................................................. 36

Additional Notes from the Precert ................................................................................................................. 37



INTRODUCTION

Thanks for downloading the 6th version of the NLS Precert Package. The first edition was developed and posted back in 2002. To date, the various editions of the NLS Precert Package have been downloaded over 2,000 times. Over the past 9 years there have been all sorts of changes to first aid, resuscitation standards, and even the Canadian NLS program itself. And although techniques change, the principles and fundamentals of lifeguarding do not. The purpose of this package is to highlight some important information pieces about lifeguarding that will hopefully remind, inform, and educate lifeguards. It is not intended to replace any manual or recognized resource materials from the Lifesaving Society or any other training agency. I hope you find the information in this package helpful for whatever purpose you’re using it for. Happy guarding!

Watch for the little “New” tags throughout the package to help identify new information or standards in this version.

EVALUATION ITEMS Candidates are often confused as to what exactly they are being evaluated on. To help inform students, the following are the evaluated items in the 2005-2011 NLS Award Guide (Feb 2004, 2nd edition):

NLS CORE Item Description 1 Lifeguarding theory and practice 2a Lifeguard Communication to public and victim 2b Lifeguard Communication to other lifeguards, supervisors, and EMS 3a Management of drowning victim 3b Management of submerged non-breathing victim 3c Management of spinal-injured victim 4 Supervision: victim recognition

NLS POOL Item Description 1 Pool Analysis 2a Pool Supervision: Scanning & Observation 2b Pool Supervision: Positioning & Rotation 3 Entries & Removals 4 Specialized Techniques 5 Pool Search: Missing Person 6a Physical Standard: Spinal Carry 6b Physical Standard: Object Recovery 6c Physical Standard: Approach and Carry 6d Physical Standard: Rescue Drill 7 Pool Lifeguarding Simulations



EVALUATION CRITERIA AND SIMULATIONS

You will be evaluated using the Lifesaving Society’s PASS / FAIL system of evaluation. The only true publication that lists the standards is the National Lifeguard Service Award Guide. The following is a list of common scenarios and/or errors that MAY constitute a Failed item. Please note that this list is only a guideline to be used by students who may not have access to the Award Guide. The author of this document takes no responsibility for failed candidates based on these criteria:

Resuscitation Techniques Unconscious breathing patient removed from water to their back Significant delay in removal from water Pool airway management of unconscious patient CPR Compressor not switched off every 2 minutes Unecessary delay of compression during CPR (more than 10 seconds) No roll for vomiting or regurgitating patient Incorrect landmarking for chest compressions (adult, child, or infant) No abdominal thrust:back blows combo for conscous patient with severe obstruction No visual check of airway during unconscious obstruction procedure Excessive delay in activating EMS for any unconscious patient

Lifeguarding Techniques Scanning - no recognition within reasonable time of DNS/Major Emergency Pool coverage not maintained for an unreasonable amount of time Pool not cleared when unsupervised for extended period of time No effort made to backup other lifeguard during emergency No repositioning to cover other lifeguard if necessary Leaving deck area without signaling to other lifeguard No signaling for backup when responding to a major emergency Negative attitude towards patrons/public during public relation incident Public relation incident completely unresolved

Lifeguarding Skills & Procedures Unsafe entry used (ie. Shallow dive) DNS approached unsafely (ie. guard directly in front of patient) No assessment or education/follow-up for a distressed or drowning swimming Head and airway submerged for any patient ABC assessment not done at nearest point of safety Barrier devices (personal protective equipment) not used Airway not protected during recovery of submerged patient Rough handling and excessive movement of patient Missing person scenario not immediately communicated to other lifeguard No immediate underwater search performed for missing person Inability to adapt to unique facility design (hot tub, sauna, deck spinal, etc.)

Use of Equipment Patient not immobilized from stable to unstable on spineboard Poor lifting techniques causing uncessary movement to patient on board Improper lifting techniques (using back for lifting) Sandbags or V-blocks not removed for victim roll on spine board (vomit/regurgitation) Oxygen not used when necessary and available No oral airway used when necessary and available Unfamilar with oxygen unit Dangerous handling of oxygen unit



Evaluation Criteria (cont) Patient Care / First Aid

General No hazard check before entering scene ABC’s not assessed Failure to perform a systematic secondary survey/assessment of a major patient

Spinal-Injured Patient Modified jaw-thurst not used when assessing or resuscitating spinal-injured patient Full body immobilization not done for any spinal-injured patient (cervical, thoracic, lumbar, etc.) Any loss of immobilization for spinal-injured patient No assessment of severity of spinal injuries Spine board strap done directly over injury site

Cardio-Respiratory Emergency Excessive movement of chest pain / shortness of breath patient Chest pain / S.O.B. patient not assisted into position of comfort No attempt to intervene in respiratory distress (medication, pursed-lip breathing, assisted vents)

Soft Tissue Wounds/Burns No control of deadly bleeding No cooling of any degree burn Dry chemical burn not brushed off before flushing Non-superficial embedded object removed Needle prick not allowed to bleed for 10 minutes and/or not washed with soap and water

Medical Emergencies Proper history not obtained regarding ASA for chest pain patient (4A’s) No check for history of E.D. drug use prior to assisting with nitroglycerine Auto-injector (EpiPen® or TwinJect®) not administed to anaphylactic patient when patient cannot self-

administer Auto-injector (EpiPen® or TwinJect®) administered correctly to anaphylaxis patient (safety cap not

removed, not held for correct time, no post-injection massage,etc.) TwinJect® second dose not administered correctly Medications not determined or assisted for patient experiencing medical emergency Insulin assisted to diabetic patient with low blood sugar (hypoglycemic) Sugar adminstered to unconscious patient Restraining of seizing patient

Environmental Conditions Improper re-warming of hypothermic patient (ie. placing in hot tub, rubbing extremities) Improper cooling of heat-related patient depending on condition

Fracture/Joint Injury No assessment of fracture/joint injury (distal circulation and point tenderness) to determine severity No immobilization of fracture/joint injury Ice applied to injury with decreased distal circulation Attempt to relocate a disclocation

Head/Facial Injury Does not assess head/facial injury for potential spinal injury Vital signs not recorded for severe head injury

Poisoning Poison Control Center not contacted for poisoning



LIFEGUARDING PRINCIPLES

Principles of Preventative Lifeguarding 1) Lifeguards should move into action before swimmers realize they are in trouble

2) The closest lifeguard should deal with each incident

3) Each lifeguard must know where and what each other lifeguard is doing on deck at all times

4) When one lifeguard moves to deal with an incident, the other lifeguards must relocate to

adequately cover the 1st lifeguard’s area

5) Lifeguard-to-patron communication must be handled with courtesy and care

6) Scanning must be continuous to be effective. NEVER TURN BACK TO POOL.

7) Scan the BOTTOM of the pool as well as the top.

Principles of Aquatic Emergency Care

1) Effective preparation for emergencies is geared towards minimizing the number of decisions made

under stress. Preparing for emergencies include the use of focal points, specific emergency

procedures, and inservice training.

2) It is faster to move on deck than it is on water.

3) Whenever a lifeguard enters water over his/her head, backup must follow immediately

4) During a rescue, getting the victim’s head out of the water is the primary concern

5) In all near-drownings, the lifeguard needs to concern themselves with the need for speed of

treatment, the need for oxygen in treatment, and the need to minimize the gross motor movements

of the victim.

6) Clearing the pool during an emergency is a lower priority than care for the patient

7) Gathering rescue equipment is a lower priority than providing backup and assessing patient.

8) When handling an unconscious victim, we must maintain an open airway and reduce the number

of gross motor movements which can induce vomiting

9) When handling an injured patient, we must provide basic life support while immobilizing the

injured area. Especially important in a spinal injury

10) When handling a heart attack, we must provide basic life support and reduce the patient’s

movement and stress.

11) A lifeguard’s function in any emergency is to provide basic life support, remove the patient from

the water, and prepare him for the ambulance crew.

PREVENTION is our number one job

Lifeguard procedures are based on having trained backup

Focal Points are used to reduce decision making

Set procedures help reduce decision making during stressful situations

Although every second counts in an emergency, we must still consider

the importance of providing QUALITY care



SCANNING

Moving is a very important part of an effective scanning technique. It helps maintain vigilance, reduces blind spots, and can help avoid glare. Don’t plant your feet!

Lifeguards need to scan the area right at their feet as this area is often missed since lifeguards tend to scan “outward”.

Scanning time should not be divided equally. You should be spending more time watching high-risk areas.

Avoid turning your back to the pool. Similarly, try to avoid ever having to use a 360° scan (if possible).

The “RID factor” summarizes reasons why victim’s still go missed (especially at the bottom):

R failure to RECOGNIZE

I INTRUSION of non-scanning duties

D DISTRACTTION from scanning

Failure to recognize victims can often be because they tend to “disappear” before ideas; this is the result of the reflection/refraction of the light hitting the water surface (image from “Disappearing Dummies by Tom Griffith)

Sample scanning

techniques that you may find helpful



NLS PROCEDURAL UPDATE Over the years, many lifeguards were taught a specific procedure designed for the management of a lower spinal cord injury. This procedure was referred to as a “Lumbar Procedure.” It typically involved immobilization from the chest to the feet with specific attention to minimizing any movement of the legs.

Recent consensus amongst the Branch medical directors and committees of the Lifesaving Society have concluded that this specific procedure may not provide enough effective immobilization for the patient. Therefore, all spinal injuries, whether they be cervical, thoracic, lumbar, etc, are to be immobilized fully from head to toe.

Trauma to the spine regardless of location (cervical, thoracic, or lumbar), is to be treated as a cervical spine injury and he victim be fully packaged. On patient request, padding may still be applied under the legs. Non-traumatic lower back injuries will continue to be addressed as a “lower systems injury.”

Spinal Injuries Lower System Injuries Mechanism of

Injury

Diving

Falls from height

Direct blow/trauma to head/neck/back

Motor Vehicle Accidents

Lifting or twisting

Repetitive movement

Previous back injury

Poor posture, muscle tone or physical conditioning

Signs &

Symptoms

Pain and/or stiffness at the site of the injury

Tenderness or muscle rigidity along the spine

Bruising, deformity or swelling along the spine

Numbness, tingling or weakness in the extremities (spinal nerve or cord injury)

Paralysis (spinal nerve or cord injury)

Pain limited to the injury site and worsened by movement

Pain may radiate away from the injury site

Muscle spasms limit the range of motion

Patient may assume a stooped position and be unable to stand up straight

Procedure

Adaptation

Full Spine Immobilization: chest, head, lower body (traditional “C-Spine” procedure)

May need to have legs supported in lower spine injury if they cannot lower them

Load in position of comfort (lateral or supine)

Head does not need to be immobilzed

Use padding for comfort

Example

[Notice no head

restraints being used. ]

“The Spine is the Spine” All spinal-injured patients should be immobilized head to toe

Padding if necessary to maintain position found



LIFEGUARDING TECHNIQUES

“Double guarding” is one of the worst habits in lifeguarding. No matter what we try to convince ourselves, when we are talking, we are dividing our attention from scanning and are therefore less effective. Keep all conversations to an absolute minimum while on duty. The focal point is a pre-determined location where all major victims are brought. Typically, this is in the same place or close by to where the emergency equipment is stored. If you ever need to leave the deck, signal your other guard with a “cover me” sign or something that ensures he/she knows you are leaving the area and are no longer scanning. Backup is needed anytime one lifeguard enters the water. If one lifeguard has a non-major victim under complete control before the other guard arrives, they may call off their backup to maximize pool coverage. Remember though, patients are your number 1 priority. Your profession is one trained in teamwork. Use it to your advantage. You must NEVER delay being backup by asking your in-water guard if they need assistance. Unless you are directly called off, you MUST enter the water to act as backup Lifeguards may be required to move quickly on the pool deck when responding to an emergency. Extreme care should be taken to avoid slipping or falling. The lifeguard must remain in control at all times. In a 2-guard situation, EMS might not be called until a victim has been removed from the water. We need to prioritize the removal. It is more important to remove the patient from the water as a team, than it is to leave the patient in water to make an early EMS call. Another staff member or bystander can always be sent to initiate a call. Likewise clearing the pool is a second priority to patient removal.

PUBLIC RELATIONS

When dealing with any public relations concern or problem, it is important to communicate to your other guard by signaling “PR.” This ensures that your other guard is aware you may not be scanning as effective as normally until you finish dealing with the situation. A few tips to remember when dealing with PR’s:

Ensure you can still guard the pool while talking to the patron. Explain to the patron why you are not keeping eye contact with them

Avoid being negative. Tell patrons what they CAN do, not what they CAN’T

Stop all dangerous activities immediately. Always follow-up with an explanation as to WHY a patron can’t do something. All rules should have a rationale.

REDIRECT all activities to something safe and fun (kids come to the pool with energy - don’t try to suppress it)

Minimize the distance between you and the patron you are dealing with (avoid the yelling)

When a patron is upset, utilize active listening skills: listen to what the person is saying, repeat their concern back to them to ensure you understand why they are upset, attempt to resolve the issue as efficiently as possible.



DROWNING PHYSIOLOGY

To drown is to suffocate in water or other fluid. A victim can drown in as little as 12-20 seconds.

Series of events in a drowning patient:

Our priority when dealing with any victim who is drowning is to quickly remove them from the pool. If they are conscious this means supporting them with their head and shoulders above the water while we transport to the nearest edge. If they are unconscious, this means protecting their airway from having water enter it and transporting to the focal point.

DELAYED DROWNING EFFECTS DUE TO ASPIRATION

Some individuals may be familiar with this as being called “secondary drowning” however this is an outdated term which should no longer be used.

As lifeguards, this is a major concern in every near-drowning person we rescue

Is caused by as a fluid accumulation in the lungs which can begin to occur within minutes to 72 hours after a drowning incident

Fluid in lungs destroys the alveoli and causes problems with breathing and eventually lack of air exchange.

This can result in “Pulmonary Edema” or swelling of the lungs. Signs and Symptoms: - Trouble breathing/Shortness of Breath

- Painful or persistent coughing - Chest Congestion - Extreme Fatigue

- Strange and abnormal behavior (especially in children)

Any patient suffering from any of these symptoms should immediately seek medical attention.

In all drowning victims, we must assess for and educate each victim about the dangers of delayed drowning

symptoms.

Example of a follow-up for any rescue of distressed swimmer:

Assess: “Can you take 2 deep breaths for me? Did you breathe in any water?”

Educate: “You have just had a near-drowning episode. Over the next 72 hours if you experience any trouble

breathing, persistent coughing, chest congestion, or extreme fatigue, you need to contact a doctor or go to

the hospital immediately and tell them what happened. Please report back to me before leaving the pool

today so I can check on you again. ”

Follow-Up: Record all information in an incident report form.

Encourage the patron to stay in shallow water or wear a lifejacket.

STRESS/ PANIC

HOLDING BREATH

TERMINAL GASP

DEATH

“SECONDARY

DROWNING”



EMS

When calling 911, speak in a calm, steady tone. Provide all information that is asked of you by the dispatcher. Ensure you are the last one to hang-up. Try to send a bystander to wait for EMS to arrive. When EMS arrives on the scene, be aware that they probably will not immediately take over from you. They will ask you to continue your treatment or resuscitation attempts, while they prepare their equipment, do further assessments, etc. Do not give them a diagnosis - that is for

the doctor to do. Tell them what happened, what you have done, any paperwork, information, vitals, etc. you have taken, as well as the patient’s personal belongings that have been gathered. Do not diagnose your victim.

LIFEGUARD & THE LAW

Liability refers to being held legally responsible for your actions/inactions. To be found liable, the plaintiff in a court case will attempt to show negligence on your behalf. In order to prove NEGLIGENCE in a court case, the following 3 items must be proved:

1) a DUTY OF CARE (was present) The lifeguard had a duty to care for the plaintiff

e.g.: patrons paid money to enter a facility that was protected by a lifeguard

2) the STANDARD OF CARE (was not met) Your standard of care are the NLS Standards

During the treatment of a victim, a standard must not have been met

This is relative to a “reasonable person in your profession” e.g.: a Victim who vomited was not rolled immediately to their side.

3) CAUSATION (was a result of not meeting the standard) Something you did was directly responsible (i.e. caused) the victim’s condition

e.g.: by not rolling the victim quickly enough when he vomited, he aspirated and died due to complications in the lungs.

Contributory Negligence is when the victim/plaintiff is partially or fully responsible for his/her condition. ex: After several warnings, a child continues to dive in the shallow end of the pool and eventually suffers a serious spinal injury. He therefore, contributed to his own condition. An important legal responsibility of lifeguards is to keep accurate and well-kept records. This can include pool chemical records, pool clarity reports, incidents, and maintenance logs. These can prove to be valuable for:

Pool Chemistry trends (to anticipate problems)

Legal situations such as lawsuits

Pool Operation Cost analysis

Staff work records

Problem/Hazard areas in the pool



POOL CHEMISTRY

Disinfection (Chlorine/Bromine)

Chlorine (or Bromine) is used to disinfect the pool water. It can be used in 3 different states: solid, liquid, or gas (most effective). Once the chlorine is in the water, there are 3 forms of it. FAC (free available chlorine) is the amount of chlorine molecules free to attack the nasty little ammonia products that were left by the bus load of preschoolers. According to the 2010 BC Pool Regulations FAC levels should be maintained at:

0.5 ppm for a pool less than 30 degrees

1.5 ppm for a pool over 30 degrees CAC (combined available chlorine) is the amount of chlorine molecules combined with an ammonia product – these are also known as chloramines (chloramines are what can be smelt at many pools when you walk in).

When CAC levels get too high or a pool fouling occurs, a superchlorination is done. TAC (total available chlorine) is the total chlorine in the pool. This is obtained by adding FAC + CAC.

Ozone Ozone (O3) is an alternate way of disinfection. In an Ozone pool, water is sent through an ozone generator in the mechanical room where the “baddies” are destroyed. However, even in an ozone system, there is still a need for chlorine in the main pool to deal with immediate contaminations. Ozone leaks can be very dangerous. As such, alarm systems are installed and emergency procedures regarding a leak must be practiced.

Ultraviolet Although still more expensive, many pools are using a UV system for disinfection. Advantages of a UV system include:

Requirement reduction by up to 60%

Reduction of chloramines and other pollutants.

Much like ozone, because the disinfection happens outside of the pool, a residual chlorine level must be maintained in the pool.

pH

acidic neutral basic

1 2 3 4 5 6 7 8 9 10 11 12 13 14

pH measures the concentration of H+ ions in the water. This should be maintained between 7.4 and 7.8. Low pH is acidic and can cause pipe corrosion. High pH is basic and can cause pipe scaling. Both can cause patron discomfort. To lower the pH, use muriatic or hydrochloric acid. To raise the pH use Soda Ash or Sodium Bicarbonate (Baking Soda).

BC Pool Regulations: 7.2-7.8

FAC Ammonia “Baddies”

CAC



BC POOL REGULATIONS (2010)

In October 2010, after 38 years, the BC Government replaced the 1972 Health Act with the 2010 Pool Regulations. The following is a highlight of what lifeguards need to be aware of:

Definition of a Lifeguard A lifeguard must be 16 years old, hold certification(s) as outlined in the Pool Safety Plan and receive training in the Pool Safety Plan prior to lifeguarding.

A lifeguard is responsible for the conduct and safety of all pool patrons, and is to perform no duty other than pool surveillance.

Pool Safety Plan: By Oct 2011, all public pools must have an approved written pool safety plan which is a detailed written plan containing emergency, operating and cleaning/maintenance procedures in addition to required first aid/lifesaving equipment. The facility must:

a) prepare a written pool safety plan to ensure the health and safety of pool patrons, b) make the plan readily available to pool employees, c) train each pool employee in the procedures and in the use of the equipment described in the plan, d) review and update the pool safety plan at least once each year.

The pool safety plan must include:

a) procedures to be followed in the event of a serious injury, emergency or incident, b) the type of lifesaving, lifeguarding and first aid equipment to be kept within the immediate vicinity of the pool, c) the number of lifeguards and other employees who are to be on duty while the pool is in use in order to ensure

adequate supervision of pool patrons, d) operating procedures for the pool, and e) the program of cleaning and maintenance of the pool, including the nature and frequency of the cleaning and

maintenance.

Staffing Levels

Must open with at least 1 lifeguard and 1 assistant

Max Ratio of Lifeguard to Patrons = As outlined in P.S.P.

Water Clarity and Chemical Standards

Pattern of the main drain OR a black disc (150mm in diameter) must be visible at the deepest point of the pool

Water must be tested minimum twice a day

Maximum main pool temperature 37°C (98.6°F)

pH maintained between 7.2-7.8

FAC: 0.5ppm for a pool less than 30°C 1.5ppm for a pool over 30°C

Other “No diving into the pool, except in designated areas” (note: draft guidelines stated minimum 2 m)



RESPIRATORY/CIRCULATORY SYSTEM ANATOMY

Oxygen is needed for the body to live. We breathe in 21% O2 in the air during inhalation. The air enters the body through the nose or mouth, travels past the pharynx, past the larynx (voice-box) and down the trachea. The trachea splits into two bronchi which each enter the 2 lobes of the lungs. Each bronchi splits into many bronchioles (small air passage ways) and terminate at alveoli, the small capillary-lined air-sacs where O2 and CO2 is exchanged in the blood. We exhale 16% O2. The diaphragm is the major muscle of respiration. When it contracts, it allows the chest cavity to fill with air. A high-level Cervical-fracture (C3, C4, C5) can paralyze the diaphragm making breathing impossible even if the victim is conscious!

The heart is made up of four chambers: 2 Atria (collecting chambers) and 2 Ventricles (pumps). Blood vessels (arteries, veins, and capillaries) are used to transport blood around the body. Arteries always come away from the heart (“a-away”) and always carry oxygenated blood. The one exception is the pulmonary artery which carries de-O2’d blood from the Right Ventricle to the lungs to become O2’d. Similarly, veins always carry de-O2’d blood except for the Pulmonary Veins which carry O2’d blood from the lungs to the heart. Arteries and veins are connected by capillaries, the smallest of vessels where O2 and CO2 are exchanged.

SUPERIOR

VENA CAVA

INFERIOR

VENA CAVA

AORTA

PULMONARY

ARTERIES

Carries de-O2’d blood from

upper body back to heart

Carries de-O2’d blood from lower

body back to heart

Carries O2’d blood from heart to rest of the body

Carries de-O2’d blood from heart to lungs to get O2’d

PULMONARY

VEINS

Carries O2’d blood from lungs to heart

LEFT

ATRIUM

RIGHT

ATRIUM

RIGHT

VENTRICLE

LEFT

VENTRICLE



ABC’S (THE PRIORITY ACTION APPROACH)

I. Rescue Scene Evaluation i) Ensure no danger; remove applicable dangers. ii) “What Happened?” Get history of the incident iii) Introduce self as lifeguard. Instruct victims to not move. iv) Obtain permission to help v) Check number of bystanders/number of patients vi) Don Personal Protective Equipment (gloves, mask, etc.)

II. Primary Survey i) delicate spine ii) LOC – Assess level of consciousness iii) Open Airway iv) Check Breathing v) EMS/AED

If in water, removal is typically done here vi) Check for Circulation problems (shock) vii) Rapid body survey – check for Deadly bleeding, Escaping air, Medical Alerts

III. EMS – Ensure EMS has been called

IV. Treatment (including shock) i) Blanket ii) Oxygen/Oral Airway iii) Treat patient’s condition iv) Position patient appropriately (recovery, semi-sitting, etc.) v) Rest & Reassurance

V. Secondary Survey

a) History i) Chief complaint – “What is bothering you the most right now” ii) History of chief complaint – “How did it happen? Has it happened before? etc.” iii) Allergies – Does the victim have any allergies? iv) Medications – Is the victim taking any medications? What are they for? v) Medical history – “Do you have any medical problems such as cardiac problems, respiratory problems,

asthma, diabetes, etc.” vi) PQRST – pneumonic for “Pain, Quality, Radiating, Severity, and Timing” vii) Personal Info – patients name, address, phone number, age, sex, and doctors name viii) Last Meal – When and what was the patient’s last meal?

b) Vital Signs i) Time of Day ii) LOC – level of consciousness (Alert, Responds to Voice, Responds to Pain, unresponsive) iii) P – Pulse rate and character iv) R – Respirations rate and character v) E – Eyes (equal and reactive? Size?) vi) S – Skin temp, colour, and condition.

c) Head to Toe i) Thoroughly assess the entire body to check for further injuries and/or conditions. Check for minor

bleeds, bruising, swelling, deformities, symmetry, distension, rigidity, odors, sensory function, motor function, etc.

Critical Interventions

occur here.



2010 AHA CPR STANDARDS Highlights from the new 2010 AHA CPR Standards:

C-A-B In a non-aquatic history, the rescuer should immediately begin chest

compressions after discovering no breathing or abnormal breathing. Note in an aquatic rescue, the traditional ABC protocol is still used.

Back Blows

For a conscious severely obstructed airway of an adult or child, a combination of 5 abdominal thrusts (or chest thrusts) and 5 Back Blows should be used to clear the airway.

Breathing Checks Breathing checks in the unconscious patient should be a minimum of 5

and a maximum 10 seconds in length.

In-Water Resuscitation

Research has shown that it would not be unrealistic to provide rescue breaths not exceeding 20 seconds prior to starting CPR as victims with only respiratory arrest usually respond after a few artificial breaths are given. Therefore, for any unresponsive, non-breathing patient with an aquatic history, rescuers should give 2 breaths at the nearest point of safety. 3 additional breaths at 5 second intervals should follow. If breathing does not spontaneously return after these 5 breaths, the patient should be removed immediately and CPR initiated.

EMS Call EMS should not be sent for until the breathing check is complete

AED An AED should be sent for in all unresponsive patients.

Hypothermic Assessment In the past, hypothermic patients were to be assessed for upwards of one minute before

initiating CPR. This has been reduced to a 5-10 second check.

CPR Updates Reminders

Compress at least 100 compressions/min

Adults: At least 2” compression depth

Children: At least 1/3 chest width (about 2”)depth

Infant: At least 1/3 chest width (about 1.5”) depth

Ensure proper chest recoil

Compressions should not be interrupted for more than 10 seconds

Only stop to reassess for a “sign of life”



Scene Evaluation

Level of Consciousness

Open Airway

Send for EMS & AED

Give 2 stacked Rescue

Breaths (in water)

Give 3 additional rescue

breaths (in water) Initiate CPR & AED

Sequence

REMOVAL

Initiate CPR &

AED Sequence

NO BREATHING/NO NORMAL BREATHING

Follow-Up Care

Clear Pool Call EMS

Carry Equip

delicate Spine Precautions

Check Breathing (5 sec)

PRIMARY SURVEY

PURPOSE: To discover and treat any immediately life-threatening conditions

NO

N-

AQ

UA

TIC

HIS

TO

RY

A

QU

AT

IC H

IST

OR

Y

If victim shows signs of life, reassess

breathing



AUTOMATED EXTERNAL DEFIBRILLATOR

An AED should be sent for in all unconscious patients. Whereas CPR simply keeps basic body functionality alive, an AED can actually “jump-start” the heart into a regular pattern As soon as the AED arrives on scene, the lifeguards should follow the following basic steps: 1) Turn machine on 2) Follow Prompts:

“Place Pads on Chest”

3) Shock as Advised

ON

SHOCK

AED Reminders Ensure patient is not in a puddle or somewhat in water

Dry the chest before applying pads

Chest hair should be shaved; medical patches removed

Remove oxygen before shocking patient

Children should have pads placed front and back

Child Pad Placement



SECONDARY SURVEY

PURPOSE: To continually monitor and determine more information about the patient’s condition A secondary survey should be done for any victim that requires EMS or that there is a worry that the patient may deteriorate. The Secondary survey has 3 parts: History, Vitals, and a Head-to-Toe. All information gathered during a secondary survey should be written down.

HISTORY VITALS HEAD-TO-TOE

C – Chief Complaint What is bothering the patient most right now?

H – History of C/C How did this problem occur? Has it ever happened before?

A – Allergies Is the patient allergic to anything?

M – Medications/Med. Conditions Does the patient have any medical conditions (high BP, angina, diabetes, etc.)? Does the patient have any medication? Does the medication usually help the victim when they feel this way? How do they take their medication?

P – PQRST Pain Assess P – Pain Location? Q – Quality of Pain? (sharp, dull, squeezing) R – Radiating Pain? S – Severity of Pain? (Scale of 1-10) T – Timing Pain? (Constant? How long?)

P – Patient Information Name, age, sex, address, care card #, etc.)

L – Last Meal When/what was the patient’s last meal?

T – Time Note the time? Vitals should be taken every 3-5 minutes.

LOC – Level of Consciousness A – Alert L – Lowered LOC (confused) V – Verbal stimuli produces response P – Pain stimuli produces response U – Unresponsive

P – Pulse Rate: #beats/15 sec * 4 Character: Weak/Strong, Rapid/Slow?

R – Respirations Rate: #breaths/15 sec * 4 Character: Shallow/Deep, Labored?

E – Eyes Check pupil size & reactivity Pupils Equal And Reactive to Light?

S – Skin Check skin colour, temperature, and condition. Pale, Cool, Clammy? Normal, Warm, Dry? Hot, Red, Dry?

The head-to-toe should be done to assess for any further injuries. Note, these are injuries that are NOT immediately life-threatening (these should have been discovered and dealt with during the primary survey). The Head-to-Toe is a very detailed and thorough examination. Look for symmetry, deformity, bruising, point tenderness, minor bleeds, etc. Divide the body into 6 Areas. ABCs should be continually assessed.

1) Head/Neck 4) Pelvis/Hips 2) Chest/Back 5) Legs 3) Abdomen 6) Arms



Fill in the Blanks

Oxygen cylinders always come in one of the following

colours: _silver_, __white_ or __green__

As lifeguards we use a ”__D__” size cylinder

This type of cylinder holds __2000- 2200__ psi when full

When the pressure reaches _500__ psi it must be

changed

All Unconscious victims need to receive an _____Oropharyngeal Airway______.

OXYGEN THERAPY AND OROPHARYNGEAL AIRWAYS

Understanding the benefit of using supplementary O2: As a victim goes into shock, or experience any condition that lowers their amount of oxygen to the cells, they become hypoxic. This can be noticed by seeing paleness, tingling in the extremities or cyanosis (blue-tinge around the lips). Using oxygen can greatly reverse the hypoxia and help the patient recover more quickly than without. We should be encouraging all patients to accept oxygen during our treatment. Hazards of O2 (i.e. things to avoid) F – Fire/Flame O – Oil/Grease R – Rough Handling T – Tunnel Vision OXYGEN DOES NOT BREATHE FOR A PATIENT!! IT SIMPLY SUPPLEMENTS THE AIR YOU BREATH FOR THEM!! O2 Use Flow rate is measured in: Liters per minute (Lpm)

10 Lpm is used for all BREATHING patients 15 Lpm is used for all NON-BREATHING or ASSISTED VENTS patients Oxygen flow has nothing to do with level of consciousness. How Long (in minutes) will O2 last in a tank?

10 Lpm Flow: 2100

PSI

ex: min362182100

1800 x

15 Lpm Flow: 1100

PSI

ex: min181181100

1800 x

MEASURING AN AIRWAY Measure the CURVED part of the airway from the corner of the jaw to the corner of the mouth. DO NOT use the straight part of the OPA in your measurement.

http://search.live.com/images/results.aspx?q=oxygen&FORM=BIRE&adlt_set=strict



ANAPHYLAXIS

Anaphylaxis is a severe allergic reaction that can affect multiple body systems. An anaphylactic reaction can be caused by any number of known or unknown allergens. Some common allergens include peanuts, bee stings, seafood, and latex.

Normal Appearance Anaphylactic Reaction Appearance

Signs and Symptoms Generalized itching Blotchy, raised, red bumps on

the skin (hives) Wheezing; difficulty breathing Swelling – including throat,

tongue, and face Dizziness, light headedness Unconsciousness

Treatment: EMS Monitor ABC’s Medication (Auto-Injector) Treat for Shock Monitor Carefully

Ensure the following steps have been taken BEFORE ever administering a patient’s Auto-Injector:

EMS has been called Patient has history of anaphylaxis and contact with

known allergen Only the patient’s TwinJect is used. DO NOT

administer another person’s Twinject Victim is unable to self-administer (including unconsciousness) Medication window is clear in colour

*An expired auto-injector may still be administered provided the medication window shows a clear fluid with no discoloration or precipitate.

Lifeguards are trained in the administration of Epinephrine to the anaphylactic patient

via a patient’s auto-injector (EpiPen® or TwinJect®). You should be trained with

both trainers and consult with your facility to determine their standpoint on this

procedure.

Window

s



AUTO-INJECTORS (TWINJECT® AND EPI-PEN

®)

Lifeguards should be familiar with the administration protocol of both Twinject and EpiPen brand auto-injectors. Although the principles of administration remain constant, there are slight variations in the technique. Use this as a summary of the two devices.

TWINJECT EPI-PEN

Epinephrine

Active Ingredient

Epinephrine

1. Remove BOTH Caps 2. Press red tip firmly into outer thigh

(should hear a click) 3. Hold for 10 seconds 4. Massage injection site for quick

dispersal NOTE TIME OF ADMINISTRATION

1st DOSE Protocol

1. Remove safety cap 2. Press black tip firmly into outer

thigh (should hear a click) 3. Hold for 10 seconds 4. Massage injection site for quick

dispersal NOTE TIME OF ADMINISTRATION

a. Do not bend needle

b. Place used needle carefully into the original case

Follow-Up

c. Return used auto-injector to original case or sharps container.

d. If no case is available, needle may be bent back on a hard surface to avoid an accidental prick.

After 10 minutes from 1st dose, if patient shows no signs of improvement, prepare 2nd dose: 1. Carefully unscrew base from red tip 2. Remove syringe from base unit by

gripping the blue plastic 3. Remove yellow safety collar 4. Inject needle into opposite leg of first

dose 5. Push plunger all the way down. 6. Massage injection site

2nd DOSE Protocol

No second dose available in EpiPen

Place used needle in original container Follow-Up

Cap 2 Cap

Cap 1

Twinject



BLEEDING MANAGEMENT

Bleeding can be arterial, venous, or capillary

Arterial: Blood from an artery spurts or pulses out and is bright red

Venous: Blood from a vein flows in a steadily and is a dark red col or

Capillary: Bleeding from capillaries is a continuous steady ooze; usually superficial

MINOR BLEEDING MAJOR BLEEDING

Capillaries and Veins Eg. abrasions, small cuts

TYPE Arteries and veins Eg. amputation, large, deep cuts

Blood oozes from wound SIGNS &

SYMPTOMS

Blood spurts or flows heavily from wound

INFECTION CONCERN SHOCK DEATH

Clean wound

Disinfect

Bandage

Educate

TREATMENT

Apply direct pressure

Rest Patient

Ice

EMS

Treat Shock

Indirect pressure if needed

Internal Bleeding Skin is not broken and bleeding may not be visible. An internal blood vessel may have been severed from a broken bone or severe trauma. Signs and symptoms include pain, distension, bruising and discoloration of area. This patient must obtain medical aid IMMEDIATELY. EMS priority, Minimize all movement, Place in a comfortable position, monitor and treat for shock.

2010 AHA Recommendation

“NO LONGER ELEVATE BLEEDS”

“Bleeding is best controlled by applying firm pressure that can be maintained for a long period of time. Elevation reduces the amount of pressure applied and can aggravate other injuries. “

NEEDLE PRICKS Wash with soap & water. Allow to bleed for 10 min. Send to hospital



BURN MANAGEMENT

BURN TYPE

1st Degree Burn

2nd Degree Burn

3rd Degree Burn

Description

Reddening of epidermal layer of skin.

Often caused by scalding or sunburn

Blistering of skin with accompanying reddening from damage to underlying capillaries.

Concerned with infection

Black, gray, white, leathery, dry, or charred appearance.

Damage to fatty tissue/muscle layer of skin.

Encircled by 1st and 2nd degree burns.

Treatment

Cool burn with cool running water

Cool burn with cool running water for approx 10 minutes... Ensure no high pressure which could rupture the blister.

Cover with loose, dry, sterile roll gauze

EMS needed if burn covers 15% or more of body area

EMS

Monitor ABC’s

Cool burn with running water for approx 10 minutes. Cover with non-stick, dry, sterile gauze and wrap loosely.

Administer O2, treat for shock

Monitor carefully

* Any burn that encircles a limb or covers a specialized area of the body such as the face, neck, or genitalia also requires immediate medical attention.

BURN TYPE

Chemical

Burn (Wet)

Chemical

Burn (Dry)

Electrical Burn

Description

Caused by spilling chemical onto skin.

Chemical continues to burn while in contact with skin

Caused by spilling chemical onto skin.

Chemical continues to burn while in contact with skin

May react with water

Keep yourself and others away from any uncontrolled electrical source

Do not enter scene until power has been shut off

Burns will appear similar to 3rd degree

Treatment

Immediately FLUSH with running water for a minimum of 15 minutes (20 minutes if in eyes)

Contact EMS

Retrieve MSDS Sheet

Treat victim for shock

BRUSH AND FLUSH!!

Brush Chemical off with towel, gloves, etc.

Flush with running water for a minimum of 15 minutes (20 minutes if in eyes)

Contact EMS

Retrieve MSDS Sheet

Treat victim for shock

EMS!

Monitor ABC’s

Locate both enter and exit wounds.

Cool burn for approx 10 minutes.

Wrap loosely in dry, sterile gauze.

O2, Treat for Shock

Monitor Carefully



BREATHING EMERGENCIES

The heart and lungs are the 2 main organs which maintain life (by taking in oxygen and transporting it around the body). There are many conditions that can be affected by this breathing and circulatory machinery. Asthma Attack – Attacks can be brought on by stress, excitement, or exercise. The body cannot get enough oxygen to feed itself due to airway constrictions. Patients typically take “Ventolin” in the form of puffer (it is a “bronchodilator”) which provides breathing relief. In addition, provide blanket, O2, and R&R. Contact EMS if normal breathing cannot be restored. Hyperventilation – The body’s normal drive to breath is high levels of CO2. In hyperventilation, the body’s CO2 levels decrease while the O2 levels change insignificantly. This may result in a sensation of numbness and tingling in the fingers and toes due to a lack of oxygen getting to them as well as rapid, uncontrollable respirations.. This can be treated by resting the victim and coaching them in “pursed-lip breathing” to slow down the breathing rate. Supplementary Oxygen will benefit this patient. COPD - Chronic Obstructed Pulmonary Disease includes Chronic Bronchitis, and Emphysema. These patients have permanently inflamed airways with excess mucous making it hard to breathe on an everyday basis. A COPD patient’s drive to breath is low levels of O2 (not high levels of CO2). If in respiratory distress, these patients should still be given supplementary oxygen as part of their treatment. Contact EMS and start the flow rate at 10Lpm. If their condition appears to be getting worse, reduce the flow rate of oxygen. Continue treating for shock. Assist ventilations if necessary Some common causes of inadequate breathing include:

• Chest injuries (open pneumothorax, rib fracture, flail segment, etc.) • Anaphylactic reactions • Drug overdose • Hyperventilation

BREATHING EMERGENCY TREATMENT

d-spine – ruled out LOC - conscious Airway - clear Breathing – PROBLEM Circulation…

Asthma Attack

Normal Airways

COPD

Inflamed Lining

Excess Mucous

1) Ask for Mx 2) Coach breathing 3) Apply O2 4) Assist Vents

Contact EMS if step 2 not able to help patient



CARDIOVASCULAR EMERGENCIES

Angina Attack – Occurs in patients with angina pectoris. Caused by over exertion, excitement, stress, etc. Defined as a partial blockage or LACK of blood to the heart resulting in chest pain. Usually reoccurring. Patients take Nitroglycerine (a “vasodilator”) to relieve the pain. Patient should take a maximum of 3 doses (sprays or pills) at times 0, 5, and 10 minutes. EMS should be called for all chest pain emergencies. High flow rate of O2 may help the O2 levels in the body. Make the patient comfortable and continue treating for shock. Heart Attack (Myocardial Infarction) – Defined as death or damage to an area of the heart due to a complete blockage of blood flow to that area (usually from a blood clot). Patient may have no history of chest pain. Nitroglycerine will not help the pain. This is a serious condition which requires immediate medical attention. EMS should be called for all chest pain emergencies. High flow rate of O2 will help the O2 levels in the body. Make the patient comfortable and continue treating for shock.

** Remember, we don’t diagnose our patients. Therefore we don’t have a “Heart Attack Procedure,” an “Angina Attack Procedure,” a “Congestive Heart Failure Procedure,” etc. We simply have a “CHEST PAIN PROCEDURE”

Cardiac Arrest - Patient has no blood circulation (ie. the heart is not circulating blood). Heart may be in fibrillation (rapid fluttering of the heart) or completely still (asystole). If the patient is not breathing or not breathing normally, CPR needs to be initiated. EMS should also be immediately called & an AED sent for and hooked up. NOTE: Perfect CPR only provides 25% normal blood flow through the body. It is not designed to “jump-start” the heart. It is simply a means provide oxygen and blood flow through the body until advanced care can provide further treatments. We need to minimize the time taken to contact EMS for all cardiac arrests. Stroke (CVA) – A “Brain Attack” or complete lack of blood flow to an area of brain. Because each side of the brain controls a different s ide of the body, a patient who has had a stroke may show bilateral asymmetry. Ie. Paralysis of one half the body, drooling from corner of mouth, unequal pupils, incoherent speech, etc. Place patient in a lateral position and maintain ABC’s. EMS should be called as soon as possible. TIA – A transient ischemic attack is a “mini-stroke” that may show signs and symptoms of a full stroke, although the symptoms may suddenly stop. A person suffering from a TIA has a 10x greater chance of experiencing a true stroke within 12 months. This is a warning sign. EMS should be contacted for all TIA’s and the patient treated for shock in position of comfort.

ASA (Aspirin Protocol) In the event that a responsive patient is suffering from non-traumatic chest pain, we should assist the patient in taking their own ASA (Aspirin) as part of our treatment protocol) PROVIDED they: A – are not ALLERGIC to ASA or Ibuprofen A – have no ASTHMA history A – have not been ADVISED against it by their Dr. A – have no ACTIVE bleeds (stomach, head, etc.) Adults should CHEW 1 adult ASA or 2 child ASA tablets



2005 NLS Award Guide: “Never administer anything by mouth

to an unconscious victim”

DIABETIC EMERGENCIES

Diabetes is the inability to regulate the level of blood-sugar in the body (glucose). This is usually because of a problem with insulin production in the pancreas. Without insulin, sugar in the blood stream cannot enter the cells. (think of insulin as the key that opens the door of the cell to allow sugar to enter).

Because diabetics cannot produce enough insulin on their own, they are required to obtain it by other means (regular injections, insulin pump, etc.). If a diabetic does not regulate their sugar-insulin balance carefully enough, they can suffer from serious medical conditions.

Try to determine the sugar-insulin balance in a diabetic patient using the following information.

INSULIN SHOCK (Hypoglycemia)

CONDITION DIABETIC COMA (Hyperglycemia)

BALANCE

Lack of food ( sugar)

Excessive exercise

Too much insulin Can onset over several hours

CAUSES

Patient fails to take insulin

Eats too much ( sugar)

Has an infection/cold Several days to onset

Confusion, dizziness

Drunk-Like, aggressive

Strong, rapid pulse

Cool, clammy skin

Hunger

SIGNS AND SYMPTOMS

Weakness, dizziness

Weak, rapid pulse

Warm, dry skin

Thirsty

Sweet odor on breath

Glucose in any form (juice, Monogel, sugar)

ABC’s

Shock Treatment

EMS

TREATMENT

EMS!

ABC’s

Assist with insulin

Shock Treatment

Sugar/Fuel

Insulin

Unless a diabetic patient can clearly tell you that he/she needs their insulin, don’t ever

administer or even assist with it. Always encourage sugar!!



FRACTURES/JOINT INJURIES

Large Arm Sling

Lower Arm Splint

Tube Sling

Lower Arm Splint

Collar & Cuff Sling

All fractures require medical attention. EMS or hospital transport is required in all fracture management. Fractures can be Closed (simple) in which case the bone does not break the skin surface or Open (compound) in which case the bone does break the skin surface. Examine carefully to determine if a fracture is present. Stabilize the fracture and treat any major wounds (protruding bone, etc.). After treating the wound, you should be assessing the distal circulation to assess blood flow to the lower limb. The fractures should then be immobilized in position found. This can be done using a variety of techniques including splinting, sandbags, and using the spine board (for lower system injuries in the water). Remember patients can help maintain upper system fractures by holding it in place. Following fracture treatment, the distal circulation should again be assessed. Apply ice to reduce swelling and help with pain only is if does not affect distal circulation. The Victim knows what hurts and what doesn’t, therefore allow them to tell you what form of immobilization is best for them. Never replace any dislocation.



HEAD INJURIES

All patients with any head injury severe enough to have a loss of consciousness, memory loss, or confusion must seek medical attention immediately.

CONCUSSION COMPRESSION (ICP)

TREATMENT EMS Immobilize (delicate spine) Assess ABCs Oxygen Treat for Shock Monitor ABCs Carefully

Brief short circuit of brain.

Brain bounces or rattles against the

skull following head trauma

No actual damage to brain

tissue

Internal bleeding in the cranium

Mass trauma tears blood vessel(s) on brain surface

Blood accumulation compresses the brain

Signs & Symptoms Possible loss of

consciousness

Confusion

Disorientation

Agitation

Loss of memory

Headache

Dizziness

Nausea

Signs & Symptoms Rapid deterioration

of level of consciousness

Convulsions

Paralysis

Airway Complications

Respiratory Arrest

Cardiac Arrest

Severe shock

Any patient with a head injury or facial injuries must also be assessed for the possibility of a

spinal injury.



HEAT-RELATED DISORDERS

1) Heat Cramps

Can be induced by acute exposure to heat for some duration. Often worsened by exercise. Commonly occur in extremities and abdomen.

Tx: Stretch and massage cramped area.

2) Heat Syncope (“sin-co-pee”)

Occurs when victim is sitting in hot environment such as hot tub or steam room for some amount of time. Blood vessels going to the brain become dilated and blood starts thinning slightly.

Victim then may stand up very quickly; blood rushes down the body (leaving the brain) and passes out immediately.

Victim will regain consciousness very quickly. Our biggest concern is head injury/spinal injury from falling.

Tx: ABC’s, Treat other injuries if any, O2 , EMS, Education.

3) Heat Exhaustion and Heat Stroke

HEAT EXHAUSTION HEAT STROKE

A serious disturbance of the circulation due to excessive loss of

salt and fluids from sweating Definition

A failure of the body’s heat-regulating mechanism to function. This leaves

body unable to cool. Exposure to hot, humid

environment/ excessive exercise in sun

History Exposure to a hot, humid environment or extreme heat for extended periods of

time.

Conscious and Responsive LOC Unconscious, confused, disoriented

Weak, rapid Pulse Strong, bounding, fast

Shallow and Quiet Respirations Deep and fast

PEARL Eyes Dilated, equal, reactive

Eventually Pale, Cool, Clammy Skin Red, Hot, Dry

May experience heat cramps Dehydration is a concern

Other May go into convulsions

Life-threatening Remove from source Loosen tight clothing Position of comfort Gently assist with cooling (wet

sponge, towel, etc.) Monitor Temperature Carefully Can give SMALL amount water Oxygen Educate

Treatment

Remove from source EMS ABC’s Oxygen & Treat for Shock actively cool body using cool

water over body or submersion in cool water (if alert)

Monitor carefully



SEIZURES (AND EPILEPSY)

Epilepsy is the condition of having chronic seizures. A seizure is the effect of a disturbance in the brain. Although the actual cause is not known, patients typically take medication to lessen the frequency of their episodes. Seizures are usually reoccurring therefore most epileptics wear medic alert tags on their wrist, ankle, or around their neck. NOTE: Seizures may also occur as a result of other conditions including heat-problems, drug overdoses, and hypoxic states. There are two types of seizures we should be aware of:

GRAND MAL SEIZURE PETIT MAL / “ABSENCE”

SEIZURE Progressive Phases of a grand mal seizure: 1) Aura

• Occurs several sec. before the seizure begins

• Characterized by a smell, taste, sound, etc.

• Acts as a mini-warning of the seizure

2) Tonic-Clonic • Lasts several seconds to several

minutes

• Intermittent contractions and relaxing of muscles

• Results in rapid, jerking movements

• Because of jerky movements, normal breathing is interrupted.

3) Postictal • Recovery Phase lasting upwards of 30 minutes

• Patient slowly awakes

• Patient shows decreased LOC and drowsiness

• May complain of headache, muscle ache, and sore tongue (from being bit)

Minor Form of Seizure. No separate phases:

• Seizure is very brief

• Usually occurs in children

• Characterized by staring, eye fluttering, “spacing out,” etc while patient remains conscious.

• After seizure there is a return to full and normal

• function

• Usually outgrown by adulthood

Treatment Protect Victim’s Head and Airway during seizing episode. When seizure is over, assess and maintain ABC’s, Treat for Shock, etc. EMS should be called for all seizures. DO NOT place anything in the mouth DO NOT restrain victim during seizing episode

STATUS EPILEPTICUS (“Status Seizure”):

A patient may have a prolonged seizure with convulsive activity lasting upwards of 20 minutes or more. If an in water patient continues to seizure AFTER 1 MINUTE, he/she should be carefully removed from the water during the seizing episode and continued to treat on land.



SPINAL INJURIES

The principles of any spinal injury are MMOBILIZATION and ABC’s. Regardless of the technique you choose, You must ask yourself, “Am I maintaining proper immobilization and am I keeping this person alive?” If you can answer yes to both questions you have met the principles. A Cervical Spinal Injury* can result in quadriplegia. A Lumbar Spinal Injury can result in paraplegia. History of a Spinal Injury

Shallow water dive

Head or neck trauma

Car Accident

Fall from height

Un-witnessed unconscious Signs and Symptoms of a Spinal Injury

Pain with or without movement

Point Tenderness

Deformity/ Cuts and Bruises

Loss of Bowel/Bladder control

Priapism (Males only)

Numbness and tingling

Paralysis Treatment of a Spinal Injury

Immobilize in position found (roll to prone only if patient is not breathing. Maintain immobilization throughout)

ABC’s

EMS

Oxygen/Airway

Blanket

Secondary Survey

Monitor Carefully THE GUPPY BREATHER:

A high-level Cervical Spinal Injury (C3, C4, C5) can result in paralysis of the diaphragm. This can leave the victim conscious but unable to breathe on their own. Therefore, you may have to ventilate a conscious patient in this condition. Remember: “C3,C4,C5 – Keep the Diaphragm Alive” ventilate a conscious patient in this condition. Remember: “C3,C4,C5 – Keep the Diaphragm Alive”

7 Vertebrae

12 Vertebrae

5 Vertebrae

Fused

Cervical or Lumbar Procedure?

Regardless of the area where the injury is located (C,T,L), all potential spinal injuries should be full immobilized from head to toe. All patients are securely strapped to a spine board using all straps.



FREQUENTLY ASKED QUESTIONS

Q: What does the “initial 5 breaths” mean? I’ve never heard of this before. When you take a normal first aid or CPR course, you are taught that if the patient is not breathing (or not breathing normally), you contact EMS, send for an AED, and initiate CPR. This is the latest protocol for rescuers dealing with sudden cardiac arrests. When we talk about an aquatic history, this is known as a hypoxic (low oxygen) event. There is substantial research that shows that initiating rescue breathing as quickly as possible in such an event provides the best possible patient outcome. Therefore, in the case of a drowning, we should initiate 5 breaths at the nearest point of safety (typically shallow water). The actual delivery is as possible:

“Breathe” [chest rise, chest fall] “Breathe” [5 seconds] “Breathe” [5 seconds] “Breathe” [5 seconds] “Breathe”

Following the 5th breath, is breathing has not spontaneously returned, we should immediately remove patient (if not already done) and initiate CPR.

Q: How long should a “breath” take when ventilating? According to the AHA 2010 Recommendations, a single breath of air should only take 1 second (enough to make the chest rise). A child or infant will require a smaller amount

Q: Can we demonstrate 2 breaths in the water, then 3 breaths out of the water? No. When we demonstrate this skill we want to have five quality rescue breaths in a row as soon as possible. If we are in a depth were we can control complications, then we do this in the water. If we can't control complications, then we do this out of the water. We should not demonstrate any unnecessary pauses in those five initial breaths or trying to do other things. It needs to be high quality 5 breaths... not 2 here and 3 there. And it needs to be as soon as possible (as soon as we are in a position to control complications).

Q: What is a “Sign of Life” When performing CPR, a number of reactions from the patient can occur. Some of these are involuntary, while other indicate a sign of life. It is important to only stop CPR to reassess a patient if a clear sign of life presents itself. This is not an exhaustive list, but may help guide you as to what may happen during a resuscitation.

SIGN OF LIFE NOT A SIGN OF LIFE

Victim starts to breathe normally

Active vomiting

Coughing

Seizure

Coordinated movements

Agonal breathing

Fluid buildup (regurgitation)

Loss of bowel/bladder control

Flickering eyes

Strange movements (posturing)



Q: What is the difference between vomit and regurgitation? When performing CPR, especially in an aquatic related incident, it is to be expected that fluid will begin to accumulate in the mouth and upper airway. This is considered a REGURGITATION (ie. a passive mechanism causing a backward motion of gastric content to travel up the airway). This is caused by a rescuer's actions such as rescue breathing or chest compressions. There is a common misconception from many lifeguards (and first aiders) that regurgitation and vomiting are the same thing. VOMITING is an active mechanism caused by the muscular action of the stomach to "throw up" it's contents. A patient actively vomiting may indicate something about this patient has changed and we need to be aware of this change.

If the victim vomits while performing CPR: • Roll the patient, and sweep to clear the airway • Reassess ABC's

if there is a change in victim status, the victim's vital signs should re-assessed. If a victim takes a breath or actively begins vomiting suddenly when CPR or ventilation of a victim is being performed, then the rescuer should stop and re-assess the pulse (and breathing, if breaths are recurrent). THIS IS A CHANGE IN VICTIM STATUS suggesting revival.

If the victim regurgitates while performing CPR:

• Finish the 30 compressions

• Roll the patient, and sweep to clear the airway

• Give 2 breaths

• Position and Resume CPR Regurgitation is not a change in victim status . Pausing to re-assess vital signs only delays critical circulation which, at best, during CPR provides only one-fourth to one-third of the body's normal circulation. This more acceptable management of regurgitation is confirmed in BCLS literature and has been supported by emergency physicians who have queried why re-assessment was ever taught for regurgitation. One of the underlying principles of the 2010 CPR Guidelines is to “Minimize interruptions in chest compressions.” Reassessing every time you notice some fluid causes excessive interruptions and simply diminishes the patient's prognosis.

Q: What are agonal respirations? Agonal respirations are an abnormal pattern of breathing characterized by shallow, slow (3-4 per minute), irregular inspirations followed by irregular pauses. They may also be characterized as gasping, laboured breathing, perhaps accompanied by strange vocalizations and myoclonus (a brief, involuntary twitching of a muscle ). In some cases, agonal respirations can mirror normal breathing however become less frequest with time. The cause is due to cerebral ischemia, due to extreme hypoxia or even anoxia which accompanies sudden cardiac arrest. Agonal breathing is an extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea and heralds death. Agonal respirations are commonly seen in cases of cardiac arrest , and may persist for several minutes after cessation of heartbeat. The presence of agonal respirations in these cases indicates a more favourable prognosis than in cases of cardiac arrest without agonal respirations.

Q: What is a “Guppy Breather” Spinal? Imagine a patron were to dive into shallow water and come up floating. You would assume this patient to be unconscious. However, upon rollover, the patron is wide awake but cannot speak. He is pale, appears scared, and appears to be trying to “gulp” or suck air into his lungs. This patient has caused (possibly irreversible) damage to a high level of the cervical region of the spinal cord. As a result, not only is his entire body paralyzed, but his diaphragm is paralyzed as well. This patient is conscious, but unable to breath on his own. Your job as a lifeguard is to maintain ventilations throughout your procedure. A “guppy breather” is essentially a conscious, non-breathing patient.



Q: What is the difference between “Lateral”, “3/4 Prone”, Recovery, Drainage, and Semi-Prone Position?

LATERAL ¾ Prone / Recovery / Drainage / Semi-Prone

Used for continuous monitoring of unc. victim

Cannot leave the patient (they may vomit and aspirate OR their airway may fall forward and close)

Used for unconscious, breathing victims

Used for when a lifesaver must leave a patient for some reason (to call 911, etc)

Typically not used by lifeguards

Remember: Lateral is for lifeguards; Recovery is for rescuers.

Q: Can I administer sugar to an unconscious, diabetic patient? NO. Regardless of prior training, the latest printing of the National Lifeguard Service Award Guide does not condone this procedure. As lifeguards, sugar may only be assisted to a patient who can readily control their own airway.

Q: What are some simple tests to help check for signs of a stroke/TIA? Besides a lowered LOC, confusion, poor coordination, and trouble speaking, a patient suffering from a TIA or Stroke often displays numbness or weakness on one side of the body (this has to do with one side of the brain being affected). Some simple bilateral symmetry tests can be used to help determine if the patient is suffering from this condition:

• Pupil Reactivity – Check to see if the pupils are equal and whether or not they both react appropriately to light.

• Tongue Test – Ask victim to stick their tongue straight out. The tongue may deviate to one side.

• Smile Test – Have patient smile for you. Check to ensure both sides of the mouth curl up equally.

• Squeeze Test – Have patient squeeze each of your hands as hard as they can. Check for equal strength as they do so.

• Arm Lift – Have patient lift both arms up at the same time. Watch for one side raising an arm faster or higher than the other.

Q: Can a patient who has taken Viagra or Cialis safely take nitroglycerine? No. A patient who is on nitroglycerine should be directed by their Doctor not to take Viagra or Cialis as the two drugs are contraindicated (see references below). A rescuer should consult with the EMS dispatcher prior to administering nitroglycerine to a patient who has taken Viagra or Cialis. As per pharmaceutical guidelines, a patient can potentially take nitroglycerine 1 full day (24 hours) after their last Viagra OR 4 full days (96 hours) after their last Cialis.

Q: Can a patient suffering from angina take both nitroglycerine and ASA? Which should be taken first? How long between medications? Yes. As per the CFAM (page 34) the nitroglycerine protocol for a patient suffering from chest pain is 1 dose every 3 minutes to a maximum of 3 doses in 10 minutes. If the first dose of nitroglycerine does not make the pain go away within 3-5 minutes, have the patient take a second dose of nitroglycerine. Provided the patient has ASA and meets the criteria of the 4A’s they can also chew a tablet.



Q: Is it true we’re doing Back Blows for obstructions now? Yes. According to the 2010 AHA Guidelines, back blows should be used as part of the protocol for conscious severely

obstructed patients. The treatment protocol will include: Alternating 5 abdominal thrusts and 5 back blows for adults and children

Alternating 5 chest thrusts and 5 back blows for obese or pregnant patients

Alternating 5 back blows and 5 chest thrusts for infants (no change)

IMPORTANT: The patient’s airway is parallel to the ground during back blows. The rescuer can wrap one arm diagonally across the patient’s chest and have them bend forward.

Deliver 5 firm back blows with the heel of their hand between the shoulder blades of the patient.

The patient must have a good level of consciousness prior to attempting this procedure.

Q: Can I administer an expired EpiPen or TwinJect? Yes. If an anaphylactic patient requires their AutoInjector, but it is expired, it can still be administered provided the window showing the drug appears clean and not discoloured.

Q: How do I remove a bee stinger? A small sac attached to the end of a bee stinger can still be present after a patient is stung. We don’t want the contents of the sac to be injected into the patient so DO NOT use your fingers, or even tweezers to remove the stinger. Instead, use a plastic card or your hand to brush or “scrape” the stinger out. Rarely are they any more than superficial.

Q: What do I do if someone steps on a hypodermic needle? The patient’s (and our) biggest concern will be that their may be a pathogen or disease –carrying agent on or in the needle. Ensure the needle has been secured or safely disposed of first. The wound should be thoroughly washed with soap and water and allowed to freely bleed for 10 minutes. The hope is that the pathogen will be flushed out f the body. After 10 minutes, the wound should be bandaged and the patient sent to the hospital for exposure treatment. It is not necessary to transport the needle to the hospital.

During Back Blows: Ask victim to lean forward with their airway parallel to the ground.



ADDITIONAL NOTES FROM THE PRECERT

updated for 2011 precert package - antonssports.netlifeguard/downloads/resources/precert... · 2010...

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