LD-34 First aid and CPR

Assessment criteria

***Breathing*** ACTIONS -Clear airway if necessary -Measure respiration rate •no respiration---classify victim as DECEASED •over 30 cycles/min.---classify victim as IMMEDIATE •below 30 cycles/min.---continue assessment by checking the victim's circulation ***Circulation (pulse)*** ACTIONS -Capillary refill on extremities •more than 2 seconds---classify victim as IMMEDIATE •less than 2 seconds---continue assessment by checking the victim's mental status ***Mental status*** ACTIONS -Give simple commands such as "Open your eyes," or "Close your eyes." •unable to follow commands---classify as IMMEDIATE •follows commands---classify victim as DELAYED or MINOR

Conscious infant becomes unconscious

1. • Activate the EMS system • If someone responds, send that person to activate the emergency response system. • Place the infant on a firm, flat surface 2. • Begin CPR (starting with compressions) with 1 extra step: each time you open the airway, look for the obstructing object in the back of the throat. If you see an object and can easily remove it, remove it 3. • After approximately 2 minutes of CPR (C-A-B sequence), activate the emergency response system (if no one has done so) NOTE: Do not perform blind finger sweeps in infants and children because sweeps may push the foreign body back into the airway, causing further obstruction or injury. If the infant victim becomes unresponsive, stop giving back slaps and begin CPR. NOTE: Repeat steps 3 through 5 until obstruction is cleared.

Secondary assessment

1. Check and document vital signs: - Skin Color - Temperature - Respiratory Rate - Pulse Rate 2. Gather initial information regarding the victim and the incident 3. Conduct a head-to-toe check to identify injuries

Refusal of care

A conscious and competent adult has the right to refuse any emergency medical services offered by emergency rescue personnel. The refusal must be honored as long as the person is mentally competent. Depending on specific agency policy or guidelines, an individual who refuses emergency medical services may be required to sign a release form relinquishing EMS personnel of responsibility for that individual.

Open wounds

An open wound is any injury where the skin has been broken, exposing the tissue underneath. Abrasions, incisions, lacerations, punctures, avulsions, and amputations are all examples of open wounds requiring attention to control bleeding.

Assessment and care of victim

Based on this initial assessment, peace officers may be required to provide basic care for the victim. Such care may include providing basic emergency medical services (EMS) until relieved of the responsibility by other personnel with equal or higher levels of training.

Exposure

Because of the nature of their occupation, peace officers are at a high risk of being exposed to both airborne and blood borne pathogens. NOTE: Exposure does not necessarily mean an individual will contract the illness.

Responsiveness

Before taking any action, the victim's level of responsiveness (mental status) should be determined. To determine responsiveness, the peace officer should speak with the victim directly, asking, "Are you okay?" If the victim does not respond, the officer should tap the victim or shout in order to elicit a response from the victim. Depending on the level of responsiveness, a victim may be determined to be: • alert, awake and oriented (i.e., can talk and answer question appropriately) • responsive to verbal stimuli (e.g., talking or shouting) • responsive to painful stimuli (e.g., tapping or pinching, earlobe, or skin above collar bone rubbing) If the VICTIM is...unresponsive THEN the officer should... • activate the EMS system • check the victim's breathing and circulation If the VICTIM is...responsive THEN the officer should... • control any major bleeding • treat for shock • activate the EMS system if necessary

Personal Protective Equipment (PPE)

By using personal protective equipment (PPE), EMS personnel can break the chain of transmission and prevent possible exposure and infection. Equipment to be effective, must be used and cared for properly. •protective gloves •eye protection •masks •gowns •ventilation devices •general supplies and equipment

Stopping CPR

CPR must be continued until: • the victim's breathing resumes • the officer is relieved by an equally or higher medically trained person • the officer is too exhausted to continue • environmental hazards endanger the rescuer (e.g., gun shots)

Cardiopulmonary resuscitation (CPR)

Cardiopulmonary Resuscitation (CPR) is a method of artificially restoring and maintaining a victim's breathing and circulation. CPR is a key element of basic life support. In order to survive, oxygenated blood must circulate through the body and reach the victim's brain. In order to ensure that this process takes place, a peace officer/first responder must: - provide external chest compressions to circulate the victim's blood - maintain an open airway - provide rescue breaths

Chain of Transmission

Chain of transmission is how pathogens are spread such as: • Infectious agent (bacteria, viruses, fungi, and parasites) • reservoir • portal of exit • mode of transmission • portal of entry • susceptible host

Rescue Breathing

Rescue breathing is the process of using one's own breaths to artificially breathe for a victim. The rescue breathing process continues until the victim is able to breathe without assistance or other breathing support is provided by EMS personnel.

Care for open wounds

Care of open wounds will require an initial assessment and then action to stop bleeding and prevention of shock. ASSESSMENT • Expose the injury site before applying bleeding control (e.g., remove, loosen, or cut away clothing covering the wound) • Assess for possible fractures associated with open wound IMMEDIATE CARE -Control bleeding • Apply direct pressure to stop bleeding • Apply a pressure bandage • Apply a tourniquet • Apply bandages snugly but not so tight as to impair circulation to portions of the body distal (farther away) -Impaled objects • Do not attempt to remove the object (Any movement of the object could cause further damage or increased bleeding.) • Control bleeding by applying pressure on both sides of the object • Do not put pressure on the object itself • Stabilize object in place by use of absorbent material NOTE: If initial bandaging does not stop the blood flow, add additional bandaging. (Do not remove initial bandaging) -Avulsions/amputations • Place partially separated skin or tissue back in proper position before applying dressing and bandage • Attempt to locate any avulsed part or amputated extremity • Keep separated part/extremity dry, cool, and protected • Do not immerse, pack in ice, or freeze separated part/extremity • Transport separated part/extremity with victim for possible surgical replacement CIRCULATION • Monitor pulse below the injury site • Check capillary circulation by pinching fingertips or toes (Color should return within two seconds to pinched area.) • If circulation is impaired, loosen bandage (do not remove) until circulation improves CONTINUED CARE • If necessary, immobilize the injury site (e.g., open fracture) • Keep the victim lying still • Maintain pressure on wound • Monitor the victim • Reassure the victim (Fear and anxiety can increase a victim's heart rate and circulation.) • Treat for shock

Bleeding control techniques

DIRECT PRESSURE -Direct pressure applied to the bleeding site until bleeding is controlled NOTE: If clean dressing is not available, a gloved hand or other clean material may be used. NOTE: Local cold therapy, such as an instant cold pack, can be useful for closed injuries such as a bruise to the extremities or scalp. Cold therapy should be used with caution in children because of the risk of hypothermia. TOURNIQUET -Use of a device to close off all blood flow to and from a limb -Should only be used for life-threatening conditions when direct pressure has failed NOTE: A dressing is any material applied to a wound to control bleeding and prevent contamination. A bandage is any material used to hold a dressing in place. NOTE: Direct pressure and/or tourniquet should be used as the primary bleeding control technique; however, peace officer/first responder's may use elevation or pressure points.

Scene safety

Ensure scene safety and use PPE by taking universal precautions.

Thirst

Even though the victim may be thirsty, do not give anything to drink. Shock can cause the gastrointestinal system to shut down. Fluids given orally may lead to vomiting.

Law enforcement actions

If the care and well-being of the victim has been turned over to other EMS personnel, peace officers may be required to continue additional enforcement actions including: • documenting their initial observations when first arriving at the scene • maintaining control of the scene to protect potential evidence • identifying and isolating witnesses and involved parties • recording statements or information provided by the victims, witnesses, etc. • noting whether items were moved in order to render medical emergency services (e.g., recording what was touched and by whom) • any other investigative actions required

Mild airway obstruction

If the victim indicates an airway problem (i.e., choking) but is able to speak or cough, the victim is experiencing a mild airway obstruction. With a mild airway obstruction, it may be assumed that there is adequate air exchange to prevent respiratory failure. A victim who is conscious with a mild airway obstruction should be encouraged to cough forcefully to dislodge and expel the object. Do not interfere with the victim's attempts to cough (e.g., pound on the victim's back). This could lodge the obstruction even further, causing a severe airway obstruction. If the obstruction cannot be removed by coughing and the victim has labored breathing, is making unusual breathing sounds, or is turning blue/grey, the victim should be treated as if there is a severe airway obstruction. NOTE: Grabbing the throat with one or both hands, indicating the victim is unable to breathe, is considered the universal sign of choking.

Recovery position

If the victim resumes adequate breathing and there are no indications of major bleeding or spinal injury, then the victim can be placed in the recovery position. This position allows for drainage from the mouth and prevents the victim's tongue from blocking the airway. To place a victim in the recovery position: • roll the victim onto their left side toward the rescuer • keep the victim's body in one unit with the spine as straight as possible • move the victim's lower arm up and bend at the elbow • move the victim's top leg toward the victim's chest, continue monitoring the victim's breathing

Other conditions

If the victim's mouth is injured and cannot be used for rescue breathing, the peace officer should use a mask-to-nose position. If the victim has a laryngectomy, a surgical procedure that implants an artificial airway (stoma) in the neck, the peace officer should use a mask-to-stoma position. For both positions, the same methods should be used as with mouth-to-mouth/face mask techniques for rescue breathing.

Pathogens

Infection and disease are caused by pathogens that are spread through the air or by contact with another person's blood or body fluids. Bacteria are microscopic organisms that can live in water, soil, or organic material, or within the bodies of plants, animals, and humans. The human body contains a number of both beneficial and harmful bacteria. Only when a bacteria is harmful would it be considered a pathogen. A virus is a submicroscopic agent that is capable of infecting living cells. Once inside the cells of plants, animals, or humans, viruses can reproduce and cause various types of illness or disease.

Pausing CPR

Minimize interruptions in compressions to 10 seconds or less. It should be paused for as short a time as possible not longer than 10 seconds.

Safety

Peace officers are responsible for taking action to protect their own safety as well as the safety of other EMS personnel, the ill or injured person, the public, and to control the scene. When determining appropriate safety precautions to take, peace officers should consider possible dangers from: • exposure to biological hazards (e.g., body fluids such as blood, saliva, etc.) • armed suspects, angry bystanders, etc. • unsafe scene conditions (e.g., unstable buildings, nearby vehicle traffic, etc.) • environmental hazards (e.g., fire, exposure to dangerous chemicals, chance of explosion, etc.) • animals (e.g., pets, wild animals)

Personal preventive measures

Peace officers should also be aware of personal preventive measures they may take to remain healthy and support their own immune systems. Staying in good physical condition can help breach the chain of transmission of pathogens to which they may be exposed.

Dental emergency

TREATMENT • Request additional EMS resources • Ensure that the airway is clear and unobstructed. • Visually inspect the oral cavity to ensure that there are no teeth or fragments. • Control bleeding as necessary • Do not attempt to replace the tooth or dental apparatus • You may transport the tooth in a variety of solutions (e.g., saline, whole milk, or victim's saliva) • Reassure the victim • Continue to monitor victim

Conscious choking adult (chest thrust)

The following identifies techniques for performing a chest thrust on a conscious victim who is pregnant or obese. 1. • Ask the victim, "Are you choking?" "Can I help you?" • Determine that the victim is choking (i.e., unable to speak, cough, or breathe) • Inform the victim before taking action 2. • Take a position behind the victim who is standing or sitting • Slide arms under the victim's armpits and encircle the victim's chest 3. • Form a fist with one hand • Place the thumb side of fist on the midline of the victim's sternum, level with the armpits • Grasp the fist with the free hand 4. • Direct thrusts straight back toward the victim's spine • Use care not to direct thrusts up, down, or to either side 5. • Repeat thrusts until object is expelled or victim loses consciousness

En route to the scene

The primary objective of all peace officers responding to any emergency call should be to get to the location as quickly and safely as possible.

Types of Chest and abdominal injuries

Traumatic injury to the chest and/or abdomen can lead to bleeding (external and internal) as well as damage to the lungs, heart, and other vital organs. The chest and/or abdomen may be injured in a number of ways. Three of the most common are identified in the following: BLUNT TRAUMA Blow to the chest and/or abdomen causing: • fractured bones and cartilage • bleeding • damage to the lungs, heart, great blood vessels (aorta, vena cava), or other vital organs PENETRATING OBJECT Caused by bullets, knives, metal or glass, etc., can lead to: • blood loss • impaired breathing or vital organ damage COMPRESSION Blunt trauma along with rapid chest and/or abdomen compression (e.g., striking a steering wheel) can lead to: • blood loss • heart and vital organ damage • fractured bones and cartilage • ruptured lungs, spleen, or other organs

Occlusive dressing

An occlusive dressing: • is a nonporous dressing (e.g., plastic bag) • used to cover the wound • creates an air-tight seal NOTE: As the victim inhales, the dressing is sucked tight to the skin, providing a seal over the wound. If the dressing is placed properly, respiration should partially stabilize.

Unconscious choking adult or child (abdominal thrust)

1. • Activate the EMS system • Place victim in a supine position NOTE: When the victim is a child, officers should have a second person (if available) activate the EMS system, while the peace officers/first responders begin the maneuver immediately. 2. • Open the victim's airway • Look inside the victim's mouth • Conduct a finger sweep of the victim's mouth, only if you see the object (Do not use a blind finger sweep.) • Attempt to ventilate victim's lungs • If airway remains obstructed, reposition the victim's head and attempt to ventilate again • If airway remains obstructed, perform 30 chest compressions, look in the airway, remove any visible debris, attempt to ventilate • Repeat this procedure until chest rise is achieved during an attempted ventilation NOTE: Abdominal thrusts should not be used on infants, pregnant women or obese patients. Instead use chest thrusts. NOTE: Prior to each ventilation, look in mouth for obstruction.

Conscious choking adult or child (abdominal thrust)

1. • Ask the victim, "Are you choking?", "Can I help you?" • Determine that the victim is choking (i.e., unable to speak, cough, or breathe) • Inform the victim before taking action 2. • Stand or kneel behind the victim and wrap your arms around the victim's waist 3. • Make a fist with one hand 4. • Place the thumb side of the fist against the victim's abdomen, in the midline slightly above the navel and well below the breastbone 5. • Grasp your fist with your other hand and press your fist into the victim's abdomen with a quick, forceful upward thrust 6 • Give each new thrust with a separate, distinct movement to relieve the obstruction

Rescue breathing technique

1. • Open the victim's airway using the head-tilt-/chin-tilt or jaw-thrust maneuver (whichever is most appropriate for the situation) 2. • Take a position at the top of the victim's head • Place portable pocket mask on the victim so the top of the mask is over the victim's nose while the base of the mask is between the lower lip and chin 3. • Take a breath and exhale directly into the victim's mouth or through the one-way valve of the mask (one second) • Use only enough air to create a visible chest rise • Do not over inflate the lungs 4. • If breaths do not enter the victim's lungs: - reposition the victim's head to open the airway - attempt to breathe into the victim's lungs again 5. • Continue rescue breathing until: - victim begins to breathe without assistance - officer is relieved by an equally or higher medically trained person - officer becomes too exhausted to continue - unable to detect a pulse after 2 minutes of rescue breathing, (begin CPR) - victim is declared dead by an authority NOTE: If the victim begins to breathe without assistance, continue to assess the victim's condition. Place in the recovery position, and provide care for shock.

Primary assessment

1.Check for responsiveness 2.Check (ABC) - Airway - Breathing - Circulation (pulse) 3.Control major bleeding 4.Treat for shock 5.Consider C-spine stabilization based on mechanism of injury

Applying an occlusive dressing

1.Place a gloved hand over the wound to "seal" the wound 2. Without moving the hand covering the wound, use the free hand to place a piece of plastic over the hand covering the wound site NOTE: The plastic should be at least two inches wider than the wound itself. 3. While using the free hand to apply gentle pressure and maintain the seal around the wound, gently remove the other hand from under the plastic 4. Tape all but one corner of the plastic in place. The untaped corner will allow air to escape from the chest cavity when the victim coughs 5. Provide care to prevent shock. Continue to monitor the victim NOTE: If the chest has both entrance and exit wounds, occlusive (airtight) dressings should be placed on both wounds. The physically higher wound should be vented.

Conscious choking infant

A combination of back blows and chest compressions may be used to clear a foreign body from an infant's airway. The following identifies techniques for chest thrusts on both conscious and unconscious infants: 1. • Kneel or sit with the infant in your lap 2. • If it is easy to do, remove clothing from the infant's chest 3. • Deliver up to 5 back slaps forcefully between the infant's shoulder blades, using the heel of your hand. Deliver each slap with sufficient force to attempt to dislodge the foreign body 4. • After delivering up to 5 back slaps, place your free hand on the infant's back, supporting the back of the infant's head with the palm of your hand. The infant will be adequately cradled between your 2 forearms, with the palm of one hand supporting the face and jaw while the palm of the other hand supports the back of the infant's head 5. • Turn the infant as a unit while carefully supporting the head and neck. Hold the infant face-up, with your forearm resting on your thigh. Keep the infant's head lower than the trunk 6. • Provide up to 5 quick downward chest thrusts in the middle of the chest over the lower half of the breastbone (same as for chest compressions during CPR). Deliver chest thrusts at a rate of about 1 per second, each with the intention of creating enough force to dislodge the foreign body 7. • Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until the object is removed or the infant becomes unresponsive

Tongue obstruction

A large number of severe airway obstructions leading to respiratory failure are caused by the victim's own tongue. In the unconscious victim, the muscles of the lower jaw relax and the tongue can lose muscle tone. When this happens, the tongue may block the victim's airway.

Shoulder drag

A number of different techniques may be used to move an injured victim. One maneuver that may be used is the shoulder drag technique. To avoid straining their backs when dragging a victim, peace officers should: - bend their knees - keep their backs straight - let their leg muscles do most of the work 1. Use hands and grasp the victim under the armpits. 2. Stabilize the victim's head and neck to reduce the risk of injury. 3. Carefully lift the victim keeping the head and shoulders as close to the ground as possible. 4. Drag the victim so that the head, torso, and legs remain in a straight line. DO NOT pull sideways. 5. Gently place the victim in the new location. Assess the victim's condition.

"Do not resuscitate" orders

A valid "do not resuscitate" (DNR) or "no-CPR" directive would also be a reason for not beginning CPR on a victim. If there is doubt that the order may not be valid start CPR.

Clinical and biological death

A victim is clinically dead the moment breathing and circulation stop. Clinical death may be reversible if basic life support techniques such as CPR are initiated immediately. When a victim's breathing and circulation stop and brain cells die due to lack of oxygen, irreversible changes begin to take place, and vital organs begin to deteriorate. At this point, a victim is biologically dead. Biological death usually takes place within four to six minutes after breathing and circulation stop. NOTE: If any doubt exists as to whether or not the victim is alive, CPR should be started. NOTE: The point at which a victim is considered to be biologically dead may be defined by specific agency guidelines and policy.

Conditions for moving a victim

A victim should be moved only when the victim is in a life-threatening situation. IMMINENT DANGER -When the danger outweighs the risk of further injury from being moved. UNABLE TO ASSESS -When it is not possible to do a primary survey of the victim's condition -When the victim's condition or an officer's ability to provide basic life-saving procedures is not possible due to the victim's position

Closed abdominal wound

A victim with a closed abdominal wound will have no external bleeding but may have internal bleeding that can be severe and potentially life-threatening. If a closed abdominal wound is suspected, peace officers should initiate the following first aid measures. INDICATORS • Victim found lying in a fetal position (with legs pulled up to chest) • Rapid shallow breathing • Rapid pulse • Rigid or tender abdomen with or without swelling • Pain or tenderness to the touch during secondary survey FIRST AID MEASURES • Activate EMS system • If no spinal injury suspected, place victim in a comfortable position (e.g., supine with knees bent up) • Treat for shock • Continue to monitor the victim • Be prepared for the victim to vomit

Initial assessment during obstructed airway

An initial survey of the victim should take place. The initial assessment should include determining the victim's responsiveness and breathing • Breathing to determine if the victim is breathing adequately • Circulation to identify if the victim has a pulse If it is determined that the victim is not responsive and not breathing or not breathing adequately chest compressions should be started.

Rescue breathing rates and duration

ADULT (puberty and above) -Give 1 breath every 5-6 seconds (about 10 to 12 breaths per minute). CHILDREN (newborn to puberty) -Give 1 breath every 3-5 seconds (about 12 to 20 breaths per minute). • Give each breath in 1 second • Each breath should result in visible chest rise • Check the pulse about every 2 minutes NOTE: Peace officers should use their best judgment when estimating the age of a child or infant. NOTE: Signs of puberty include chest or underarm hair on males and any breast development in females.

Words of caution

AEDs are designed to be used for adults, children and infants. • AEDs are safe in all weather conditions (on dry skin) • Never place AED electrode pads directly on top of medication patches. Remove patches first and wipe the skin dry • If the victim has a pacemaker or an internal defibrillator with a battery pack (visible as a lump under the skin, approximately two inches long) avoid placing pads directly on top of the implant • If the victim is lying on a metal surface (e.g. bleachers) avoid contact of the electrodes with the metal surface NOTE: Remove any jewelry from the patient's chest. NOTE: Persons with excessive chest hair may need to be shaved prior to application of the AED electrodes.

Ventilation

After 30 compressions attempt to ventilate. If the breath does not go in the victim's airway should be repositioned and ventilation should be reattempted. If the breaths still do not go in the rescuer should give 30 compressions.

Begin treatment

After completing the assessment and classification of all victims, treatment of victims classified as IMMEDIATE can begin.

Open chest wound

All open wounds to the chest should be considered life-threatening. For respiration to take place properly, the chest must function as a vacuum. With an open chest wound, air may enter the chest area causing a lung to collapse (e.g., sucking chest wound with a punctured lung). Under such conditions, the victim's ability to breathe, and the victim's heart function can be greatly impaired. To prevent air from entering the chest cavity, an occlusive dressing should be applied to the wound as quickly as possible.

Treating shock

All victims should be treated for shock even if no indications of shock are evident. When providing care to treat shock, peace officers/first responders should: • control all external bleeding and treat other injuries • be alert for vomiting • maintain the victim's body temperature • place the victim in a position to help maintain blood flow • reassure the victim • continue to monitor the victim and be prepared to take action if necessary (e.g., rescue breathing, CPR)

Universal precautions

Along with using PPE, there are a number of universal precautions that peace officers as first responders in the EMS system should take. • Treat all body fluids as if they are contaminated! • If possible, wash hands thoroughly with warm water and antiseptic soap before and after each exposure, even when gloves are worn • Use hand sanitizer if hand washing is not available • Use proper cleaning procedures to disinfect and decontaminate any equipment that may have been exposed (e.g., vehicle steering wheel and interior, firearm, radio, etc.) • Use extra caution when handling broken glass or sharp objects • Use band-aids or other cover protections when open cuts or sores exist NOTE: A solution of one part bleach and ten parts water can be used when disinfecting equipment except leather.

Closed chest wound

Although there may not appear to be any serious injury to the chest, blunt trauma or compression to the chest area can lead to a condition referred to as flail chest. Flail chest is the condition where the ribs and/or sternum are fractured in such a way that a segment of the chest wall does not move with the rest of chest wall during respiration. It is caused when two or more ribs next to each other are broken The following presents the indicators and first aid measures for closed chest wounds: INDICATORS • Paradoxical breathing (when both sides of the chest do not move in a synchronized manner • Painful and shallow breathing FIRST AID MEASURES • Activate EMS system • Place victim in a - recovery position, if appropriate, on the injured side with support for the victim's back - supine position with a soft object (e.g., coat held firmly over the injured area) • Both methods will: - apply pressure to the injured area - reduce pain - help the victim breathe easier - keep the broken section of the chest in line with the rest of the chest • Treat for shock • Continue to monitor the victim

Airway obstructions

An airway obstruction can be either mild or severe. They are caused by a number of different materials blocking the person's air passages. Examples include, but are not limited to the following. • Victim's tongue • Vomit or blood • Broken teeth or dentures • Foreign objects such as toys, ice, food

Open abdominal wounds

An open abdominal wound can be caused by lacerations and punctures to the abdomen. Blood loss and the potential for infection should be of concern when dealing with an open wound to the abdomen. FIRST AID MEASURES FOR PENETRATING OBJECT ASSESSMENT • Determine the victim's state of consciousness • Conduct primary and secondary surveys TREATMENT • Activate EMS system, • If no spinal injury is suspected, place the victim in a supine position with the knees up, • Apply sterile dressing over the wound to control bleeding, • Treat for shock, • Continue to monitor the victim.

Primary responsibilities

As first responders, peace officers should assume the primary responsibility for: • ensuring peace officer safety as well as the safety of ill or injured individuals and the public • evaluating the emergency situation • taking necessary enforcement actions related to the incident • initiating actions regarding the well-being and care of ill or injured persons

Responsibility to act

As trained professionals, peace officers have a responsibility to: • assess emergency situations • initiate appropriate emergency medical services within the scope of the officer's training and specific agency policy A peace officer is not required to render care when reasonable danger exists (e.g., while under fire, exposure to hazardous materials, etc.).

Scene size-up

At the scene peace officers should evaluate the nature of the incident and communicate critical information to dispatch and other involved units as soon as possible. Location • Exact address or location of the incident • Conditions present at the scene (e.g., large number of bystanders, heavy vehicle traffic in the area, remote location, etc.) • Potential hazards related to the incident or the area (e.g., fire, gas/chemical leak, presence of hazardous materials, etc.) Type of Emergency • Conditions related to the actual emergency such as, but not limited to: - a vehicle collision involving injuries - an individual complaining of severe chest pain - a person injured as a result of criminal action (e.g., shot during a robbery), etc. Nature of Ill/Injured Person(s) • Number of victims • Apparent age of the victim(s) (i.e., adult, adolescent, child, infant) • Whether victim(s) is conscious or unconscious • Appearance of injury (e.g., heavy bleeding, exposed bone, location of wound, etc.) Need for Additional Resources • Fire department • Additional law enforcement units • Medical emergency services (e.g., ambulance, EMTs) • Public utility services • Other specialty units (e.g., search and rescue, HAZMAT, etc.) Urgent Enforcement Actions Required • Protection of victim(s) from aggressor(s) • Control of suspect(s) and/or bystanders • Immediate protection of a crime scene

Positioning victim

During treatment for shock, the position in which the victim is placed is dependent upon the nature of the injury or illness. THE VICTIM: -may have spinal or head injuries THEN: •do not elevate legs •consider spinal immobilize THE VICTIM: -may have experienced a stroke THEN: •elevate the victim's head and shoulders THE VICTIM: -is having difficulty breathing THEN: •place the victim in a semi-sitting position •a position of comfort THE VICTIM: -has fracture(s) of the lower limbs THEN: •do not elevate legs •a position of comfort THE VICTIM: -has any other injuries or conditions THEN: •place the victim in a supine position •elevate legs approximately 6-12 inches

Fainting

Fainting is a form of shock characterized by sudden unconsciousness. It is caused by dilation of blood vessels resulting in reduced flow of oxygenated blood to the brain.

PPE disposal

Gloves, along with other equipment intended for single use, must be disposed disposal of in an approved manner according to manufacturer recommendations after use or contamination. Disposal may include but not be limited to use of: • biohazard bags • sharps containers • liquid proof containers NOTE: Peace officers are responsible for being aware of and complying with their agency's policies and Occupational Safety and Health Administration (OSHA) guidelines regarding the disposal of hazardous PPE and materials.

Indications of head injury

Head injuries can involve injuries to the skull, scalp, brain, blood vessels and fluid around the brain, and/or neck. They may vary from those involving minor bleeding to those leading to life-threatening conditions and spinal cord injury. Mechanism of injury • Striking a vehicle's windshield or dashboard • Blow to the head • Falls Mental status • Agitated or confused • Combative or appears intoxicated • Decreased level of consciousness (e.g., appears "groggy") • Loss of short term memory • Loss of consciousness (even for a short period of time) Vital signs • Abnormal breathing patterns (e.g., snoring respirations) • Decreased pulse • General deterioration of vital signs Visible injury • Deformity of head/skull (e.g., protrusions, depressions, swelling, bruising, etc.) • Visible bone fragments Appearance • Clear or bloody fluid from ears and/or nose • Unequal pupils • Bruises behind ears (i.e., "Battle's sign") • Discoloration around eyes (i.e., "raccoon eyes") • Paralysis • Priapism (i.e., penile erection) Other • Blurred vision • Projectile vomiting

Special consideration

INFANTS AND CHILDREN • Trachea ("windpipe") is narrower, softer, and more flexible than in adults • Over extension of an infant's/child's neck may occlude the trachea • Tongue takes up more space in the mouth than adults • Airways are smaller and easily obstructed FACIAL INJURIES • Severe swelling and bleeding may block airway DENTAL APPLIANCES • Normally, full/partial dentures should be left in • Remove only if they have become dislodged during the emergency and endanger the victim's airway

Document to exposure

If a peace officer is exposed to an infectious pathogen (or even suspects exposure), no matter how slight, that officer should report the exposure verbally and in writing as soon as possible. NOTE: Peace officers should be aware of and comply with their agency policies or guidelines regarding reporting exposure information should be in compliance with Health Insurance Portability and Accountability Act (HIPAA) and OSHA regulations and specific actions to be taken.

Vomiting

If a victim vomits, the vomit may enter the lungs and cause further life-threatening complications. If vomiting should occur: • Quickly turn the victim onto their side (not just the head) as one unit to keep the spine straight. • wipe the vomit from the victim's mouth • return the victim to the supine position • open the airway • continue rescue breathing This process should take less than 10 seconds to complete.

Removing obstruction

If any object causing the obstruction can be seen it might be removed by using a finger sweep. To conduct a finger sweep: • open the victim's mouth by grasping both the tongue and lower jaw between the thumb and fingers • insert the index finger of the other hand down along the cheek and then gently into the throat in a "hooking" motion • if the object can be felt, grasp it and remove it NOTE: The finger sweep maneuver should be done with care so that the object is not forced further into the victim's throat. NOTE: Do not use a blind finger sweep. Objects should be removed from their mouths only if the objects can be seen clearly.

Protruding organs

If any organs or portion of an organ protrude from the abdominal wound, do not attempt to touch, move, or replace them. Cover the organ and the rest of the wound with a moist dressing and seal with an occlusive dressing. FIRST AID MEASURES FOR EXPOSED ORGANS ASSESSMENT • Determine the victim's state of consciousness • Conduct primary and secondary surveysi TREATMENT • Activate EMS system, • If no spinal injury is suspected, place the victim in a supine position with the knees up, • Cover with moist sterile dressing, if available, • Seal with airtight bandage, • Treat for shock, • Continue to monitor the victim. NOTE: If sterile materials are not available the airtight bandage should be applied over the injury.

Life-threatening conditions

If it is determined that an illness or injury is such that if left untreated the victim's condition will degenerate to a life-threatening condition, the emergency rescue personnel may provide medical services regardless of the victim's conscious condition. NOTE: Individuals who are terminally ill may have given specific do not resuscitate (DNR) instructions. Peace officers are responsible for being aware of and complying with state and local policies and guidelines regarding following such instructions in an emergency situation.

Negligence

If peace officers attempt to provide emergency medical services beyond the scope of their training, or if they act in a grossly negligent manner, they can be held liable for any injuries they may cause. Failure to provide care, even though the peace officer has had the appropriate level of training to do so, may also lead to the officer being liable for any injuries caused because of lack of care (e.g., not providing CPR to a victim who is HIV positive). NOTE: Peace officers are responsible for complying with their agency policies regarding providing emergency medical services.

Implied consent

Implied consent is a legal position that assumes that an unconscious or confused victim would consent to receiving emergency medical services if that person were able to do so. Emergency rescue personnel have a responsibility to administer emergency medical services under implied consent whenever a victim is: • unconscious • incapable of giving consent due to a developmental, emotional, or mental disability • in an altered mental state due to alcohol, drugs, head injury, etc. • a juvenile, and the parent or guardian is not present NOTE: Whenever implied consent is assumed or if medical services are provided based on the seriousness of the victim's condition, emergency rescue personnel should carefully document the conditions or the basis for their decision to treat the victim.

Do not move a victim

More harm can be done to a victim by moving them than by the original injury. This is especially true if a spinal cord injury is suspected. DO NOT MOVE any injured victim unless it is absolutely necessary. An unconscious, injured victim should be treated as though the victim has a spinal injury and therefore should not be moved unless it is absolutely necessary.

Musculoskeletal system

Musculoskeletal injuries may have a grotesque appearance. Peace officers should not be distracted by the injury's appearance or begin first aid measures until an assessment is completed and treatment for other life-threatening measures are taken The musculoskeletal system is the system of bones, muscles, and other tissue that support and protect the body and permit movement. The components of the musculoskeletal system include bones, joints, skeletal muscles, cartilage, tendons, and ligaments. The following further describes each component BONE • Hard yet flexible tissue • Provides support for the body as well as protection of the vital organs JOINT • Place where bones fit together • Proper function critical in order for the body to move SKELETAL MUSCLE • Soft fibrous tissue • Controls all conscious or deliberate movement of bones and joints CARTILAGE • Connective tissue that covers the outside of the ends of bones • Firm but less rigid than bone • Helps form certain flexible structures of the body (e.g., external ear, connections between the ribs and sternum, etc.) • Allows for smooth movement of bones at joints TENDON • Bands of connective tissue that bind muscles to bones LIGAMENT • Connective tissue that attaches to the ends of bones and supports joints • Allows for a stable range of motion

Adult CPR one-person

Once a peace officer has confirmed the victim's level of consciousness, conduct a primary assessment, and has determined that there is no breathing or circulation, CPR should be initiated immediately. -DETERMINE RESPONSIVENESS •Tap & shout • Assess for breathing • No breathing or abnormal breathing • Activate the EMS system and get AED if available -PULSE CHECK •Locate the trachea, using 2 or 3 fingers • Slide these 2 or 3 fingers into the groove between the trachea and the muscles at the side of the neck, where you can feel the carotid pulse • Feel for a pulse for at least 5 but no more than 10 seconds. If you do not definitely feel a pulse, begin CPR, starting with chest compressions -CHEST COMPRESSION • Position yourself at the victim's side • Make sure the victim is lying face-up on a firm, flat surface. If the victim is lying facedown, carefully roll him face-up. If you suspect the victim has a head or neck injury, try to keep the head, neck, and torso in a line when rolling the victim to a face-up position • Put the heel of one hand on the center of the victim's chest on the lower half of the breastbone • Put the heel of your other hand on top of the first hand • Straighten your arms and position you shoulders directly over your hands • Push hard and fast -Press down at least 2 inches (5 cm) not to exceed 2.4 inches (6 cm) with each compression (this requires hard work). For each chest compression, make sure you push straight down on the victims breastbone -Deliver compressions at a rate of 100/min to 120/min -At the end of each compression, make sure you allow the chest to recoil (re-expand) completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the flood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be approximately equal -Limit interruptions to less than 10 seconds -VENTILATION • Open the victim's airway using head-tilt or jaw-thrust maneuver • Provide ventilation • Give 2 breaths with each lasting 1 second • Victim's chest to visibly rise -COMPRESSION CYCLE • After 30 compressions, open victim's airway, give two breaths • Continue cycle of 30 compressions to 2 breaths

Duty to continue

Once a peace officer initiates medical services, that officer must remain with the victim until: • the officer is relieved by: - an individual with equal or greater training and skill, or - the scene becomes unsafe for the officer to remain or the officer is physically unable to continue

Life- threatening conditions

Once it is determined that the victim is breathing and has a pulse, the peace officer must control any major bleeding and treat the victim for shock. Such conditions must be treated first before any further assessment of the victim takes place. NOTE: Techniques for administering emergency first aid measures for controlling bleeding, treatment for shock, and other conditions are noted in later chapters of this workbook.

General guidelines

PLAN AHEAD - Identify a safe location before attempting to move the victim - Move only as far as is absolutely necessary REASSURE VICTIM - Tell the victim(s) what is going on and why the victim is going to be moved - Keep the victim as calm as possible VICTIM STABILITY - Keep victim in a straight line during the movement - Keep victim lying down - Move the victim rapidly but also as carefully and gently as possible - Be careful not to bump the victim's head during movement NOTE: If an infant is fastened in an infant seat, do not remove the infant. Move infant and the seat together.

Emergency medical services (EMS)

Peace officers must recognize they have a responsibility to act in good faith and to provide emergency medical services (EMS) to the best of their abilities and within the scope of their training. The first person at the scene of an emergency situation is often a peace officer. When the situation involves a medical emergency, peace officers assume the role of EMS first responder.

Expressed consent

Peace officers should clearly identify themselves and ask for consent to administer emergency medical services. Consent (i.e., permission) must be obtained from the ill or injured person before providing emergency care. In order to give lawful consent, the ill or injured person must be: • conscious and oriented • mentally competent enough to make rational decisions regarding their well-being • 18 years or older, or an emancipated minor

Classification catergories

Peace officers should move from one victim to another, making a quick (less than one minute) assessment of each victim's condition and classifying each victim into a category. DECEASED -No respiration after opening the airway IMMEDIATE -Receives treatment first, once all victims are classified DELAYED -Receives treatment once all victims classified as IMMEDIATE have been treated MINOR -Direct to a safe area away from other victims and possible scene safety hazards

Spinal cord injury

Prior to any attempt to open a victim's airway, peace officers must consider whether or not the victim may have suffered any type of spinal injury. If head, neck, or spinal cord injury is suspected, the victim's head and neck may need to be protected by providing as much manual stabilization as possible. Indications of head, neck, or spinal injury may include, but not be limited to: • the mechanism of injury (e.g., falling from a high position, vehicle collision, etc.) • information provided by bystanders/witnesses NOTE: Whenever a victim is found unconscious, responding officers should suspect a spinal cord injury and act accordingly.

Victim assessment for burns

Prior to any first aid measures, no matter how extreme the burn, a victim assessment including primary and secondary surveys should be conducted. Only when immediate life-threatening conditions have been addressed, should the peace officer's attention be directed to first aid treatment for the burns themselves. Burns to the face, nose and mouth may be life threatening due to respiratory distress.

Gastric distention

Rescue breathing can force some air into the victim's stomach as well as lungs, causing the stomach to become distended. This condition is referred to as gastric distention. NOTE: If gastric distention is observed, reposition the airway and give smaller, slower breaths.

Shock

Shock is a life-threatening condition. If not immediately cared for, the victim can die. Perfusion is the continued flow of blood through the capillaries supplying the body's tissues and organs with oxygen and removing waste products. Inadequate perfusion leads to shock.

Immunity from liability

The California Legislature has declared that emergency rescue personnel qualify for immunity from liability from civil damages for any injury caused by an action taken when providing emergency medical services under certain specified conditions. (Health and Safety Code Section 1799.102) To be protected from liability for civil damages, emergency rescue personnel must: • act within the scope of their employment • act in good faith • provide a standard of care that is within the scope of their training and specific agency policy Emergency rescue personnel means any person who is a peace officer, employee or member of a fire department, fire protection, or firefighting agency of the federal, state, city, or county government. Emergency medical services include, but are not limited to, first aid and medical services, rescue procedures and transportation, or other related activities necessary to ensure the health or safety of a person in imminent peril

Abdominal thrust

The abdominal thrust (also referred to as the Heimlich maneuver) is one method used to force obstructions from a victim's airway that cannot be removed with a finger sweep. Abdominal thrusts force air out of the lungs, expelling the obstruction, and clearing the victim's airway.

Automated external defibrillators (AED)

The best treatment for most cases of sudden cardiac arrest is immediate treatment with a defibrillator, a device that shocks the heart out of fatal rhythm, allowing normal, healthy rhythm to resume. Automated External Defibrillators (AED) are placed in many public places. Peace officers will become familiar with the operation and location of these devices. The AED protocol has seven basic steps: • Check for responsiveness and breathing • Activate the EMS system if unresponsive • Get the AED if readily available • Check for pulse. A second rescuer should continue CPR until the AED is attached • Attach the AED electrode pads • Allow the AED to analyze the heart rhythm. Make sure no one is touching the victim • If a shock is indicated verbalize "all clear" prior to pressing the "shock" button. Follow the voice prompts from the AED • Current AHA guidelines recommend that an AED should be used as soon as available.

Chest thrust

The chest thrust is another maneuver that can be used to force obstructions from a victim's airway. Chest thrusts are used in place of abdominal thrusts when the victim is: • pregnant • obese

Head injury

The extent of a head injury may not always be obvious. Whenever a victim has suffered a traumatic head or neck injury, brain and spinal cord damage should always be assumed First aid measures are noted in the following: POSITION • Do not move the victim's head or neck • Have the victim remain in the position in which found ASSESSMENT • Determine level of consciousness • Conduct a primary and secondary survey • If unable to establish an open airway using the jaw-thrust technique, the head-tilt chin-lift method may be used TREATMENT • Activate the EMS system • Control bleeding if necessary • Be alert for the presence of cerebrospinal fluid in ears or nose. If present, bandage loosely so as not to restrict the flow • Do not apply direct pressure to any head/skull deformity • Be prepared for sudden and forceful projectile vomiting • Treat for shock • Do not elevate the victim's legs • Reassure the victim • Continue to monitor victim

Circulatory system

The three components to the human circulatory system are the: • heart • blood vessels • blood If any one component does not function properly, oxygen and nutrients will not reach the body's major organs in sufficient enough supply to support life.

Severe obstruction

The victim may be experiencing a severe airway obstruction if: -unconscious and unable to be ventilated after the airway has been opened -conscious but unable to speak, cough, or breathe Under such conditions, additional measures may be required to free the victim's airway from a severe obstruction. The two primary maneuvers used are the abdominal thrust (if conscious) and chest compressions/attempt to ventilate (if unconscious).

Breathing/pulse checks

The victim's pulse and breathing should be checked approximately every two minutes. If the victim is: • not breathing but has a pulse, continue rescue breathing • not breathing and has no pulse, begin Cardiopulmonary Resuscitation (CPR)

Opening an airway

There are two maneuvers that peace officers/First Responders can use to open a victim's airway: head-tilt/chin-lift, and jaw-thrust. The following table provides information regarding each maneuver: Head-Tilt/ Chin-Lift • Provides maximum airway opening 1. • Place one hand on the victim's forehead • Place the fingers of the other hand under the bony area at the center of the victim's lower jaw 2. • Tilt the victim's head back by: - pressing backward on the forehead - lifting the chin with the fingers 3. • Move the jaw forward to a point where the lower teeth are almost touching the upper teeth • If necessary, use the thumb of the hand supporting the chin to pull open the victim's mouth NOTE: Should not use the head-tilt/chin-lift maneuver if there are any indications of possible head, neck, or spinal cord injury. NOTE: Do not compress the soft tissues under the lower jaw. This may obstruct the victim's airway. NOTE: Do not place thumb or finger(s) inside the victim's mouth. Jaw-Thrust • When head, neck, or spinal injury is suspected • To open airway on an unconscious victim • Allows airway to be opened without moving the victim's head or neck 1. • Take a position at the top of the victim's head 2. • Gently place one hand on each side of the victim's head • Place your fingers under the angles of the victim's lower jaw and lift with both hands, displacing the jaw forward • Place thumbs on the victim's cheeks • Stabilize the victim's head 3. • Using the fingers, gently push the victim's jaw forward • If necessary, use thumb to pull open the victim's lips NOTE: Do not tilt or rotate the victim's neck if airway does not open, with the jaw thrust, head tilt, chin lift technique.

Transfer of pathogens

There are two primary methods by which pathogens can be transferred from one human being to another. Airborne pathogens are spread by tiny droplets sprayed during breathing, coughing, or sneezing. Airborne pathogens can be absorbed through the eyes or when contaminated particles are inhaled. Blood borne pathogens may be spread when the blood or other body fluids (e.g., semen, phlegm, mucus, etc.) of one person comes into contact with an open wound or sore of another.

Severity of injury

There may be no relationship between severity of an injury and the onset of shock. Victims may appear to have no major injury but still show signs of restlessness or anxiety, which are early stages of shock. For this reason, all victims of traumatic or medical emergencies should be treated for shock upon initial contact. NOTE: Injuries that might appear be minor or the absence of obvious internal injury can cause a person to go into irreversible shock causing death.

Musculoskeletal injuries

Three types of force can cause injury to the musculoskeletal system, and are identified in the following: TYPE OF FORCE Direct • Direct blow to an area (being struck by an automobile) Indirect • Force from a direct blow to one area which causes damage to another (Landing on feet from a fall and injuring ankles, knees, etc.) Twisting • Sudden rapid movement that stretches or tears (Football and other sport related injuries)

Bone, muscle, and joint injuries

Unless there is an obvious deformity or open wound with exposed bone, it is not possible to determine whether an injury is a fracture, dislocation, sprain, or strain without x-ray and other diagnostic procedures. When a musculoskeletal injury is suspected and the injury is severe (e.g., fracture), peace officers should use the following first aid measures. FIRST AID MEASURES -ASSESSMENT • Conduct a primary and secondary assessment to determine if there are any life-threatening injuries -TREATMENT • Activate EMS system, if necessary • Do not attempt to manipulate or "straighten out" an injury • Expose the injury by removing clothing covering the area • Control bleeding associated with open fractures • Stabilize the injury by immobilizing the bones above and below the joint • Check capillary refill and warmth of affected limb • Treat for shock • Do not elevate legs if injury is to the lower extremities

Impaled objects

Unlike treatment for other situations involving impaled objects, any object (e.g., knives, arrows, screw drivers, etc.) that is impaled into a victim's cheek or face and causes an airway obstruction should be removed. If there is no airway obstruction, do not attempt to remove the object. If the impaled object is obstructing the victim's airway: • carefully pull the object out from the direction it entered • place dressings on both the inside and outside of the cheek to control bleeding If the object resists coming out, stop. Do not pull any farther. Place a protective device around it to stabilize the object (e.g., paper cup) and secure the device with a bandage

Nosebleeds

Victims with facial injuries may experience an accompanying nosebleed. If this occurs and no spinal injury is suspected, have the victim: • assume a seated position • lean slightly forward • pinch the nose midway at the point where bone and cartilage meet • maintain the position until bleeding stops If the victim is unconscious: • place the victim in the recovery position, if appropriate • maintain an open airway NOTE: Do not pack the victim's nostrils. This could cause blood to back up and create an obstructed airway

Primary survey

When a victim is alert and able to speak, it can be assumed that the victim has a clear airway and is able to breath. If the victim is unable to speak or is not responsive, then appropriate steps should be taken to check the victim. • Breathing • Circulation

Adult CPR two-person

When performed correctly, two-person CPR is more efficient than CPR performed by one person. With two people, chest compressions are interrupted less and the individuals performing the CPR do not tire as easily. -DETERMINE RESPONSIVENESS • Tap & shout • Assess for breathing • No breathing or abnormal breathing • Activate the EMS system and get AED if available -PULSE CHECK • Locate the trachea, using 2 or 3 fingers • Slide these 2 or 3 fingers into the groove between the trachea and the muscles at the side of the neck, where you can feel the carotid pulse • Feel for a pulse for at least 5 but no more than 10 seconds. If you do not definitely feel a pulse, begin CPR, starting with chest compressions -CHEST COMPRESSION • Position yourself at the victim's side • Make sure the victim is lying face-up on a firm, flat surface. If the victim is lying facedown, carefully roll him face-up. If you suspect the victim has a head or neck injury, try to keep the head, neck, and torso in a line when rolling the victim to a face-up position • Put the heel of one hand on the center of the victim's chest on the lower half of the breastbone • Put the heel of your other hand on top of the first hand • Straighten your arms and position you shoulders directly over your hands • Push hard and fast • Press down at least 2 inches (5 cm) not to exceed 2.4 inches (6 cm) with each compression (this requires hard work). For each chest compression, make sure you push straight down on the victims breastbone • Deliver compressions at a rate of 100/min to 120/min • At the end of each compression, make sure you allow the chest to recoil (re-expand) completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the flood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be approximately equal • Limit interruptions to less than 10 seconds -VENTILATION • Open the victim's airway using head-tilt or jaw-thrust maneuver • Provide ventilation • Give 2 breaths with each lasting 1 second • Victim's chest to visibly rise -COMPRESSION CYCLE • After 30 compressions, open victim's airway, give two breaths • Continue cycle of 30 compressions to 2 breaths • Every 5 cycles or approximately every 2 minutes duties should be switched • Switching duties with the second rescuer should take less than 5 seconds NOTE: If unsure there is a pulse, continue CPR. NOTE: All findings, counting, etc. should be announced clearly and out loud to avoid confusion between the assisting peace officers. NOTE: When performing two-person CPR, the rescuer providing chest compressions may become fatigued and reduce the effectiveness of CPR.

Indications of shock

• Altered mental status such as: - confusion - anxiety - restlessness - combativeness - sudden unconsciousness • Pale, cool, moist skin • Profuse sweating • Thirst, nausea, vomiting • Blue/grey lips, nail beds, tongue, ears (i.e., cyanosis) • Dull eyes, dilated pupils • Rapid pulse rate • Weak pulse • Abnormal respiration rate • Shallow, labored breathing

Types of injuries

• FRACTURES -Description • Complete or partial break of a bone • Includes: - open fractures where there is a break in the skin at the site of the fracture - closed fractures where there is no break in the skin at the site of the fracture -Indicators • Limb deformity (differences in size or shape) • Swelling or discoloration to the area • Tenderness and localized pain • Breaking and/or grating sound • Possible loss of function • DISLOCATIONS - Description • When a bone is pushed or pulled out of alignment from a joint -Indicators • Constant pain • Increased pain with movement • Joint deformity • Swelling • Loss of movement (i.e., "frozen joint") • SPRAINS -Description • Severely stretched or torn ligaments • Associated with joint injuries -Indicators • Pain • Swelling • Discoloration • STRAINS -Description • Over-stretching or tearing of muscle -Indicators • Pain • Swelling • Discoloration