Emergency – Knowledge You Need to Know and Things to Keep in Mind

This article will provide basic knowledge about first aid in some common situations, including drowning, snakebites, poisoning, hyperkalemia, and hyponatremia. Please note that this is general information only and cannot replace medical advice.

1. First Aid for Drowning

Causes of Drowning:

• Freshwater drowning:

• Blood dilution, circulatory collapse, cerebral edema.

• Hemolysis, hyperkalemia.

• Destruction of alveolar membranes causing respiratory distress, lung injury.

• Saltwater drowning:

• Dehydration, blood concentration, respiratory distress.

• Lung injury.

Management:

• Motto: Immediate first aid at the scene, actively, correctly. Persist in first aid for many hours.

• Objectives: Clear the airway, provide oxygen, prevent and treat timely cardiovascular and pulmonary disorders, and metabolic disorders.

First aid at the scene:

• If the victim is cyanotic, cardiac arrest and/or respiratory arrest, no femoral pulse:

• Open the airway.

• Place the victim on their back, head tilted back.

• Mouth-to-mouth or mouth-to-nose artificial respiration.

• External chest compression if there is cardiac arrest.

First aid when the emergency team arrives:

• Artificial respiration with Ambu bag with 100% oxygen.

• Open the airway, insert a suction tube to clear phlegm, dirt.

• If the victim is conscious and able to breathe on their own: oxygen through nasal cannula or oxygen mask 4-6 liters/minute.

• If the victim is still cyanotic, intubate, give oxygen through the endotracheal tube.

• Insert a nasogastric tube to prevent regurgitation.

• Blood draw at the scene: 250-300 ml in 10-15 minutes when there is severe respiratory distress, respiratory failure.

Antibiotics used:

• 3rd generation cephalosporin + aminoglycoside + metronidazole.

Notes:

• Cerebral edema: Intravenous mannitol 20% 1g/kg body weight every 5 hours, infuse for 5-10 minutes.

• Pulmonary embolism: Low-dose intravenous heparin 1-2mg/kg body weight for 24 hours or use low-molecular-weight heparin for prophylactic subcutaneous injection.

2. First Aid for Snakebites

Types of Snakes:

• Cạp nong: Black and yellow.

• Cạp nia: Black and white.

• Hổ chúa: Up to 7m long, head without round glasses, vertical neck expansion.

• Hổ phì: With round glasses, horizontal neck expansion.

• Sea snake: Round head, paddle tail.

Symptoms:

• Cạp nia, cạp nong:

• Not obvious.

• Full body paralysis.

• Dilated pupils, drooping eyelids.

• Almost no rhabdomyolysis.

• Cạp nia paralyzes both the roots and tips of the limbs.

• Hổ phì, hổ chúa:

• Necrosis, swelling, pain.

• Rhabdomyolysis, dark urine.

• Mainly slight paralysis of the root of the limb.

• Green snake:

• Swelling after 6 hours, cyanosis after 12 hours, rapid necrosis spreading upwards, uncontrollable bleeding.

• Coagulation disorder: bleeding, blood loss, dark urine due to rhabdomyolysis.

• Almost no muscle paralysis.

First aid at the scene:

• Immobilize the bite site with a wide bandage 5-10cm above the bite, immobilize the limb.

• Do not tourniquet.

• Incise the bite site widely, incise parallel to the bite: 10mm long, 3mm deep. Aspirate blood with a suction cup or by mouth and then spit it out (only perform in the first 30 minutes, after 1 hour do not do so).

Transportation:

• Immobilize, transport quickly by motor vehicle or car. Do not use bicycles or motorcycles if there is shock, circulatory collapse or limb paralysis.

• If there is respiratory distress, give Ambu bag ventilation, intubate. If breathing is fast > 30 times/minute, weak breathing, cyanotic lips then support breathing.

Indications for antivenom:

• Spontaneous bleeding or coagulation disorder on testing or decreased platelets.

• Neurological disorder: signs of paralysis.

• Cardiovascular abnormalities.

• Acute renal failure.

• Evidence of hemolysis, rhabdomyolysis on clinical and laboratory tests.

• Evidence of systemic venom poisoning.

• Swelling at the bite site more than half of the bitten limb, no tourniquet, swelling when bitten on fingers, toes.

• Swelling spreading rapidly.

• Tender regional lymph nodes.

General principles when using antivenom:

• Adjust the dose according to the specific case. Dilute at a ratio of 1/10 G5% or 0.9% NaCl, infuse slowly (at least 30 minutes).

• Prioritize single-dose use.

Notes:

• Green snakebites need additional proton pump inhibitors.

• The most effective measure after using antivenom is plasma exchange in the first 6 hours.

3. First Aid for Poisoning

Types of poisoning:

• Anticholinergic poisoning: Atropine, Parkinson’s, tricyclic antidepressants.

• Symptoms: Red, hot, dry skin. Urinary retention, decreased intestinal motility.

• Barbiturate poisoning:

• Symptoms: Deep coma, quiet. Decreased tendon reflexes. Constriction of pupils, still light reflexes.

• Examination: Gastric fluid, urine, blood.

• Treatment:

• Conscious: Gastric lavage, activated charcoal.

• Coma: Intubate, ensure respiration, circulation, then lavage.

• Forced diuresis and urinary alkalinization.

• Hemodialysis: severe poisoning, liver failure, kidney failure (excreted 1/2 barbiturate in 6 hours).

• Cholinergic hyperactivity syndrome:

• Includes:

• Muscarine poisoning.

• Nicotine poisoning.

• Central nervous system poisoning.

• Muscarine poisoning causes:

• Intestinal, bronchial, bladder spasms, pupil constriction.

• Decreased light reflexes.

• Increased secretion: saliva, intestinal fluid, sweat, tears.

• Abdominal pain, nausea, vomiting, diarrhea, urinary incontinence.

• Nicotine poisoning causes:

• Muscle twitching, muscle spasms, respiratory muscle paralysis.

• Cold, cyanotic skin.

• Rapid pulse, increased blood pressure, sweating, dilated pupils.

• Central nervous system poisoning causes:

• Impaired consciousness, coma, severe poisoning inhibiting the respiratory and circulatory centers, seizures and deep coma.

• Intermediate syndrome: Muscle paralysis 24-96 hours after poisoning when cholinergic hyperactivity has subsided. Characteristic paralysis: Root muscles, neck flexor muscles, flaccid paralysis, decreased tendon reflexes. Paralysis does not respond to atropine and PAM.

• Late peripheral nerve poisoning: 8-14 days after pesticide poisoning. Muscle weakness, muscle paralysis, numbness and tingling. Regress after many months, many years causing muscle atrophy.

• Diagnose organophosphate poisoning when cholinesterase <50%.

• Paracetamol poisoning:

• Indication for N-acetylcysteine (NAC) detoxification in Paracetamol poisoning:

• Ingestion over 140mg/kg/72h + liver enzymes not elevated, no Paracetamol concentration test.

• Overdose, repeated treatment with Paracetamol concentration > 20 mcg/ml or elevated transaminases.

• Paracetamol overdose (>4g/24h) late, regardless of Paracetamol concentration, but with hepatitis/liver failure.

• Symptoms:

• Stage 1 (0.5-24h): Loss of appetite, nausea, vomiting. Sweating, discomfort.

• Stage 2 (24-72h): Elevated liver enzymes, bilirubin, PT. Renal failure.

• Stage 3 (72-96h): Liver cell necrosis (central lobules). Can lead to multi-organ failure.

• Stage 4 (4-14 days): If survive, liver recovers completely, no sequelae.

• Paracetamol poisoning when ingested:

• Adults: > 4g or 140 mg/kg/ 8h.

• Children: > 200 mg/kg/ 8h.

• Repeated ingestion: >4g/> 8h (adults); > 90mg/kg (children).

• Management:

• Go to the hospital early (within the first hour): Gastric lavage + activated charcoal (if after 1 hour but slow transit).

• Opiate poisoning:

• Examination for toxic substances: Urine.

• Mechanism of action of Naloxone in treating opiate poisoning:

• Displace morphine from the respiratory center receptors.

• Make the respiratory center resensitized to CO2.

• Antagonize the sedative, analgesic, pupil constricting effects.

• Recover central nervous system inhibitory substances: GABA.

• Symptoms:

• Triad: Impaired consciousness, respiratory depression, constricted pupils.

• Opiate withdrawal: Lack of drugs/discontinuation of drugs.

Notes:

• Examination for toxic substances: Take gastric fluid (100ml), urine (100ml), blood (10ml).

• Induce vomiting: Give 200ml of water (100ml for children). Use a tongue depressor: Angle of the jaw.

• Gastric lavage: Most effective in the first hour. Solution: Normal saline/salt water (5g/l). 200ml for adults, 50ml for children <5 years. Contraindicated: Ingestion of corrosive substances.

• Activated charcoal: 1-2g/kg + 100ml.

• Symptomatic antidotes: Drugs with physiological effects opposite to the poison.

• Chemical antidotes: Drugs that can neutralize, deactivate the poison, increase excretion.

• Whole bowel irrigation: Used in poisoning with iron, heavy metals, lithium, borate, unruptured drug packets. 500 ml/h through nasogastric tube, 1000-2000ml if no vomiting; children: 100-200ml/h.

• Laxatives: Used in one dose along with activated charcoal. Sorbitol 1g/kg.

4. First Aid for Electric Shock

• Current intensity that causes death: The level of danger depends on the current intensity, duration of contact, path of the current and the health of the victim.

• Voltage that causes burns: The degree of burns depends on the voltage, duration of contact, and current intensity.

• Current intensity that causes muscle contraction, twitching: 9 mA.

• Current intensity that causes ventricular fibrillation: 80 mA.

• Current intensity level A: Brain damage.

• Treatment of acute renal failure due to myoglobin blockage of the renal tubules: Ensure urine output > 2500 ml/24h.

5. Electrolyte Disorders

• Hyponatremia:

• Cause: Excess water in cells.

• Symptoms: Nausea, vomiting, headache, fatigue, dizziness, confusion, seizures, coma.

• Treatment:

• Severe hyponatremia (<120, symptomatic and acute is under 48h): Infuse hypertonic sodium (depending on extracellular volume, whether or not there are symptoms).

• Average rate of sodium increase/decrease: 0.5 mmol/l/h or 10mmol/l/24h.

• Hypernatremia:

• Cause: Excess water outside cells, lack of water inside cells.

• Symptoms: Thirst, dry mouth, fatigue, confusion, coma.

• Treatment:

• Infuse hypotonic fluids (depending on extracellular volume).

• Average rate of sodium increase/decrease: 0.5 mmol/l/h or 10mmol/l/24h.

• Hyperkalemia:

• Cause:

• Increased ALTT, acidosis causing potassium to go out of cells.

• Insulin, alkalosis causing potassium to go into cells.

• Symptoms:

• Muscle weakness, numbness, cardiac arrhythmias.

• ECG: Tall, symmetrical T waves, shortened QT interval (mild, moderate).

• ECG: Prolonged PR interval, widened QRS complex, then loss of P wave (severe).

• ECG: Sine wave, ventricular fibrillation, asystole (very severe).

• Treatment:

• Membrane stabilizing drugs: Calcium gluconate 1g slow intravenous injection (effective after 1-3 minutes, lasting 30-60 minutes).

• Drugs that transport potassium into cells: Insulin 10 UI + 125 ml 20% glucose IV infusion over 30 minutes. Salbutamol 2.5-5 mg nebulized over 30 minutes.

• Potassium supplementation: Depending on the level of potassium in the blood and whether or not there is cardiac arrhythmia.

• Hypokalemia:

• Cause:

• Potassium deficiency due to diet, vomiting, diarrhea.

• Potassium movement into cells: Alkalinization, insulin.

• Symptoms:

• Fatigue, muscle weakness, cramps, numbness, cardiac arrhythmias.

• Treatment:

• Potassium supplementation: Depending on the level of potassium in the blood and whether or not there is cardiac arrhythmia.

Notes:

• When there is a disorder, pH changes 0.1, potassium changes 0.6.

• Manage hypernatremia with hemodynamic changes, low blood pressure: Infuse isotonic fluids to replenish circulating volume first, then hypotonic fluids later.

6. Some Additional Information

• Normal plasma ALTT: 280-295.

• Formula to calculate corrected sodium: Measured sodium + 3 x (Glucose – 6)/10.

• Snakebites known to cause rhabdomyolysis do not perform CK, CKMM tests.

Notes:

• The information in this article is for reference only.

• In any emergency, call 115 immediately or contact the nearest health facility immediately.

• Do not self-treat without a doctor’s prescription.