COMMUNITY FIRST RESPONDER INDUCTION TRAINING COURSE Contents THE HUMAN BODY IN HEALTH ......................................................................................... 3 THE UNCONCIOUS PATIENT ............................................................................................. 8 ADULT BASIC LIFE SUPPORT ........................................................................................... 9 AIRWAY MANAGEMENT .................................................................................................. 12 RECOVERY POSITION ...................................................................................................... 18 DEFIBRILLATION ...................................................................................................... 19 PAEDIATRIC BASIC LIFE SUPPORT ............................................................................... 26 DNACPR INSTRUCTIONS ................................................................................................. 31 PATIENT ASSESSMENT............................................................................................ 34 PULSE OXIMETRY .....................................................................................................40 OXYGEN ............................................................................................................................ 43 RESPIRATORY EMERGENCIES ....................................................................................... 48 CARDIAC and CIRCULATORY EMERGENCIES .............................................................. 55 USE OF ASPIRIN .......................................................................................................58 STROKES/CVI ................................................................................................................... 62 SEIZURES .......................................................................................................................... 63 HEAD INJURY ................................................................................................................... 65 DIABETIC EMERGENCIES ................................................................................................ 66 PHYSIOLOGICAL SHOCK ................................................................................................ 68 ANAPHYLAXIS...........................................................................................................69 BURNS and SCALDS ........................................................................................................ 71 HAEMORRHAGE ........................................................................................................73 SKELETAL SYSTEM EMERGENCIES .............................................................................. 75 SPINAL INJURIES ............................................................................................................. 77 GLOSSARY OF TERMS .................................................................................................... 78 -2- The Human Body in Health -3- Skeletal System The Functions of the Skeletal System • Support for the soft tissues, giving shape and form and to provide a point of attachment • Protection of the vital organs • Movement is facilitated by the bones and joints which act as levers to the attached muscles • Mineral Storage which is then distributed to other parts of the body as required • Blood Cells created within the marrow of certain bones. Some are red and carry oxygen and some white that help fight infection -4- Respiratory System The Functions of the Respiratory System • Extracts oxygen from the atmosphere and transfers it to the bloodstream • Excretes waste carbon dioxide, other gases and water vapour • Ventilate the lung • Maintain the chemical balance within the body • The breathing process is a three stage process consisting of:  Breathing in (active)  Breathing out (passive)  Pause • A process that is normally involuntary but we can override this (for a limited period) • Adults have average breathing rate of 12 -20 breaths per minute (b.p.m.) -5- Circulatory System • The heart beats approximately 60100 times per minute • The left hand side pumps oxygenated blood to the cells of the body • The right hand side pumps deoxygenated blood to the lungs • Blood carries oxygen and nutrients to the cells and removes waste products • Blood travels through arteries, veins and capillaries • Oxygenated blood is supplied to the heart muscle via the coronary arteries • A disruption to this blood supply can lead to either angina or a heart attack (MI) -6- Nervous System The Functions of the Brain • Stores information • Controls mood and emotion • Manages Intellect • Communication to the body and organs using electrical impulses via the spinal cord and nerves The Autonomic Nervous System automatically regulates • The heart and blood vessels • Respiration • Coughing & Swallowing • Sneezing • Vomiting -7- The Unconscious Patient An unconscious person is someone who is hard to rouse or can't be made aware of his or her surroundings; this may be caused by illness, injury or emotional shock. There are many levels of unconsciousness with some more serious than others. Different levels may present as: • Brief – Such as fainting or blacking out. • Extended – Where the victim is incoherent when roused. • Prolonged – A person in a coma, for example, can be motionless and not at all aware of his or her surroundings for a very long time. Causes of Unconsciousness Management of unconsciousness • Faint • Scene management • Imbalance of heat • Patient assessment (D.R.A.B.) • Shock • Recovery position • Head injury • Where possible, treat the cause • Stroke • Provide oxygen therapy • Heart Conditions • Monitor • Asphyxia • Poisoning (including Epilepsy • Diabetes record patient condition • Await arrival response alcohol) • and -8- of ambulance Adult Basic Life Support -9- Basic Life Support AIRWAY BREATHING Check the airway is open Look, Listen and Feel for 10 seconds Use head tilt & chin lift manoeuvre Is it adequate? If inadequate or no breathing effort – commence CPR at a rate of 30 compressions to 2 breaths 1. Place hands in centre of the chest/breastbone 2. Compress chest to a depth of 5-6cm 3. Compress & release in one smooth, controlled movement 4. Aim for a tempo of 100 - 120 compressions per minute - 10 - Adult Basic Life Support Protocol Check for Danger & Check Response (AVPU) Head Tilt/Chin Lift Method Remember, in case of spinal injury use the jaw thrust method Check for 10 seconds Sequence starts with chest compressions Place hands in the centre of the chest and compress to 1/3 depth of the chest. Rescue breaths to last 1 second each seconds - 11 - Airway Management Equipment Pocket Masks Baby/Infant Adult/Older Child • May be used on patient’s of any age, fit according to size of patient • Position mask and apply an even pressure to form a complete seal • Provide two effective rescue breaths • Chest should rise, take mouth away between breaths & watch chest fall before commencing the second breath - 12 - Airway Management Equipment Bag, Valve and Mask Resuscitation Device (BVM) Uses • May be used on any patient who is over 8 years of age and not breathing • Provides a controlled artificial ventilation to the patient • May be connected to high flow oxygen for greater effectiveness Possible Complications • Poor mask placement • Inadequate seal (use secure grip) • Poor ventilation technique • Over/under inflation • Inflation vomiting) - 13 - of stomach (may induce Airway Management Equipment Oropharyngeal Airways (OPA) • Prevents the tongue from obstructing the airway • Sizes used: 1. White 2. Green 3. Orange 4. Red • Sized to individual patient (not age specific) Not to be used on: • Conscious Patients • Unconscious patients with a gag reflex • A patient suffering with clenched teeth (Trismus) - 14 - Airway Management Equipment Inserting an Oropharyngeal Airway Measure either: • From the centre of the lips to the angle of the jaw or • From the corner of the mouth to the ear lobe To insert: • Insert with the tip pointing towards roof of patient’s mouth • Rotate the OPA when it is inserted halfway • Advance the OPA forward until it rests outside of the lips General points • Ensure the airway is clear before inserting an OPA (consider suction) • Do not continue to insert an OPA if the patient shows any signs of rejecting it • Once inserted check that air is flowing through the OPA • Ensure regular checks of the OPA to ensure it does not become blocked - 15 - Airway Management Equipment Suction Indications for use Possible Complications • Vomit or regurgitated material by Failure to use suction may lead to: the unconscious patient • • Airway obstruction Patients over 8 years of age • • Stomach contents entering the Excessive sputum or saliva (for a patient with reduced lungs (aspiration) swallow • function) • Pneumonia (bacterial infection of lungs) Blood (from facial/head injury, • nasal or gastric bleeding) - 16 - Collapsed lung (pnuemothorax) Airway Management Equipment Suction Using the equipment After Use • Wear appropriate PPE • • Assemble component parts ready for and the used receptacle as clinical use waste • • Measure the catheter for use (as OPA’s) always suction under direct Use appropriate hard • Check that the equipment serviceable after replacement of not touch the end which will be collection container and catheter Rotate the catheter during suction to avoid adherence to the soft tissues of the mouth • is Hold the catheter in the middle, do inserted into the patient’s mouth • surface wipes to clean the pump handle vision • Dispose of all single use items Never over insert the catheter, ensure that you always keep sight of the tip General Points Do not over insert the catheter Do not overfill the aspirate receptacle Carry out regular serviceability checks (repairs should only be carried out by the manufacturer/ authorised repairers) Consider retaining a sample of the aspirated material in cases of unknown poisoning or in suspicious circumstances - 17 - The Recovery Position What is the Recovery Position? • A safe position for the patient as it maintains an open airway • It allows body fluids to drain from the mouth i.e. vomit, blood etc • A patient may be left in this position should you need to leave them • A patient can be constantly monitored in this position • Pregnant ladies must only be put on their left hand side • If appropriate, patients should be turned after 20 mins In the case of spinal injury, the patient may be left on their back, providing the airway is open (using jaw thrust method), not obstructed and they are not left unattended. - 18 - Automated External Defibrillation - 19 - Automated External Defibrillation In the UK approximately 30,000 people sustain cardiac arrest outside hospital and are treated by the ambulance service each year. Automated external defibrillation (AED) is well established as the only effective therapy for cardiac arrest caused by either ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The scientific evidence to support early defibrillation is overwhelming; the delay from collapse to delivery of the first shock is the single most important determinant of survival. If defibrillation is delivered promptly, survival rates as high as 75% have been reported, however the chances of successful defibrillation decline at a rate of about 10% with each minute of delay and whilst basic life support will help to maintain a shockable rhythm but is not a definitive treatment. The Chain of Survival Early Access: Somebody has to witness the event and dial the emergency services immediately. Early CPR: CPR must be carried out right away, this can extend the time a person in cardiac arrest is able to recover by supplying oxygenated blood to vital organs until their heart can be re-started. Early Defibrillation: In a lot of cardiac arrest victims, the heart goes into ventricular fibrillation (VF), this is where the heart muscles are contracting too fast and they lose their rhythm. Defibrillation by shocking the heart causes the heart muscles to "reset" themselves and start beating in rhythm again. This is the single most important link in the chain when the other links are all in place. Early ACLS: Early advanced cardiac life support is provided by the ambulance crew on arrival, although this is a very important link in the chain if the patient is to recover, it has limited effect if earlier links in the chain are not in place. - 20 - Electrical Pathways of the Heart Electrical Conduction of the Heart Blood Circulation of the Heart The heart beats approximately 60-100 times per minute, with the left hand side delivering oxygenated blood to the cells of the body and the right hand side pumping deoxygenated blood to the lungs for re-oxygenation and waste removal. For this process to happen, the heart muscle is made to contract by an organised pattern of electrical activity originating within the brain. Impulses received from the brain are passed to the first area of the heart, the Sinoatrial (SA) Node, this passes impulses across the top two chambers (atrium) causing these to contract and push blood into the ventricles below. The SA node also passes a further impulse to the next node called the Atrioventricular (AV) Node which causes the ventricles to contract, pumping blood oxygenated blood to the cells of the body and de-oxygenated blood to the lungs. If this electrical system is disrupted either by illness or injury, this can cause the electrical signals to become very random and disorganised or stop all together, therefore stopping the heart from pumping, this is a cardiac arrest. - 21 - How to use an AED • Check that the patient is unconscious and not breathing using D.R.A.B. • Ensure that the chest is prepared and all safety aspects considered • Switch the AED on • Attach the electrodes (pads) to the patient’s chest • The AED will automatically analyse the patient’s heart rhythm • Listen and follow the voice prompts - 22 - AED Pad Placement and Preparation AED Pad Positioning Patient Preparation AED Safety Considerations  Remove clothing to expose the bare chest (cutting the clothing off if necessary)  Water  Direct Contact (yourself and others)  Chest must be dry – remove any fluids on the chest  Indirect contact (yourself and others) Pad Position  Chest may need shaving in areas of pads  Avoid any potential conducting surfaces  Keep pads away from pacemakers  Ensure any oxygen supply is moved to one side prior to defibrillation (at least 1 metre)  Remove any jewellery from chest area  Remove any GTN / Medication patches  On female patients, the left pad should be placed under the left breast and not directly onto the breast tissue - 23 - Adult BLS with an AED - 24 - AED Handover The following information should be given to the ambulance crew on handover where possible: • Current situation on arrival of crew • How long since patient collapse • Number of shocks delivered • Any public/bystander CPR? • Relevant History Laerdal FR2 Cardiac Science G3 Zoll AED Plus - 25 - Paediatric Basic Life Support - 26 - Paediatric Basic Life Support The Facts Whilst arguably one of the most difficult incidents that any emergency care provider can experience, mercifully paediatric cardiac arrests are a very rare event. Recent studies have found that many children do not receive resuscitation because potential rescuers fear causing them harm. It is important to understand that it’s far better to perform “adult style” resuscitation on a child (who is unresponsive and not breathing) than to do nothing at all. Approximately only 7-15% of cases require a defibrillator as cardiac arrest is usually secondary to another cause such as Hypoxia. Unfortunately the majority of paediatric cardiac arrests have a poor prognosis with survival rates estimated somewhere between 3-17%. Causes • 60% are due to progressive respiratory problems (e.g. croup, bronchiolitis, asthma, pneumonia, FB’s) • Respiratory depression caused by prolonged convulsions, raised I.C.P. (head injury), neuromuscular disease or drug overdose • Sepsis (major infection) • Dehydration • Hypovolaemia • Electrocution • Congenital heart defect - 27 - Paediatric Basic Life Support (continued) Providing CPR to a child in cardiac arrest Supporting the child Always ensure that all children are held in a safe and secure manner:  For babies, this will necessitate cradling in your arms  For older children this will normally require either lying them across your lap or onto a suitable surface If possible, for ease and security, it is advisable to get all paediatric cardiac arrest patients lying flat onto a firm surface such as a table or the floor. Maintaining the airway There are subtle anatomical differences between a child’s and an adult’s airway. Whilst many of the structures are smaller, the tongue is actually much larger than an adult (in relative terms) which means that the airway is easily obstructed by the tongue. Dependant upon the child’s size, the technique used to open the airway will need to be varied:  For babies/small infants, the head should always remain in neutral alignment  For toddlers/children, a small application of head tilt/chin lift should be applied to achieve a position known as ‘sniffing the morning air’ - 28 - Paediatric Basic Life Support (continued) Baby/Infant (up to 1 year) Ventilations Compressions (you may use a pocket mask) (1/3 depth of the patient’s chest Children over 1 year Adjust CPR technique according to the size of the child - 29 - Paediatric AED Use Approximately only 10% of paediatric cardiac arrests require defibrillation due to Hypoxia being the primary cause of cardiac arrest within children. Therefore, whilst an AED may be used on a paediatric patient in cardiac arrest, this is no substitute for highly effective BLS and the use of an AED should in no way unnecessarily impact or disrupt BLS efforts. By their very design, AED’s are extremely simple to use and this is no different with children, with only the following minor notes • Specific pads, smaller in physical size, automatically adjusts the AED’s charge delivery and in some cases the algorithm followed • Paediatric pads may be used on any cardiac arrest patient up to 8 years of age • Commence CPR with 5 rescue breaths and then 30:2 for 1 minute prior to using the AED • Do not delay CPR unnecessarily to use the AED • If you use an AED, follow the voice prompts as normal AED Pad Positioning for Paediatric Patients In the majority of cases, due to the size of the patient’s chest you will need to use paediatric pads in the Anterior/Posterior position, however if size dictates, then you may also use them in the normal adult AED pad positions (as pictured) Normal Paediatric AED Pad Position (Anterior/Posterior) Alternative Positioning (Apex/Sternum) - 30 - Do Not Attempt CPR Instruction (DNACPR) When some people reach a point in their illness whereby it is considered that any resuscitation attempt may be deemed futile or not conducive to them maintaining their life to the same level pre-arrest, they may have a Do Not Attempt CPR instruction applied to them. The DNACPR form will be clearly printed on lilac paper. On rare occasions you may be presented with a white copy or photocopy. These are still valid. A copy of this form is shown on the next page. The form is designed to ensure that CPR is not attempted where it clearly will not work, or that the person’s wishes not to have CPR attempted are understood and respected. It is an essential part of advanced care planning for people with advanced and life-limiting illnesses, and will be applicable across all healthcare environments within South Central SHA. How does it affect responders? All responders may discontinue/withhold resuscitation attempts if any of the following exist: 1. A formal DNACPR order is in place, printed on a lilac DNACPR form (White copies and photocopies are still valid, but these will be rare). The form will stay with the person and will be located in the following places: • Hospitals, Nursing Homes & Hospices: In the front of the person’s notes • In the Home: The tear off slip should be completed and placed in the ‘message in the bottle’ in the person’s refrigerator. The location of the DNACPR form must be clearly stated on this slip. This will usually be in the front of the persons care notes. 2. An Advanced Decision to Refuse Treatment (ADRT) (Previously called “living wills” or “advanced directive(s)”) has been made by the person. This should be attached to the DNACPR and documented on the lilac form. An ADRT enables a person over 18 years, while they have capacity, to refuse specific medical treatments, for a time in the future when they may lack the capacity or consent to refuse that treatment. These documents are legally binding when valid and applicable. - 31 - Do Not Attempt CPR Instruction (DNACPR) Important Points • A DNACPR decision does not include immediately remediable witnessed life threatening clinical emergencies such as choking or anaphylaxis. Appropriate emergency interventions, including CPR should be attempted. • CPR must not be delayed unnecessarily in an attempt to establish either the existence or location of a DNACPR form. • If a responder has any doubt as to their actions for a given emergency or the validity of a DNACPR form, then they should commence CPR. For a DNACPR form to be valid, the following sections must be completed: • Personal details section at the very top of the form • Section 1 – Reason for DNACPR decision • Section 2 – Healthcare professional making this DNACPR decision – This must be completed, dated and signed by the healthcare professional with overall responsibility for the person’s care such as a medical consultant or GP. Sections 3, 4 and 5 do not need to be completed for the form to be valid These forms do not have an expiry date, unless section 3 (review date) has been completed and signed. If there are any doubts as to the validity of a DNACPR form, then resuscitation attempts should be started and EOC contacted immediately - 32 - Do Not Attempt CPR (DNACPR) Form - 33 - Patient Assessment - 34 - Patient Assessment Primary Assessment – this should be carried out for every patient Danger – Scene safety, PPE, Gloves, Goggles Response – Alert? Airway – Is it open? Voice? Pain? Unresponsive? If not, open it Breathing – Check for 10 seconds, is the patient breathing adequately? 2+ breaths = adequate breathing effort  <=1 breath - inadequate breathing effort History: Signs: What has happened (e.g. patient fell over) What can you see (e.g. bleeding?) Symptoms: What the patient tells you (e.g. nausea) - 35 - Patient Questioning The following questions are a guide as to what to ask a patient during an assessment: • What is the main problem? • What are the symptoms? • When did it start? • How bad is the primary symptom? • Has anything changed? • Has this happened before? • Do they take any medication? • Any known allergies • Consider the ‘Mechanism of Injury’ Remember that the most effective questioning techniques are always a mixture of both open and closed questions in conjunction with active listening - 36 - Pain Scoring A pain score is an extremely important part of the assessment process as it can guide a clinician as to a possible diagnosis and also the requirement or effectiveness of any treatment. Every individual has a different pain threshold and regardless of your own thoughts or observations, you must always rely upon the patient’s perception of the pain as opposed to your own. There have been many differing ways used to assess pain over the years; however things have now been very much simplified, with the following process used: • No Pain – Score of 0 • Mild – Score between 1-3 • Moderate – Score between 4-6 • Severe – Score between 7-10 • The pain score should be noted on the patient report form For children, a visual scoring system is used Please remember that diabetic patient’s can very often have a much higher pain threshold than other people due to peripheral neuropathy (nerve damage). - 37 - Patient Handover An effective and succinct handover to the attending ambulance clinician is vital to ensure a seamless delivery of care for the patient. By following this simple pneumonic below, you will ensure that only the most relevant information is provided in an accurate, professional and timely manner. Age of the patient Time of incident/Onset of symptoms Mechanism of injury/Medical complaint Injuries/Examination findings Signs – Vital signs/Base line observations Treatment – details of any treatment provided - 38 - CFR Patient Report Form (CAS130) - 39 - Pulse Oximetry - 40 - Pulse Oximetry What is Pulse Oximetry? Pulse oximetry is a simple non-invasive method of measuring the level of oxygen saturation in the patient’s arterial blood, by assessing the absorption of infra-red light within oxygenated and non-oxygenated haemoglobin within the small arteries, usually in the finger-tip. It then calculates the percentage of haemoglobin that is oxygenated and displays this as the oxygen saturation level on the screen. The display is an LCD screen, and records the: 1. Pulse Rate 2. SaO2/SpO2 (Oxygen Saturation). 3. Signal strength bar or waveform Normal Readings In a normally healthy person, the oxygen saturation within their bloodstream spans a very narrow normal range between 94% - 98%. However illness or serious injury can cause these levels to drop very quickly: • 90 – 93% represents evidence of hypoxia • 85 - 89% represents serious hypoxia • 85% or less represents CRITICAL hypoxia Be aware of COPD patients These patients suffer with a long term respiratory illness such as Emphysema or Chronic Bronchitis which drastically affects their normal levels of oxygen. Unlike a healthy person, due to their illness, their normal oxygen levels can be very low, often between 88 – 92% Many COPD patients carry oxygen administration warning cards which clearly explain the use of oxygen and specific saturation levels particular to their condition, these must be followed. Use in Children ALL children with significant illness and/or injury must receive HIGH levels of supplementary oxygen if possible, regardless of their SpO2 reading. - 41 - Pulse Oximetry When to use Pulse Oximetry • Any patient exhibiting respiratory distress symptoms (e.g. SOB, dyspnoea, asthma). • Any cardiac patient to ensure hypoxia is not present. • Any patient with an impaired level of consciousness • Ensuring a regulated supply of oxygen to prevent respiratory acidosis in chronic respiratory conditions • If you intend to administer oxygen then pulse oximetry must be used, except in cardiac arrest Known carbon monoxide poisoning will cause the results to be artificially elevated, therefore SpO2 should not be used Possible Complications in Use • Thick or dark nail varnish and/or false nails may cause inaccurate readings • Shivering may cause failure to pick up a signal • Bright overhead lighting may cause over-reading • Carbon monoxide poisoning will cause abnormally optimistic readings • Irregular cardiac rhythms may cause an inaccurate reading • Children may be fearful or non-compliant, do not force them - 42 - Oxygen - 43 - Oxygen • The atmosphere contains approximately 21% oxygen • Every cell of our body requires oxygen in order to survive and function • Brain death will start to occur after just 3 minutes without oxygen • Medical oxygen is manufactured and is an essential tool within pre-hospital care. It is a prescription only medication (POM) with special dispensation for emergency care providers • It is a colourless, odourless naturally occurring gas • It is stored in lightweight cylinders • The cylinder is normally white in colour and marked ‘Oxygen’ (usually in black lettering) and contains approximately 460 litres of compressed medical oxygen ‘CD’ Oxygen Cylinder Oxygen Mask Face Mask with nose grip Carry Handle Flow Control Valve in litres per minute (LPM) Main On/Off Valve Oxygen Tubing Spigot (for oxygen tubing) Reservoir Bag Nasal Cannula Oxygen Tubing Nasal Prongs - 44 - Oxygen Potential Indications for Use • Cardiac/Respiratory Arrest • Trauma • Respiratory • Circulatory Compromise Compromise (e.g. suffocation) (e.g. crush injury) • Chest Pain • Stroke • Acute Medical Illness • Prolonged Seizure • Toxic Syndromes Hypoxia This is where the level of oxygen within the body becomes too low to meet the cell’s needs and can arise from the deterioration of any medical illness or injury. It can quickly reach dangerous levels causing severe brain injury and/or be fatal. Causes (list not exhaustive) Signs and Symptoms • Severe injury/blood loss • Shortness of breath • Head/chest injuries • Difficulty Breathing (Dyspnoea) • Heart disease • Low SpO2 reading • Respiratory illness • Skin Pallor • Shock • Cyanosis • Confusion • Unconsciousness Left untreated, Hypoxia can be fatal - 45 - Oxygen Oxygen Administration • Oxygen is used to treat Hypoxia only • SpO2 levels must be measured before and during all oxygen administration • Can be used on any age of patient • Delivery via:  Non re-breather oxygen mask (paediatric and adult) – titrated 12 to15 lpm  Nasal Cannula (COPD patients) – titrated 2 to 6 lpm  Bag Valve & Mask device (cardiac arrest only) – 15 lpm • Oxygen Masks, Nasal Cannula and BVM’s are single patient use only • Be aware of COPD warning cards and if present follow the instructions printed on them Safety • Do not smoke around oxygen cylinders • Do not expose oxygen cylinders to naked flames or other heat sources • Check cylinders have an intact seal upon delivery • Ensure outlet face is not damaged • Do not allow oil or grease to come into contact with oxygen cylinders - 46 - The Human Body in Illness - 47 - Respiratory Emergencies Respiratory emergencies are arguably one of the most common types of emergency call received by the ambulance service and attended by responders. Respiratory emergencies can be life threatening, and the application of timely and effective treatment can literally mean the difference between life and death. Common Breathing Problems • Chest Infection - History of productive cough, shortness of breath (SOB), feeling generally unwell, possible fever • Chronic Chest Diseases (COPD) (e.g. Emphysema, Bronchitis) – Known history, persistent cough, SOB, repeat chest infections, specific medications • Chest Injuries – Bruising or fractures, penetrating wounds, pain reduces patient’s breathing effort General Management of Breathing Problems • Asses D.R.A.B. • Ensure patient has a patent airway • Patient positioning (upright or semi-recumbent) • Provide oxygen therapy if indicated • Reassure the patient • Remove the cause (where possible) • Coach respirations if appropriate • Never remove any penetrating object • Monitor patient and record observations - 48 - Asthma More than 5.2 million people in the UK are being treated for asthma and about 1.1 million of these are children. Asthma affects approximately one in 12 adults and one in eight children meaning that there is a person with asthma in one in five households within the UK. It can affect almost anyone, at any age, anywhere, although it tends to be worse in children and young adults. It is estimated that 3 people a day die as a direct result of asthma. Asthma is a condition that affects the small airways and when a person with asthma comes into contact with a trigger (such as dust, pollen, pollution etc), the muscles around the walls of the airways tighten and the airways become narrower. The lining of the airways become red and swollen and often sticky mucus or phlegm is produced. All these reactions cause the airways to become narrower and irritated leading to the symptoms of asthma. Stages of an Asthma Attack Moderate (Stage 1) Acute Severe (Stage 2) • Speech normal • • May be a slight expiratory wheeze • RR < 25 bpm • HR < 110 bpm Unable to complete sentences • Clearly audible expiratory wheeze • RR > 25 bpm • Life Threatening (Stage 3) • Silent chest (no wheeze) • Cyanosis • Poor breathing effort • Slowing heart rate • Exhaustion • Loss of consciousness - 49 - HR > 110 bpm Asthma (continued) Management of an Asthma Attack • Reassure • Position • Encourage to use own medication/nebuliser/volumiser • Provide oxygen therapy if indicated • Reassure and encourage • Be prepared to resuscitate Types of Asthma Inhalers - 50 - Hyperventilation Hyperventilation is a state of breathing faster or deeper than normal causing excessive expulsion of the circulating carbon dioxide within the body matched by an increasing oxygen level. There can be many causes of hyperventilation and common triggers include emotions of stress, anxiety, depression, or anger. Occasionally, hyperventilation from panic can be related to a specific fear or phobia, such as a fear of heights, dying, or closed-in spaces (claustrophobia) and often, panic and hyperventilation become a vicious cycle. The cause of hyperventilation cannot always be determined with sufficient accuracy (especially in the early stages) within the pre-hospital environment. Therefore you should always presume hyperventilation is secondary to hypoxia or another underlying respiratory disorder until proven otherwise. Recognition Management • Previous history of panic attacks • Assess DRAB • Immediate history of emotional • Remove the stimuli (where stimuli possible) • Fast, shallow rate of breathing • Sit the patient upright • Chest tightness • Reassure the patient • Pins and needles/tingling in the • Monitor SpO2 levels hands, face and around the lips • Provide oxygen therapy if • Hands in spasm (claws) indicated • Focus the patient on their breathing • Coach breathing continuously • Monitor patient and record observations Hyperventilation may occur secondary to a life threatening condition - 51 - Traumatic Chest Injuries Traumatic chest injuries can be life threatening events, and whilst external injuries may appear somewhat insignificant there is a high risk of injury to the underlying organs, with unseen internal damage. Any patient with a traumatic chest injury should be treated as time critical. Common causes can include road traffic collisions, stabbings (not just with a knife!), impaled on foreign bodies , crush injuries Recognition • Foreign body still present • Difficult/laboured breathing (Dyspnoea) • Coughing up blood (bright red and frothy) • Open wound/bleeding • Signs of shock • Panic/anxiety • Pain (may be worse on inspiration) • Asymmetrical chest movement • Flail Chest Management • Assess DRAB • Provide oxygen therapy if indicated • Position patient semi-recumbent leaning to the injured side • Cover any wounds, use plastic seal (if required) • Reassure the patient • Be prepared to resuscitate • Monitor patient and record observations • Do not remove any foreign object still in situ - 52 - Choking (Adult) Choking is a serious medical emergency that is very much the epitome of a time critical incident. A complete airway obstruction will mean that air is unable to enter or leave the body with brain damage occurring as a result of hypoxia in as little as 3 minutes. Choking is often caused by the ingestion of an object like food or a foreign body into the upper airway and may either be a partial or complete obstruction. Management of a Choking Adult You first need to ask: “Are you choking?” Mild Obstruction Severe Obstruction • Says ‘yes’ • Unable to speak • Speaks • May nod • Coughs • Cannot breathe or • Breathes wheezing - 53 - • Silent cough • Unconscious Choking (Paediatric) A paediatric patient presents greater difficulty in assessing the severity of the obstruction, therefore the rescuer should look for particular verbal clues as to whether they have an effective cough reflex. Effective Cough Ineffective Cough • Cries or gives a verbal • Cannot vocalise response • Cough is silent • Coughs loudly • Cannot breathe • Breathes before coughing • Cyanosis • Fully responsive • Decreasing level of response - 54 - Cardiac and Circulatory Emergencies - 55 - Heart Attack and Angina Heart Attack and Angina – What is the difference? Heart Attack • Also referred to as a Myocardial Infarction (MI) • Caused by a complete blockage of a coronary artery Angina • May be stable or unstable • Caused by a partial obstruction of the coronary artery Signs and Symptoms Heart Attack Angina • Crushing central chest pain • Central chest pain • Pain in the left arm, face or jaw • Pain in the left arm, face or • Shortness of breath • Symptoms may start whilst at • Shortness of breath rest • Feeling weak • Ashen/cyanosed, sweating • Pale, cold, clammy • Nausea/vomiting • Nausea/vomiting • May not have any previous • May have a previous jaw cardiac history cardiac history Patients may only present with some of these features and it is clear that it is very difficult to differentiate, with a true diagnosis only being possible following a full ECG and blood tests. Regardless of the suspected diagnosis, the treatment remains exactly the same. - 56 - Heart Attack and Angina (continued) Management of a suspected Heart Attack or Angina As can be seen, both a heart attack and angina share virtually identical signs and symptoms and as a result the management for either is exactly the same. The aim of any treatment is to help reduce anxiety, reduce the workload of the heart and also treat the clot that is causing the problem. The following treatment steps should be followed: • Assess D.R.A.B. • Provide oxygen therapy if indicated • Administer aspirin if indicated • Place the patient in the semi-recumbent position and loosen any tight clothing (neck/chest) • Assist the patient to take any appropriate cardiac medication they may have (i.e., GTN spray) • Reassure the patient • Minimise the amount of movement of the patient • Be prepared to resuscitate • Monitor patient and record observations - 57 - Aspirin - 58 - Aspirin The Facts • Aspirin is also known as Acetylsalicylic Acid and was originally derived from the bark of the willow tree • It helps to reduce the chances of clot formation and also acts as an analgesic and anti-pyretic • In emergency care, it is used as a 300mg single dose in tablet form • Many patients regularly take a therapeutic dose of 75mg daily, this does not affect any emergency dose administered Why is it so important? • Large scale clinical trials have proven a definitive link between aspirin and a positive prognosis following an MI and are applicable to all groups of adult patients with a suspected MI • Aspirin decreases the chances of further clot formation by reducing the ‘stickiness’ of platelets • Early administration ensures that the risk of clot obstruction will be reduced within the affected artery, therefore helping to minimise damage to the myocardium Within healthcare, the safe administration of any drug is governed by a list of indications (when it should be administered) and contra-indications (when it absolutely should not be given). To prevent any risk to the patient and to ensure that only safe and specific treatment is provided, the indications and contra-indications should always be checked prior to the administration of any drug. - 59 - Aspirin Administration Indication for Use Contra-Indications Aspirin may be administered to: Aspirin must not be administered to:  Patients over 16 years of age presenting with cardiac sounding chest pain that is not exacerbated or eased by inspiration or expiration and who are not contra-indicated  Any patient under 16 years of age (may lead to Reye’s syndrome which, although rare, has a 50% mortality rate)  Any known allergy or hypersensitivity to aspirin  Patients diagnosed with haemophilia or other blood clotting disorders  Known active gastric/peptic ulcer  If patient has received any other dose of aspirin from either a F.A.W. or upon advice from the EOC. (not including normal daily dose of 75mg) Side Effects Although rare, aspirin may increase the chances of wheezing in asthmatics or gastric bleeding (particularly within the elderly). Administration Notes • In the interests of accountability, traceability within the supply chain and adherence to Trust clinical policy, only aspirin supplied by SCAS is to be used • All aspirin stock must be securely stored within the main responder bag and not in any outside pockets to aid child safety • 1x 300mg tablet to be given and the patient advised to chew the tablet or dissolve it under the tongue if possible (it will taste foul!). If carried, dispersible aspirin may be given in a small amount of water. • The attending ambulance crew should be advised of:     Time given Dose Batch Number Expiry Date - 60 - Nervous System Emergencies - 61 - Stroke A stroke can be defined as damage caused to the brain by either a blocked or bleeding artery which may be caused by a variety of reasons such as medical conditions (high blood pressure, raised inter-cranial pressure etc) or significant trauma. A stroke’s effects may be either permanent, called a Cerebral Vascular Incident (CVI) or temporary which is called a Transient Ischaemic Attack (TIA). Blockage (70% of cases) Bleed (20%) Face – Arms – Speech - Test Signs and Symptoms Management • Undertake a F.A.S.T. test • • Assess DRAB Altered level of consciousness • • Position patient with head Confusion, abnormal emotional state • Facial paralysis on one side (palsy) • Limb • weakness on one slightly raised • side Provide oxygen therapy if indicated (hemiplegia) • Provide reassurance Difficulty speaking (slurred speech), • Maintain patient dignity swallowing or breathing • Monitor patient and record • Incontinence • Unequal pupils • Relevant history (e.g. visual observations • disturbances, high blood pressure, unexplained falls or unconsciousness) - 62 - Be prepared to resuscitate Seizures What is a Seizure? A seizure can be defined as an episode of disturbed brain activity that cause changes in attention or behaviour. Symptoms vary from person to person with some exhibiting simple staring spells, whilst others have violent shaking and loss of alertness. The type of seizure depends upon the part of the brain affected. Seizures may be caused by a variety of reasons such as epilepsy, diabetic emergencies, head/brain Injury, alcohol withdrawal, poisoning, stroke or hyper/hypothermia. Recognition Management • History of seizures/other • Assess DRAB relevant history • Make the area safe to reduce • Loss of consciousness (may be risk of injury • transient) Provide oxygen therapy if • Reduced level of response indicated (this may prove • Muscle twitching/rigidity difficult) • Incontinence • Breath holding • ‘Glazed’ appearance • Abnormal/inappropriate • the seizure (where possible) • Monitor patient and record observations • behaviour • Time Consider use of recovery position after seizure ‘Aura’ (smell, taste, sensation) Do not restrain the patient and never allow anyone to force the mouth open or force objects into it - 63 - Febrile Seizures What is a Febrile Seizure? Febrile seizures are a relatively common childhood condition, referring to a child having a seizure (fit) when they have a high temperature of 38ºCF (100.4ºF) or above, usually as a result of an infection. Most children have what is known as a tonic clonic seizure, during which the child's body becomes stiff, they lose consciousness and their arms and legs twitch. Some children may also wet themselves. The recognition features are the same as adult seizures and the management is the same. In addition to the normal management of a seizure, it is also advisable to suggest that the parents remove child’s clothing, but do not allow the child to become hypothermic! Watching a child having a seizure, particularly if they have no previous history of seizures, can be very frightening and distressing for the parents and many parents who have witnessed their child having a febrile seizure say they were convinced that their child was going to die. However, although febrile seizures may be very frightening, most are harmless and do not pose a threat to a child’s health. - 64 - Head Injury A head injury can occur as a result of either direct or indirect force. The brain is at risk following a head injury and may affect airway & breathing. In a significant head injury, an associated neck injury should also be suspected. Recognition Management • Relevant history • Assess DRAB • External head injury (bleeding) • Lay the patient down with • Brief or partial loss of head slightly raised • consciousness • Dizziness and unsteady balance • Nausea/vomiting • Disorientation, indicated • confusion Slurred • and/or • speech Lethargy • Prolonged headache (mild and external If unconscious, place in Monitor patient and record observations • Record any periods of unconsciousness generalised) • any recovery position incoherent • Treat bleeding and amnesia • Provide oxygen therapy if • Visual and audio disturbances Be prepared resuscitate - 65 - to Diabetic Emergencies What is Diabetes? Diabetes is a common life-long health condition. There are 2.9 million people diagnosed with diabetes within the UK and an estimated 850,000 people who have the condition but don’t know it. Diabetes is a condition where the amount of glucose in your blood is too high because the body cannot use it properly. This is because your pancreas does not produce any insulin, or not enough, to help glucose enter your body’s cells – or the insulin that is produced does not work properly (known as insulin resistance). Insulin is the hormone produced by the pancreas that allows glucose to enter the body’s cells, where it is used as fuel for energy so we can work, play and generally live our lives. It is vital for life. Glucose comes from digesting carbohydrate and is also produced by the liver. Carbohydrate comes from many different kinds of foods and drink, including starchy foods such as bread, potatoes, fruit, some dairy products, sugar and other sweet foods. If you have diabetes, your body cannot make proper use of this glucose so it builds up in the blood and isn’t able to be used as fuel. Two forms of diabetes exist: • Type 1 – Treated with diet & insulin combined • Type 2 – Treated with diet, tablets or insulin The two most common diabetic emergency presentations are: • Hypoglycaemia – Low blood sugar level • Hyperglycaemia – High blood sugar level - 66 - Diabetic Emergencies Signs and Symptoms Hypoglycaemia (Low) Hyperglycaemia (High) • Rapid onset (minutes) • • Rapid, shallow breathing • Slow, bounding pulse • Slow, deep breathing • Pale and sweaty • Rapid pulse • Irritable, confused, aggressive • Flushed, dry skin behaviour • Tiredness, lethargy, Gradual onset (hours to days) • Inability to concentrate • Confusion, dizziness & • Blurred vision headache • Excessive thirst, hunger or drowsiness • Hunger • Seizure • Smell of acetone on breath • Unconsciousness • Seizure • Unconsciousness urination Management of a Diabetic Emergency • Assess DRAB • Provide oxygen therapy if indicated • If conscious: Encourage the patient to eat/drink something with a high sugar content if able • If unconscious: Place in recovery position • Reassure the patient • Monitor and record observations • Be prepared to resuscitate - 67 - Physiological Shock Shock can be simply defined as a potentially fatal physiological reaction to a variety of conditions, including illness, injury, haemorrhage or dehydration, usually characterised by a marked loss of blood pressure, diminished blood circulation, and inadequate blood flow to the tissues and cells of the body. The main types of shock are: • Toxic – poisoning • Cardiogenic – heart failing • Neurogenic – disruption of nervous system • Hypovolaemic – loss of body fluid Responders will most commonly deal with hypovolaemic shock which is caused by an insufficient oxygen supply to the cells of the body due to the loss of circulating blood/fluid volume. Recognition Management • Pale, cold, clammy skin • Treat the cause (where possible) • Rapid, shallow • Administer high flow oxygen breathing/rapid weak • Lay the patient down and raise their legs pulse • Keep the patient warm • Air Hunger • Loosen any tight clothing (neck, chest & • Weak and dizzy • Nauseous / vomiting • Reassure the patient • Thirsty • Do not move the patient unnecessarily • Do not allow them to eat, drink or smoke waist) anything • Do not leave the patient unattended • Monitor patient and record observations • Be prepared to resuscitate Remember - Shock can kill very quickly - 68 - Anaphylaxis What is Anaphylaxis? Anaphylaxis is a severe over-reaction of the body’s normal protective defences (histamine) in response to a perceived threatening foreign substance which results in a sudden, massive drop in blood pressure. It is characterised by a marked and severe generalised swelling to the tissues of the body (can be a high risk to the airway) in association with widespread itching (pruritus) and redness/blotching (urticaria). The majority of people that experience anaphylaxis have had exposure to the problematic substance beforehand (often more than once) and common causes include insect stings/bites, food stuffs (nuts, eggs, etc) and drugs. - 69 - Anaphylaxis Signs and Symptoms • Swelling of the face/neck • Difficulty breathing • Shortness of breath and wheezing • A generalised blotchy rash (urticaria/wheals) • Profuse itching (pruritus) • Pale, cold, clammy skin • Light-headedness • May lead to respiratory/cardiac arrest Management of Anaphylaxis • Assess DRAB • Ensure an open airway • Sit the patient up (if conscious) • Provide oxygen therapy • Assist the patient with administering their Epi-pen* • Loosen tight clothing around the neck/chest • Reassure the patient • Monitor patient and record observations • Be prepared to resuscitate * You may actually administer the Epi-pen only if you have received suitable training - 70 - Burns and Scalds Burn and scald injuries can be grouped into two distinct categories: Burns (dry) Scalds (wet) • Flame • Boiling water • Electricity • Boiling steam • Friction • Hot fats • Radiation • Chemicals Burn Classification Superficial Partial Thickness Full Thickness - 71 - Burns and Scalds (continued) Significant Burn Awareness The following list may be classed as significant burns with particular dangers. • To children • To feet, hands, face or genitals • All burns which extend around a limb • Any size, full-thickness burn • Partial thickness > 1% body surface area • Superficial burns > 5% body surface area • Chemical burns Management of Burns • Assess D.R.A.B. • Provide high flow oxygen if indicated • Non Chemical Burns – Cool for a minimum of 10 minutes • Chemical Burns – Cool for a minimum of 20 minutes and try to identify the chemical (if possible) • Remove any contaminated/non-adherent clothing and jewellery from the affected area • Once cooled, apply cling film along the burn (not circumferential) through which you may continue cooling • DO NOT apply any lotions, creams, oils, etc • DO NOT apply adhesive dressings • DO NOT burst any blisters • Treat for shock - 72 - Blood Loss (Haemorrhage) Blood loss can occur through a variety of reasons, ranging from obvious external injuries to an internal rupture of an organ or other structure. Bleeding can occur from: Arteries – Bright red and spurting Veins – Dark red and a continuous flow Capillaries – Oozes for a short while Major blood loss is usually obvious and can rapidly lead to serious hypovolaemic shock, however long term minor loss can also be as dangerous, and should never be underestimated. Bleeding from certain areas can also present further problems in addition to hypovolaemic shock: • Nose – danger to airway, history of assault • Mouth – danger to airway, limits communication • Head – bleeds profusely, possible spinal injury • Ears – perforated ear drum, head or brain injury • Lungs – may hinder breathing • Stomach – vomit is brown, like ‘coffee grounds’ • Rectum – haemorrhoids, sexual assault • Gynaecological – any unusual bleeding? Internal Bleeding Internal bleeding can be caused by either a direct or indirect force, with the recognition features virtually the same as for external bleeding, however, bruising, swelling, tenderness and rigidity may also be witnessed within the affected area. A patient who is suffering from shock with no obvious injuries is likely to be suffering from internal bleeding and therefore an extensive patient and incident history can be particularly significant in recognition. - 73 - Blood Loss (Haemorrhage) Management of Blood Loss • Assess D.R.A.B. • Expose and examine the wound • Lay the patient down (if possible) • Apply direct pressure • Elevate the affected area above the level of the heart (where possible) • Provide oxygen therapy if indicated • Treat the patient for shock • Apply a sterile dressing (if necessary) • Monitor the patient and record observations • Do NOT remove any embedded object - 74 - Skeletal System Emergencies There are two common types of injuries that can occur to the skeletal system – Fractures and Dislocations. Whilst very different types of injury, they also share a lot of similarities in regards to cause, presentation, recognition and treatment. It can sometimes be hard to tell if a bone is dislocated or broken, however both are emergency situations and require the same immediate treatment. Fractures A fracture is a break within the continuity of a bone and it may either be partial or complete. Common causes can be either from direct force such as an arm being hit with an object and fracturing the radius (forearm bone), or indirect force such as falling onto an outstretched hand/arm and fracturing a collar bone. Closed Fracture Very often there are wounds associated with fracture sites and these can be classed as closed, open or comminuted. Comminuted Open Fracture Fracture Dislocations Patella (Kneecap) Dislocation Joints are areas where two or more bones come together. If a sudden impact injures a joint, the bones that meet at that joint may become dislocated (not connected). That means the bones are no longer in their normal position. Usually the joint capsule and ligaments tear when a joint becomes dislocated, and often the nerves are injured. - 75 - Skeletal System Emergencies (continued) Signs and Symptoms of a Fracture/Dislocation • Swelling • Loss of power • Irregularity • Pain • Deformity • Unnatural movement • Crepitus (bone grating) • Tenderness • Bruising Management of a Fracture/Dislocation • Assess D.R.A.B. • Provide oxygen therapy if indicated • Keep the affected area still (encourage the patient to hold it) • Immobilise the affected area (if necessary) • Treat any open fracture wounds by gently covering with a dressing • Reassure the patient • Monitor patient and record observations Never attempt to reduce a dislocation back to normal - 76 - Spinal Injuries Spinal cord injury (SCI) most commonly affects young and fit people and will continue to affect them to a varying degree for the rest of their lives. In the extreme, it may prove immediately fatal where the upper cervical cord is damaged, paralysing the diaphragm and respiratory muscles. Partial cord damage, however, may solely affect individual sensory or motor nerve tracts producing varying long-term disability. Common Causes Recognition • Falls from height • • Road traffic collisions • Any significant head injury Any of the above, or mechanism of injury you suspect may result in spinal injury • Multiple injuries • Sensation of burning or electric shock in trunk or limbs • Diving into shallow water • • Fall from horse Tingling or loss of movement or sensation in the limbs • Any injury resulting in neck or back pain. • Pain in neck or back • Loss of control bowel or bladder Management Asses D.R.A.B. If required use jaw thrust method to open airway Do not move the patient unless required to maintain airway, or patient is in a dangerous position. Only place unconscious patient in recovery position if airway cannot be maintained or patient has to be left alone. Remember that the unconscious patient cannot tell you any history or symptoms so always suspect a spinal injury - 77 - Glossary of Terms Acute (of disease): Severe, rapidly developing, or of a sudden onset. Ambulance Technician: Experienced ambulance crew member capable of delivering a wide range of drugs and treatments to patients. Angina: Condition of gripping chest pain associated with disease and the narrowing of the arteries of the heart which can be described as cramping of the heart muscle. Asphyxia: Suffocation by smothering or any condition that prevents oxygen being taken up by the blood. Aspirator: A suction device used in the removal of fluids from the airway and other cavities. Asthma: Tightening or restriction of the lower small airways accompanied by a sense of suffocation or tightness of the chest. Cardiac: Relating to the heart. Casualty: Any victim of an accident or sudden illness. Catheter: A tube designed to be passed into a body cavity. Chronic (of disease): persistent and lasting disease or medical condition, or one that has developed slowly. Communication assistance device: A portable device which may provide a communication-challenged person with a means of communication. (i.e. an enhanced or artificial voice, script on a monitor screen). Community Nurse: A nurse who specialises in care for people within their own home or local health centres. - 78 - Glossary of Terms (continued) Coronary Thrombus: Blockage of one or more of the arteries that supply blood to the cardiac muscle usually caused by blood clots and/or fatty tissue. Cyanosis: A dusky bluish tint to the skin due to a lack of oxygen in the blood. Diabetes Mellitus: Disease caused by either insulin deficiency or uptake problems. Dyspnoea: Difficult or laboured breathing. Emergency Care Assistant: Ambulance crew member usually working alongside a more experienced colleague in the delivery of emergency care. Emergency Care Practitioner: Senior and highly skilled ambulance crew member capable of delivering advanced medical skills and treatments above and beyond that of a Paramedic. Emergency Operations Centre (EOC): Where 999 calls are received and ambulance resources despatched/managed from. Emphysema: A chronic and debilitating condition affecting the very small airways within the lungs, the primary cause being smoking. Epilepsy: Convulsive seizures caused by a disorder of the normal functioning of the brain. Fibrillation: Uncoordinated contraction of muscle fibres and cells within the heart. Hyperglycaemia: High levels of glucose in the blood. Hypoglycaemia: Low levels of glucose in the blood. Hypoxia: Low levels of oxygen within the blood and tissues of the body. Incident: Any accident, occurrence or other unforeseen event requiring an ambulance response. - 79 - Glossary of Terms (continued) Pacemaker: An apparatus for artificially controlling the rhythm and rate of the heart. Paramedic: Senior and highly skilled ambulance crew member capable of administering a large range of drugs and medical skills. Personal protective equipment (PPE): Specialised equipment provided for your safety such as hi-visibility jacket, gloves etc Pleurisy: Inflammation of the covering of the lungs. Pneumonia: Infection of the lung tissue. Pulmonary: Relating to the lungs. Response times: The time lapse between notification of an emergency and the arrival of an ambulance response. Tachycardia: A fast heart rate, normally >100 beats per minute. Vaccination: Immunisation by giving a vaccine. Vaccine: Substance created from the germs of an infectious disease used to treat that disease (vaccine may be either active or inactive). - 80 - NOTES - 81 - NOTES - 82 - NOTES - 83 - NOTES - 84 -