The Three Killers
In emergency medicine, the three killers are airway obstruction, bleeding, and shock. They are classified as such because left untreated they will lead to death. The first priority of DMO is to attend to those potential killers by:
- Opening the airway
- Control excessive bleeding
- Treat for shock
Opening the Airway
The tongue is the most common airway obstruction – especially when a semi or unconscious victim is laying on the back. The tongue – which is a muscle – may relax and block the airway. A victim with a suspected airway obstruction must be checked immediately for breathing and, if necessary, the airway must be opened.
The Head-Tilt / Chin-Lift Method
This method causes little or no cervical-spine manipulation because only the head is manipulated.
- Position self at an arm’s length, make contact with the victim and ask, “Can our hear me?” Speak loudly but do not yell.
- If the victim does not or cannot respond, place the palm of one hand on the victim’s forehead.
- Place two fingers of the other hand under the chin and tilt the jaw upward while tilting the head slightly backwards.
Head tilt chin lift opens the airway by moving the tongue. Click on illustration to see video explanation.
- Place your ear close to the victim’s mouth looking towards the victim’s feet and place a hand on the victim’s abdomen.
- Look for chest rise.
- Listen for air exchange.
- While listening for air exchange, document abnormal lung sounds (wheezing, gasping, gurgling).
- Appearance of any sounds that are not normal classifies the victim as “I” (IMMEDIATE or red).
- Feel for abdominal movement.
- If breathing has been restored, the cleared airway must be maintained by keeping the head tilted back. If breathing has not been restored, repeat steps 1 – 7.
- If the victim still is not breathing after the second attempt, the victim is classified as “DEAD” (unresponsive) or black.
There are three types of bleeding:
- Arterial bleeding – Arteries transport blood under high pressure. Blood coming from an artery will spurt.
- Venous bleeding – Veins transport blood under low pressure. Blood coming from a vein will flow.
- Capillary bleeding – Capillaries also carry blood under low pressure. Blood coming from capillaries will ooze.
If bleeding is not controlled, shock will occur in a short period of time followed by death. An adult has about 5 liters of blood. Loss of 1 liter can result in death.
There are three main methods for controlling bleeding.
- Direct pressure
- Pressure points
- Brachial point for bleeding in the arm.
- Femoral point for bleeding in the leg.
- Popliteal point for bleeding in the lower leg.
Recognizing and Treating Shock
When blood doesn’t circulate, oxygen and other nutrients are not carried to tissues and organs. Blood vessels begin to close and organs are damaged and if left untreated, will shut down completely. Shock can worsen rapidly. The main signs of shock are:
- Rapid and shallow breathing (respiration)
- Capillary refill of greater than 2 seconds (perfusion)
- Failure to follow simple commands (mental status)
- Breaths, not pulse – count the number of breaths in 60 seconds. 30 breaths per minute or more classifies the victim as “IMMEDIATE” or red
- You should be able to complete your triage within one minute. To accomplish this, count your breaths for 15 seconds – 7 passes, 8 fails.
- “Blanch test” – applying pressure to the nail bed or palm causing the area to “blanch”, then counting the time it takes for the color to return. A time greater than 2 seconds classifies the victim as “IMMEDIATE” or red.
- An alternate way of checking blood flow is the radial pulse test. A normal pulse rate is 60-100 beats per minute. Measure the pulse rate by placing the middle and index fingers over the interior of the wrist where the thumb meets the arm.
- Mental Status
- Evaluate mental status by giving a simple command. Failure to follow the command classifies the victim as “IMMEDIATE” or red
- If you are concerned that there might be a language barrier or hearing loss, reach out with both hands and squeeze one of the victim’s hands. The normal response is for the victim to return the squeeze if they can.
Maintain the victim’s body temperature. Use a blanket, if necessary, under and/or over the victim to provide protection from extreme ground temperature. Position the victim on his/her back and elevate the feet 6 to 10 inches above the level of the heart. Victims should not eat or drink anything initially because they may be nauseated.
Removing Your Exam Gloves
Gloves should be replaced between victims. Here’s how to do it. Try removing the gloves after applying a small amount of lotion or shaving cream on the palm or finger area of the gloves. See if you transfer any substance to your skin.
If an adequate supply of gloves are not available, gloves may be sterilized between treating victims using 1 part bleach to 10 parts water.