(Ultra-Detailed Academic Textbook Style for Medical, Nursing, Pharmacy & Paramedical Students)
PART 1 – Foundations of First Aid and Basic Life Support
Chapter 1: Introduction to First Aid
1.1 Definition of First Aid
First aid is the immediate, temporary, and essential care provided to an individual who has suffered injury or sudden illness before definitive medical treatment becomes available. It bridges the critical time gap between the occurrence of an emergency and professional healthcare intervention.
First aid interventions may range from:
- Simple wound cleaning
- Hemorrhage control
- Airway positioning
- Cardiopulmonary resuscitation (CPR)
- Use of an Automated External Defibrillator (AED)
The primary objective is not to replace advanced medical care, but to stabilize the patient and prevent deterioration.
1.2 Historical Evolution of First Aid
The modern concept of organized first aid began in the 19th century. The formation of the International Committee of the Red Cross in 1863 marked a turning point in humanitarian emergency care. Battlefield medical training later evolved into civilian emergency response systems.
The St John Ambulance played a major role in formalizing structured first aid training programs.
The introduction of CPR in the 1960s revolutionized cardiac emergency survival rates. Contemporary guidelines are regularly updated by organizations such as the American Heart Association.
Chapter 2: Goals and Principles of First Aid
2.1 Core Objectives
First aid operates under three universal goals:
- Preserve Life
- Maintain airway, breathing, and circulation.
- Prevent Deterioration
- Stop bleeding, prevent shock, immobilize fractures.
- Promote Recovery
- Provide comfort and reassurance.
2.2 The “Chain of Survival” Concept
The “Chain of Survival” describes critical steps in managing life-threatening emergencies:
- Early recognition
- Early activation of emergency services
- Early CPR
- Early defibrillation
- Advanced life support
Delays in any link reduce survival probability dramatically.
Chapter 3: Legal and Ethical Considerations
3.1 Good Samaritan Principles
Many countries implement Good Samaritan laws protecting individuals who provide emergency assistance in good faith. These laws encourage prompt intervention without fear of legal repercussions.
Key principles include:
- Acting within scope of knowledge
- Obtaining consent (if possible)
- Avoiding gross negligence
3.2 Consent in Emergency Care
Consent types:
- Express Consent – Verbal agreement
- Implied Consent – Unconscious patient
- Parental Consent – For minors
Ethical duties include confidentiality, respect, and non-maleficence.
Chapter 4: Scene Safety and Initial Assessment
Before touching the patient:
4.1 Scene Survey
- Look for fire, electrical wires, toxic gas, traffic.
- Use personal protective equipment (PPE).
- Ensure environmental safety.
A rescuer becoming injured creates additional victims.
4.2 Primary Survey (DRABC Approach)
The DRABC method provides systematic assessment:
D – Danger
Ensure no hazards are present.
R – Response
Check responsiveness by verbal and tactile stimulus.
A – Airway
Open airway using head-tilt–chin-lift unless spinal injury suspected.
B – Breathing
Look, listen, and feel for breathing for 10 seconds.
C – Circulation
Check pulse (carotid in adults, brachial in infants).
Chapter 5: Basic Life Support (BLS)
Basic Life Support includes CPR and AED use.
Guidelines are periodically updated by the American Heart Association.
5.1 Adult CPR Protocol
If the patient is unresponsive and not breathing:
- Call emergency services immediately.
- Begin chest compressions:
- Rate: 100–120 per minute
- Depth: 5–6 cm
- Allow full chest recoil
- Ratio: 30 compressions : 2 breaths
- Continue until:
- AED arrives
- Professional help arrives
- Patient regains consciousness
5.2 Automated External Defibrillator (AED)
An AED analyzes heart rhythm and delivers shock if necessary.
Steps:
- Turn on device
- Attach pads
- Follow voice prompts
- Clear area before shock
Early defibrillation dramatically improves survival in ventricular fibrillation.
Chapter 6: Airway Obstruction and Choking
6.1 Complete Airway Obstruction
Signs:
- Inability to speak
- Silent cough
- Cyanosis
- Clutching throat (universal choking sign)
6.2 Heimlich Maneuver (Abdominal Thrusts)
Procedure:
- Stand behind victim
- Fist above navel
- Quick upward thrusts
For infants:
- 5 back blows
- 5 chest thrusts
Chapter 7: Shock
Shock is inadequate tissue perfusion.
Types:
- Hypovolemic
- Cardiogenic
- Anaphylactic
- Septic
- Neurogenic
Signs:
- Pale, cold skin
- Tachycardia
- Hypotension
- Confusion
First Aid:
- Lay patient flat
- Elevate legs (unless contraindicated)
- Keep warm
- Control bleeding
Chapter 8: Severe Bleeding and Hemorrhage Control
8.1 Types of Bleeding
- Arterial – Bright red, spurting
- Venous – Dark red, steady flow
- Capillary – Oozing
8.2 Hemorrhage Control Techniques
- Direct pressure
- Pressure bandage
- Elevation
- Tourniquet (last resort)
Uncontrolled bleeding can cause death within minutes.
Chapter 9: Burns
9.1 Classification
- First-degree (Superficial)
- Second-degree (Partial thickness)
- Third-degree (Full thickness)
9.2 First Aid for Burns
- Remove heat source
- Cool with running water (20 minutes)
- Do not apply ice
- Cover with sterile dressing
Electrical burns require urgent hospital referral.
Chapter 10: Fractures and Immobilization
Signs of Fracture
- Pain
- Deformity
- Swelling
- Loss of function
Management
- Immobilize joint above and below fracture
- Apply splint
- Avoid realignment unless trained
Chapter 11: Head and Spinal Injuries
Warning Signs
- Loss of consciousness
- Vomiting
- Unequal pupils
- Neck pain
First Aid
- Do not move patient unnecessarily
- Stabilize head and neck
- Call emergency services immediately
Chapter 12: Stroke Recognition
Use FAST:
- Face drooping
- Arm weakness
- Speech difficulty
- Time to call emergency
Stroke requires urgent hospital care.
Chapter 13: Seizures
During Seizure
- Protect head
- Do not restrain
- Do not put objects in mouth
- Place in recovery position after seizure ends
Chapter 14: Poisoning
Types
- Ingestion
- Inhalation
- Injection
- Absorption
Management
- Identify substance
- Do not induce vomiting unless instructed
- Call poison control
Chapter 15: Environmental Emergencies
Heat Stroke:
- High body temperature
- Confusion
- Rapid pulse
Cool rapidly and hydrate.
Hypothermia:
- Shivering
- Slurred speech
Warm gradually.
PART 2 – Advanced Airway, Breathing & Circulation Emergencies
Chapter 16: Advanced Airway Emergencies
Airway compromise is the most immediate life-threatening emergency. Brain hypoxia begins within 4–6 minutes of complete oxygen deprivation.
16.1 Causes of Airway Obstruction
Airway obstruction may result from:
- Foreign body aspiration
- Tongue obstruction in unconscious patient
- Vomitus or blood
- Anaphylaxis
- Trauma
- Infections such as epiglottitis
One classic infectious cause is acute epiglottitis, historically associated with Haemophilus influenzae type B, now reduced due to vaccination programs recommended by the World Health Organization.
16.2 Recognition of Airway Compromise
Early signs:
- Stridor
- Hoarse voice
- Difficulty speaking
- Anxiety
Late signs:
- Cyanosis
- Reduced consciousness
- Silent chest
16.3 Airway Opening Techniques
Head Tilt–Chin Lift
Used when no spinal injury suspected.
Jaw Thrust Maneuver
Used when spinal injury is suspected.
16.4 Recovery Position
Indicated when patient:
- Is unconscious
- Is breathing normally
- Has no suspected spinal injury
This prevents aspiration of vomitus.
Chapter 17: Respiratory Emergencies
Respiratory emergencies account for significant pre-hospital mortality.
17.1 Asthma Attack
Asthma is a reversible airway obstruction characterized by bronchospasm and inflammation.
Signs:
- Wheezing
- Prolonged expiration
- Accessory muscle use
- Inability to complete sentences
First Aid:
- Sit patient upright
- Assist with inhaler (short-acting beta-agonist)
- Monitor breathing
Severe asthma can progress to respiratory failure.
17.2 Anaphylaxis
Anaphylaxis is a severe systemic hypersensitivity reaction.
Common triggers:
- Foods (nuts, shellfish)
- Insect stings
- Medications
Symptoms:
- Swelling of lips and tongue
- Difficulty breathing
- Hypotension
- Urticaria
First Aid:
- Administer epinephrine auto-injector immediately
- Call emergency services
- Lay patient flat with legs elevated
Epinephrine is life-saving.
17.3 Drowning
Drowning causes hypoxia due to submersion.
Pathophysiology:
- Laryngospasm
- Aspiration
- Hypoxemia
First Aid:
- Remove from water safely
- Check breathing
- Begin CPR if necessary
Early rescue breathing is critical.
17.4 Smoke Inhalation
Often associated with fire exposure.
Signs:
- Soot around nostrils
- Burned nasal hair
- Carbon monoxide poisoning symptoms
Immediate oxygen therapy is required in hospital settings.
Chapter 18: Cardiac Emergencies
Cardiac conditions are leading causes of sudden death worldwide.
18.1 Acute Coronary Syndrome (ACS)
ACS includes:
- Unstable angina
- NSTEMI
- STEMI
Common symptom:
- Crushing chest pain radiating to left arm or jaw
First Aid:
- Sit patient upright
- Loosen tight clothing
- Administer aspirin (if not allergic)
- Call emergency services
Rapid reperfusion is essential.
18.2 Cardiac Arrest
Cardiac arrest is sudden cessation of effective circulation.
Common rhythms:
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Asystole
Guidelines for CPR are issued by the American Heart Association and the European Resuscitation Council.
Early defibrillation dramatically increases survival rates.
Chapter 19: Advanced Shock Management
Shock is circulatory failure leading to inadequate tissue perfusion.
19.1 Hypovolemic Shock
Cause:
- Hemorrhage
- Severe dehydration
Management:
- Control bleeding
- Lay patient flat
- Rapid transport
19.2 Cardiogenic Shock
Cause:
- Severe myocardial infarction
- Heart failure
Signs:
- Cold clammy skin
- Weak pulse
- Pulmonary edema
Requires urgent advanced care.
19.3 Anaphylactic Shock
Severe vasodilation due to allergic reaction.
Immediate epinephrine is life-saving.
19.4 Septic Shock
Result of severe infection.
Signs:
- Fever
- Hypotension
- Confusion
Requires hospital management.
Chapter 20: Severe Hemorrhage and Modern Bleeding Control
Uncontrolled hemorrhage is a major preventable cause of trauma death.
20.1 Tourniquet Use
Indications:
- Life-threatening limb bleeding
Steps:
- Place 5–7 cm above wound
- Tighten until bleeding stops
- Note time applied
Tourniquets can be safely left in place until surgical care.
20.2 Hemostatic Dressings
Advanced gauze impregnated with clotting agents may be used in severe bleeding scenarios.
Chapter 21: Trauma Management
21.1 Head Injury
Danger signs:
- Persistent vomiting
- Worsening headache
- Drowsiness
Never ignore head trauma.
21.2 Spinal Injury
Suspect if:
- Fall from height
- Motor vehicle accident
- Neck pain
Immobilize head and neck.
21.3 Chest Trauma
Signs:
- Difficulty breathing
- Unequal chest movement
- Sucking chest wound
Cover open chest wound with occlusive dressing.
21.4 Abdominal Trauma
Signs:
- Guarding
- Bruising
- Internal bleeding
Urgent transport required.
Chapter 22: Neurological Emergencies
22.1 Stroke
Recognize FAST signs:
- Face drooping
- Arm weakness
- Speech difficulty
Time-dependent emergency.
22.2 Seizures
If seizure lasts >5 minutes → medical emergency.
Protect from injury and maintain airway.
Chapter 23: Metabolic Emergencies
23.1 Hypoglycemia
Signs:
- Sweating
- Confusion
- Tremors
If conscious → give oral glucose.
If unconscious → emergency care.
23.2 Hyperglycemia
Signs:
- Excessive urination
- Fruity breath odor
- Deep breathing
Requires urgent medical evaluation.
Chapter 24: Environmental Emergencies (Advanced)
24.1 Heat Stroke
Core temperature >40°C.
Immediate rapid cooling required.
24.2 Hypothermia
Core temperature <35°C.
Warm gradually.
24.3 Frostbite
Do not rub affected area.
Chapter 25: Pediatric First Aid
Children are not small adults.
Key differences:
- Faster respiratory rate
- Higher heart rate
- Different CPR compression depth
Infant CPR:
- Two-finger technique
- Depth: 4 cm
- Ratio: 30:2 (single rescuer)
Chapter 26: Obstetric Emergencies
Emergency childbirth steps:
- Support baby’s head
- Do not pull
- Clear airway
- Keep newborn warm
Post-delivery:
- Monitor bleeding
- Encourage breastfeeding
PART 3 – Disaster Response, Toxicology, Psychological First Aid & Advanced Practical Skills
Chapter 27: Disaster Management and Mass Casualty Incidents (MCI)
A Mass Casualty Incident (MCI) occurs when the number of victims exceeds the available medical resources. Effective first aid during disasters depends on structured triage systems and coordinated response.
27.1 Principles of Disaster Response
Key principles include:
- Scene safety and hazard identification
- Rapid triage
- Resource allocation
- Communication with emergency services
- Psychological stabilization
Disaster management frameworks are often guided internationally by the World Health Organization and humanitarian agencies such as the International Federation of Red Cross and Red Crescent Societies.
27.2 Triage Systems
Triage means sorting patients according to urgency.
START Triage (Simple Triage and Rapid Treatment)
Categories:
- Red (Immediate) – Life-threatening but treatable
- Yellow (Delayed) – Serious but stable
- Green (Minor) – Walking wounded
- Black (Deceased/Expectant) – No signs of life
Assessment parameters:
- Respiratory rate
- Perfusion
- Mental status
Triage decisions must be rapid, often within 30–60 seconds per patient.
Chapter 28: Wilderness First Aid
Wilderness first aid applies when professional help may be delayed for hours or days.
28.1 Environmental Hazards
- Extreme temperatures
- Altitude sickness
- Dehydration
- Animal bites
- Limited resources
28.2 Improvised Medical Care
In remote settings:
- Use clothing as bandages
- Use sticks for splints
- Create shade shelters
- Purify water (boiling, filtration)
28.3 Altitude Sickness
Symptoms:
- Headache
- Nausea
- Dizziness
Severe form (HAPE/HACE):
- Shortness of breath
- Confusion
- Ataxia
Immediate descent is critical.
Chapter 29: Advanced Bandaging and Wound Care
29.1 Principles of Wound Management
Objectives:
- Prevent infection
- Control bleeding
- Promote healing
29.2 Types of Bandages
- Roller bandage
- Triangular bandage
- Elastic compression bandage
- Adhesive bandage
29.3 Dressing Techniques
- Sterile technique when possible
- Avoid touching wound directly
- Secure dressing without impairing circulation
29.4 Splinting Techniques
Rules:
- Immobilize joint above and below injury
- Check distal pulse before and after splinting
- Pad splints to avoid pressure sores
Common splints:
- Rigid splints
- Soft splints
- Anatomical splints
Chapter 30: Toxicological Emergencies
Poisoning is a major cause of morbidity and mortality worldwide.
30.1 Routes of Poison Exposure
- Ingestion
- Inhalation
- Injection
- Dermal absorption
30.2 Common Poison Categories
- Pharmaceuticals
- Household chemicals
- Carbon monoxide
- Agricultural pesticides
Carbon monoxide poisoning causes:
- Headache
- Cherry-red skin (late sign)
- Confusion
- Collapse
Immediate oxygen therapy required.
30.3 Overdose Management
General principles:
- Ensure airway patency
- Call emergency services
- Identify substance
- Do NOT induce vomiting unless instructed
Chapter 31: Psychological First Aid (PFA)
Emergencies cause emotional trauma alongside physical injury.
Psychological First Aid principles include:
- Ensure safety
- Listen actively
- Provide reassurance
- Connect to social support
- Encourage coping strategies
PFA is especially important after disasters, violence, or mass casualty events.
Chapter 32: Advanced Cardiac Life Support (Overview)
While first aid providers do not perform full ACLS, understanding its basics improves coordination.
Advanced care includes:
- Advanced airway placement
- IV medications
- Cardiac monitoring
- Defibrillation
Resuscitation algorithms are guided by organizations such as the American Heart Association and the European Resuscitation Council.
Chapter 33: First Aid Kit Design and Pharmacological Basics
33.1 Essential Components of a First Aid Kit
Basic kit should include:
- Sterile gauze
- Adhesive bandages
- Antiseptic solution
- Gloves
- CPR mask
- Tourniquet
- Scissors
- Elastic bandage
33.2 Advanced Kit Additions
- Hemostatic gauze
- Epinephrine auto-injector
- Oral glucose
- Aspirin
- Burn dressings
33.3 Medication Considerations
A first aider must:
- Check allergies
- Verify expiration date
- Avoid administering prescription drugs without authorization
Chapter 34: Emergency Transport Principles
Transport decisions depend on:
- Severity of condition
- Available resources
- Distance to hospital
Guidelines:
- Maintain spinal precautions
- Monitor airway continuously
- Keep patient warm
Chapter 35: Infection Prevention and Control
First aid providers must protect themselves.
Standard precautions:
- Gloves
- Hand hygiene
- Avoid direct contact with bodily fluids
- Proper disposal of contaminated materials
Blood-borne pathogen risks include:
- Hepatitis B
- Hepatitis C
- HIV
Vaccination against hepatitis B is strongly recommended for healthcare workers.
Chapter 36: Ethical Decision-Making in High-Stress Situations
Ethical dilemmas may include:
- Resource limitation
- Triage prioritization
- Withdrawal of care in disaster settings
Core ethical principles:
- Beneficence
- Non-maleficence
- Justice
- Autonomy
PART 4 – Advanced Pathophysiology, Special Populations & Complex Emergencies
Chapter 37: Pathophysiology of Life-Threatening Emergencies
Understanding underlying mechanisms enhances first aid effectiveness.
37.1 Hypoxia and Cellular Injury
Hypoxia occurs when tissues receive inadequate oxygen.
Cellular Effects:
- Switch from aerobic to anaerobic metabolism
- Lactic acid accumulation
- Decreased ATP production
- Failure of sodium–potassium pump
- Cellular swelling
- Organ dysfunction
Brain cells begin irreversible injury after approximately 4–6 minutes of complete oxygen deprivation.
37.2 Ischemia and Reperfusion Injury
Ischemia = Reduced blood flow.
Reperfusion injury occurs when blood returns after prolonged ischemia.
Mechanisms include:
- Free radical production
- Inflammatory cascade activation
- Calcium overload
These processes explain complications following cardiac arrest or major trauma.
Chapter 38: Advanced Pediatric First Aid
Children have unique anatomical and physiological characteristics.
38.1 Pediatric Airway Anatomy
- Larger tongue relative to mouth
- Narrower airway
- More anterior larynx
These differences increase obstruction risk.
38.2 Pediatric Respiratory Failure
Early signs:
- Tachypnea
- Nasal flaring
- Intercostal retractions
Late signs:
- Bradycardia
- Cyanosis
- Decreased consciousness
Respiratory failure is the most common cause of pediatric cardiac arrest.
38.3 Neonatal Resuscitation Principles
Newborn assessment focuses on:
- Breathing
- Heart rate
- Muscle tone
If heart rate <60 bpm → begin chest compressions.
Guidelines are periodically updated by professional bodies such as the American Academy of Pediatrics.
Chapter 39: Geriatric Emergency Considerations
Older adults present unique challenges:
39.1 Age-Related Physiological Changes
- Reduced cardiac output reserve
- Decreased lung elasticity
- Fragile skin
- Slower healing
39.2 Common Geriatric Emergencies
- Falls
- Stroke
- Myocardial infarction
- Dehydration
- Medication overdose
Elderly patients may show atypical symptoms, such as silent myocardial infarction without chest pain.
Chapter 40: Advanced Trauma Algorithms
Trauma management follows systematic assessment models.
40.1 Primary Trauma Survey (ABCDE)
A – Airway with cervical spine protection
B – Breathing
C – Circulation with hemorrhage control
D – Disability (neurological status)
E – Exposure and environmental control
This structured method reduces missed injuries.
40.2 Secondary Survey
Head-to-toe examination including:
- Vital signs
- Full patient history (AMPLE):
- Allergies
- Medications
- Past medical history
- Last meal
- Events leading to injury
Chapter 41: Chemical Emergencies
Chemical exposure may occur in industrial accidents or warfare.
41.1 Types of Chemical Hazards
- Corrosives (acids, alkalis)
- Toxic gases (chlorine, ammonia)
- Organophosphates
41.2 First Aid Principles
- Remove from exposure
- Decontaminate (remove clothing)
- Flush affected area with water
- Avoid direct contact
Organophosphate poisoning signs:
- Salivation
- Lacrimation
- Urination
- Defecation
- Bronchospasm
Immediate hospital treatment required.
Chapter 42: Biological Emergencies
Biological threats may include infectious disease outbreaks.
Public health responses are coordinated globally by the World Health Organization.
42.1 Infection Control During Outbreaks
- Mask usage
- Hand hygiene
- Isolation of infected individuals
- Vaccination campaigns
First aid providers must protect themselves to prevent disease transmission.
Chapter 43: Radiation Emergencies
Radiation exposure may result from industrial accidents or nuclear events.
43.1 Acute Radiation Syndrome (ARS)
Symptoms:
- Nausea
- Vomiting
- Skin burns
- Bone marrow suppression
43.2 First Aid Approach
- Remove from radiation source
- Remove contaminated clothing
- Wash exposed skin
- Avoid spreading contamination
Specialized medical care required.
Chapter 44: Community First Aid Systems
Community-based first aid programs increase survival.
44.1 Public Access Defibrillation (PAD)
Placement of AEDs in:
- Airports
- Shopping malls
- Schools
- Sports arenas
Public training significantly improves outcomes.
44.2 Community Training Programs
Organizations like the St John Ambulance and the International Committee of the Red Cross provide structured first aid training worldwide.
Chapter 45: Communication in Emergencies
Effective communication saves lives.
45.1 Emergency Call Information
When contacting emergency services:
Provide:
- Exact location
- Nature of emergency
- Number of victims
- Current condition
- Hazards present
Remain calm and follow dispatcher instructions.
Chapter 46: Documentation in First Aid
Documentation ensures continuity of care.
Record:
- Time of incident
- Observations
- Interventions provided
- Patient response
Accurate documentation has legal and clinical importance.
Chapter 47: Ethical Allocation of Resources in Crisis
During disasters:
- Limited ventilators
- Limited medications
- Limited personnel
Triage decisions must follow ethical frameworks emphasizing fairness and maximizing survival.
Chapter 48: Future Directions in First Aid
Emerging technologies include:
- Smartphone emergency alerts
- Drone-delivered AEDs
- Telemedicine guidance
- Wearable health monitors
Digital health systems continue evolving to improve rapid response.
PART 5 – Case-Based Clinical Applications, Advanced Hemorrhage Science, Pharmacology & Forensic Considerations
Chapter 49: Case-Based Clinical Scenarios in First Aid
Case-based learning enhances critical thinking and emergency preparedness.
Case 1: Sudden Collapse in a Public Area
Scenario:
A 55-year-old male collapses in a shopping mall. He is unresponsive and not breathing normally.
Stepwise Response:
- Ensure scene safety.
- Check responsiveness.
- Call emergency services immediately.
- Begin CPR (30:2 ratio).
- Retrieve and apply AED.
Clinical Consideration:
Most adult sudden collapses are cardiac in origin. Ventricular fibrillation is the most common initial rhythm in out-of-hospital cardiac arrest.
Early defibrillation significantly increases survival.
Guidelines for CPR are developed by organizations such as the American Heart Association and the European Resuscitation Council.
Case 2: Severe Road Traffic Trauma
Scenario:
A motorcyclist is found unconscious after collision. There is heavy bleeding from the thigh.
First Aid Actions:
- Apply direct pressure.
- If bleeding continues → apply tourniquet 5–7 cm above wound.
- Immobilize cervical spine.
- Monitor breathing continuously.
Teaching Point:
Uncontrolled femoral artery bleeding can cause death within minutes.
Case 3: Pediatric Choking Episode
Scenario:
A 2-year-old child suddenly becomes silent while eating.
Intervention:
- Perform 5 back blows.
- Perform 5 chest thrusts.
- Repeat until object expelled or child becomes unconscious.
If unconscious:
- Begin CPR.
- Check mouth for visible object before breaths.
Chapter 50: Advanced Hemorrhage Science
Hemorrhage remains a leading preventable cause of death in trauma.
50.1 Physiology of Hemostasis
Hemostasis involves:
- Vasoconstriction
- Platelet plug formation
- Coagulation cascade activation
- Clot stabilization
Severe trauma may lead to:
- Coagulopathy
- Hypothermia
- Acidosis
This combination is known as the “lethal triad” in trauma.
50.2 Types of Hemorrhage
- External hemorrhage
- Internal hemorrhage
- Compartment syndrome
- Hidden internal bleeding
Signs of internal bleeding:
- Abdominal distension
- Bruising
- Hypotension
- Tachycardia
50.3 Tourniquet Physiology
Modern research shows tourniquets are safe when applied correctly and monitored.
Risks include:
- Nerve injury
- Tissue ischemia (if prolonged)
However, life-threatening hemorrhage control takes priority.
Chapter 51: Pharmacology in First Aid
Although advanced drug therapy is hospital-based, certain medications may be administered in first aid settings.
51.1 Aspirin in Suspected Myocardial Infarction
Mechanism:
- Inhibits platelet aggregation via COX-1 inhibition.
Dose:
- 160–325 mg (chewed)
Contraindications:
- Allergy
- Active bleeding
51.2 Epinephrine in Anaphylaxis
Mechanism:
- Alpha-1 vasoconstriction
- Beta-2 bronchodilation
Route:
- Intramuscular (lateral thigh)
Repeat if symptoms persist after 5–15 minutes.
51.3 Oral Glucose in Hypoglycemia
Used in conscious patients.
Avoid in unconscious patients due to aspiration risk.
51.4 Naloxone in Opioid Overdose
Mechanism:
- Opioid receptor antagonist
Signs of overdose:
- Pinpoint pupils
- Slow breathing
- Unconsciousness
Administration may reverse respiratory depression.
Chapter 52: Pain Management in First Aid
Pain is a physiological and psychological response to injury.
52.1 Non-Pharmacological Techniques
- Immobilization
- Elevation
- Cold application
- Reassurance
52.2 Pharmacological Considerations
First aid providers should avoid administering strong analgesics unless authorized.
Overuse may mask serious injuries.
Chapter 53: Forensic Considerations in Emergency First Aid
First aid providers may encounter situations with legal implications.
53.1 Preservation of Evidence
In cases of:
- Assault
- Gunshot wounds
- Sexual violence
Avoid disturbing potential evidence unnecessarily.
53.2 Documentation
Record:
- Observations
- Statements made by patient
- Time and nature of injuries
Documentation may later serve as legal evidence.
Chapter 54: Advanced Toxicology
54.1 Organophosphate Poisoning
Common in agricultural settings.
Symptoms (SLUDGE):
- Salivation
- Lacrimation
- Urination
- Diarrhea
- Gastrointestinal cramps
- Emesis
Severe cases require antidotes such as atropine (hospital setting).
54.2 Carbon Monoxide Poisoning
CO binds hemoglobin with high affinity.
Symptoms:
- Headache
- Dizziness
- Confusion
- Collapse
Remove from exposure and provide oxygen urgently.
54.3 Alcohol Poisoning
Signs:
- Vomiting
- Slow breathing
- Hypothermia
- Unconsciousness
Place in recovery position.
Chapter 55: Algorithm-Based Emergency Approach
55.1 Unresponsive Patient Algorithm
- Check safety
- Check responsiveness
- Call for help
- Check breathing
- Start CPR if not breathing
- Apply AED
55.2 Severe Bleeding Algorithm
- Direct pressure
- Pressure dressing
- Tourniquet
- Rapid transport
55.3 Anaphylaxis Algorithm
- Recognize symptoms
- Administer epinephrine
- Call emergency services
- Lay flat
- Monitor airway
Chapter 56: Ethical Case Discussions
Scenario:
Two critically injured patients; one ventilator available.
Ethical principles guide prioritization:
- Likelihood of survival
- Severity of illness
- Resource allocation fairness
Ethical frameworks often align with public health recommendations by the World Health Organization.
Chapter 57: Education and Skill Retention
First aid skills deteriorate without practice.
Recommendations:
- Annual CPR refresher training
- Scenario-based simulations
- Community drills
Organizations such as the St John Ambulance provide structured training worldwide.
PART 6 – Advanced Cardiopulmonary Physiology, Tactical & Special Environment Emergencies, Public Health Preparedness
Chapter 58: Advanced Cardiopulmonary Physiology for First Aid Providers
Although first aid providers do not perform invasive interventions, understanding cardiopulmonary physiology improves clinical judgment.
58.1 Cardiac Electrical System Overview
The heart’s conduction system includes:
- Sinoatrial (SA) node
- Atrioventricular (AV) node
- Bundle of His
- Purkinje fibers
Cardiac arrest commonly results from:
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Asystole
Defibrillation aims to reset chaotic electrical activity and restore organized rhythm.
Guideline updates are regularly published by the American Heart Association and the European Resuscitation Council.
58.2 Respiratory Physiology
Breathing depends on:
- Airway patency
- Adequate lung expansion
- Oxygen diffusion across alveoli
- Effective hemoglobin transport
Hypoventilation causes carbon dioxide retention (hypercapnia), while hypoxia results from insufficient oxygen.
58.3 Oxygen Delivery Equation
Oxygen delivery depends on:
- Cardiac output
- Hemoglobin concentration
- Oxygen saturation
Severe anemia, shock, or respiratory failure may impair oxygen delivery.
Chapter 59: Mechanical Ventilation Awareness (Non-Technical Overview)
First aid providers should understand:
- Patients on home ventilators
- Tracheostomy emergencies
- Oxygen cylinders
59.1 Tracheostomy Emergency
If tracheostomy tube becomes blocked:
- Attempt suction (if trained)
- Remove obstruction
- Provide rescue breathing via stoma
Emergency medical services must be called immediately.
Chapter 60: Tactical and Military First Aid
Tactical Combat Casualty Care (TCCC) principles influence civilian trauma care.
60.1 Phases of Tactical Care
- Care Under Fire
- Tactical Field Care
- Tactical Evacuation Care
60.2 MARCH Algorithm
M – Massive hemorrhage
A – Airway
R – Respiration
C – Circulation
H – Hypothermia prevention
Massive bleeding control is prioritized before airway in battlefield conditions.
Chapter 61: Aviation Emergencies
Aircraft emergencies may involve:
- Cabin depressurization
- Turbulence injuries
- Cardiac events mid-flight
61.1 Cabin Decompression
Symptoms:
- Shortness of breath
- Dizziness
- Confusion
Immediate oxygen mask application is critical.
Chapter 62: Marine Emergencies
Water-related emergencies include:
- Drowning
- Hypothermia
- Marine envenomation
62.1 Jellyfish Stings
Management:
- Rinse with seawater (not freshwater)
- Remove tentacles carefully
- Apply heat (if recommended)
62.2 Severe Bleeding at Sea
Limited resources require:
- Improvised tourniquets
- Pressure bandaging
- Rapid evacuation if possible
Chapter 63: Public Health Emergencies
Public health emergencies include pandemics, bioterrorism, and large-scale outbreaks.
Global coordination is often led by the World Health Organization.
63.1 Pandemic Preparedness
Key components:
- Surveillance systems
- Vaccination programs
- Public education
- Isolation protocols
First aid providers must use:
- Masks
- Gloves
- Hand hygiene
Chapter 64: Advanced Pediatric Case Simulations
Case Study: Severe Asthma in Child
Symptoms:
- Silent chest
- Cyanosis
- Extreme fatigue
Immediate actions:
- Assist with inhaler
- Call emergency services
- Prepare for possible CPR
Case Study: Febrile Seizure
Management:
- Protect from injury
- Do not restrain
- Monitor breathing
Seek medical evaluation after seizure ends.
Chapter 65: Neonatal Emergency Simulation
Scenario: Newborn Not Breathing
Steps:
- Warm and dry infant
- Stimulate gently
- Clear airway
- If no breathing → begin rescue breaths
- Check heart rate
Neonatal resuscitation guidelines are periodically updated by the American Academy of Pediatrics.
Chapter 66: Advanced Environmental Emergencies
66.1 Lightning Strike
Effects:
- Cardiac arrest
- Neurological injury
- Burns
Victims struck by lightning do not retain electrical charge and are safe to touch.
66.2 Snake Bites
First aid:
- Keep patient calm
- Immobilize limb
- Do NOT cut or suck venom
- Rapid transport
66.3 Severe Allergic Reaction in Remote Setting
If no epinephrine available:
- Lay patient flat
- Maintain airway
- Rapid evacuation
Chapter 67: Mass Gathering Medicine
Events such as concerts, sports matches, and religious gatherings increase risk of:
- Heat stroke
- Crowd crush injuries
- Cardiac arrest
Preparedness includes:
- On-site AEDs
- Medical tents
- Trained responders
Chapter 68: Special Needs and Disability Considerations
Emergency response must consider:
- Hearing impairment
- Visual impairment
- Mobility limitations
- Cognitive disabilities
Clear communication and reassurance are essential.
Chapter 69: Emergency Communication Technologies
Modern advancements include:
- Smartphone emergency alerts
- GPS tracking for ambulances
- Drone-delivered AED systems
These innovations aim to reduce response times.
Chapter 70: Psychological Resilience for First Aid Providers
Repeated exposure to trauma may cause:
- Burnout
- Compassion fatigue
- Post-traumatic stress
Self-care strategies:
- Debriefing
- Peer support
- Mental health counseling
PART 7 – Advanced Toxicology, Shock Biochemistry, Multi-Organ Failure, Disaster Reconstruction & Global Systems
Chapter 71: Advanced Toxicology – Mechanisms and Emergency Response
Toxicological emergencies range from household exposures to industrial disasters. Understanding mechanisms improves first aid prioritization.
71.1 Cellular Mechanisms of Toxic Injury
Toxins may cause injury through:
- Enzyme inhibition
- Receptor overstimulation
- Cellular hypoxia
- Oxidative stress
- Mitochondrial dysfunction
Examples:
- Carbon monoxide → impairs oxygen transport
- Cyanide → inhibits cellular respiration
- Organophosphates → inhibit acetylcholinesterase
71.2 Carbon Monoxide Poisoning (Advanced Overview)
Carbon monoxide binds hemoglobin with greater affinity than oxygen.
Clinical Features:
- Headache
- Dizziness
- Nausea
- Confusion
- Collapse
First Aid:
- Remove from exposure
- Provide high-flow oxygen if available
- Immediate hospital referral
CO poisoning is common in poorly ventilated heating environments.
71.3 Cyanide Poisoning
Mechanism:
- Inhibits cytochrome oxidase
- Prevents cellular oxygen utilization
Symptoms:
- Rapid breathing
- Altered mental status
- Cardiovascular collapse
Requires advanced hospital antidotes.
71.4 Organophosphate Toxicity (Advanced Detail)
Organophosphates inhibit acetylcholinesterase, causing acetylcholine accumulation.
Symptoms (Cholinergic Crisis):
- Salivation
- Bronchospasm
- Bradycardia
- Muscle twitching
- Seizures
Immediate decontamination is critical.
Avoid direct contact without protective equipment.
Chapter 72: Biochemical Basis of Shock
Shock is not merely low blood pressure; it is a cellular metabolic crisis.
72.1 Oxygen Debt and Anaerobic Metabolism
Reduced perfusion causes:
- ATP depletion
- Lactic acidosis
- Cellular membrane failure
- Inflammatory mediator release
72.2 Inflammatory Cascade
Severe shock activates:
- Cytokine release
- Endothelial damage
- Capillary leakage
- Microthrombi formation
This may progress to disseminated intravascular coagulation (DIC).
72.3 Septic Shock Mechanism
Sepsis involves:
- Systemic inflammatory response
- Vasodilation
- Increased vascular permeability
- Organ hypoperfusion
Public health response coordination often involves the World Health Organization during global outbreaks.
Chapter 73: Multi-Organ Dysfunction Syndrome (MODS)
MODS may follow severe trauma or prolonged shock.
73.1 Organs Commonly Affected
- Lungs (ARDS)
- Kidneys (Acute kidney injury)
- Liver failure
- Cardiovascular collapse
First aid providers cannot reverse MODS but early recognition and rapid transport reduce progression.
Chapter 74: Disaster Case Reconstruction – Earthquake Scenario
Scenario: Major earthquake affecting urban area.
Challenges:
- Structural collapse
- Mass casualties
- Limited resources
- Delayed ambulance access
First Aid Priorities:
- Scene safety
- Triage
- Hemorrhage control
- Airway management
- Psychological stabilization
Disaster coordination may involve humanitarian agencies such as the International Federation of Red Cross and Red Crescent Societies.
Chapter 75: Disaster Case Reconstruction – Chemical Plant Explosion
Hazards include:
- Burns
- Toxic inhalation
- Structural collapse
First Aid Considerations:
- Decontamination
- Oxygen support
- Rapid evacuation
- PPE for responders
Chapter 76: Advanced Ethical Frameworks in Crisis
76.1 Utilitarian Approach
Maximize survival of greatest number.
76.2 Priority-Based Allocation
Factors:
- Likelihood of survival
- Severity
- Resource availability
76.3 Moral Distress in Providers
First aid providers may experience psychological burden when resources are insufficient.
Peer support and structured debriefing are essential.
Chapter 77: Training Curriculum Design for First Aid Education
Effective training includes:
- Theoretical knowledge
- Practical simulations
- Scenario-based drills
- Regular skill refreshers
Organizations such as the St John Ambulance and the International Committee of the Red Cross offer structured programs globally.
77.1 Simulation-Based Training
Simulation improves:
- Muscle memory
- Decision-making
- Confidence
77.2 Skill Retention Timeline
CPR skills may deteriorate within 6–12 months without practice.
Annual retraining is recommended.
Guidelines are periodically updated by the American Heart Association.
Chapter 78: Global Emergency Medical Systems Comparison
78.1 Anglo-American Model
- Paramedic-based
- Rapid hospital transport
- Advanced emergency departments
78.2 Franco-German Model
- Physician-led prehospital care
- Advanced treatment at scene
Each system has strengths and limitations.
Chapter 79: Technology and Artificial Intelligence in First Aid
Emerging innovations:
- AI-assisted dispatch systems
- Drone AED delivery
- Wearable health monitors
- Real-time telemedicine
These technologies aim to reduce time-to-treatment.
Chapter 80: Future Directions in Emergency Preparedness
Future improvements may include:
- Expanded community AED programs
- Universal CPR education in schools
- Mobile first aid training apps
- Global data-sharing systems
International collaboration enhances preparedness.
PART 8 – System-Based Emergency Reference, Advanced Neurological & Endocrine Crises, Obstetric & Pediatric Expansion
Chapter 81: System-Based Emergency Reference – Respiratory System
Respiratory emergencies are among the most rapidly fatal conditions in prehospital settings.
81.1 Acute Asthma Exacerbation (Advanced Review)
Pathophysiology:
- Bronchial smooth muscle constriction
- Airway inflammation
- Mucus plugging
Clinical Progression:
- Mild wheeze
- Increased work of breathing
- Silent chest (late sign)
- Respiratory failure
First Aid Priorities:
- Upright positioning
- Assist inhaler (short-acting beta agonist)
- Monitor mental status
- Prepare for CPR if deterioration occurs
81.2 Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Symptoms:
- Increased breathlessness
- Productive cough
- Cyanosis
Caution: Excess oxygen in severe COPD may worsen CO₂ retention (hospital-level consideration).
First aid focus remains airway support and emergency referral.
81.3 Pneumothorax
Collapsed lung due to air in pleural space.
Signs:
- Sudden chest pain
- Shortness of breath
- Unequal chest expansion
Tension pneumothorax is life-threatening and requires advanced care.
Chapter 82: Cardiovascular System Emergencies
82.1 Acute Coronary Syndrome (Advanced Review)
Symptoms:
- Crushing chest pain
- Sweating
- Nausea
- Shortness of breath
Immediate actions:
- Rest patient
- Administer aspirin (if no contraindication)
- Call emergency services
Time-dependent myocardial salvage is critical.
Guidelines are provided by the American Heart Association.
82.2 Hypertensive Crisis
Signs:
- Severe headache
- Vision changes
- Chest pain
Rapid medical referral required.
82.3 Cardiac Arrhythmias
Symptoms:
- Palpitations
- Dizziness
- Syncope
Unstable arrhythmias may progress to cardiac arrest.
Chapter 83: Neurological Emergencies – Deep Dive
83.1 Stroke (Advanced)
Two main types:
- Ischemic
- Hemorrhagic
FAST assessment:
- Face drooping
- Arm weakness
- Speech difficulty
- Time to call emergency services
Time-sensitive thrombolytic therapy is hospital-based.
83.2 Status Epilepticus
Seizure lasting >5 minutes.
First Aid:
- Protect from injury
- Monitor airway
- Call emergency services immediately
83.3 Traumatic Brain Injury (TBI)
Red Flags:
- Persistent vomiting
- Unequal pupils
- Seizures
- Worsening headache
Avoid unnecessary movement.
Chapter 84: Endocrine and Metabolic Emergencies
84.1 Hypoglycemia (Advanced)
Cause:
- Excess insulin
- Missed meals
- Intense exercise
Symptoms:
- Confusion
- Sweating
- Tremors
- Loss of consciousness
Management:
- Oral glucose if conscious
- Emergency services if unconscious
84.2 Diabetic Ketoacidosis (DKA)
Signs:
- Fruity breath odor
- Deep rapid breathing
- Dehydration
- Confusion
Requires urgent hospital management.
84.3 Thyroid Storm
Symptoms:
- High fever
- Rapid heart rate
- Agitation
Rare but life-threatening.
Chapter 85: Advanced Obstetric Emergencies
85.1 Postpartum Hemorrhage
Excessive bleeding after childbirth.
Signs:
- Heavy bleeding
- Weakness
- Pale skin
First Aid:
- Encourage uterine massage (if trained)
- Lay flat
- Urgent transport
85.2 Eclampsia
Seizures during pregnancy.
Management:
- Protect from injury
- Place in recovery position
- Immediate emergency transport
Chapter 86: Pediatric Advanced Scenarios
86.1 Severe Dehydration
Common in diarrheal illness.
Signs:
- Sunken eyes
- Dry mouth
- Lethargy
Management:
- Oral rehydration solution if conscious
- Emergency referral if severe
86.2 Croup
Signs:
- Barking cough
- Stridor
Keep child calm; severe cases require urgent care.
Chapter 87: Gastrointestinal Emergencies
87.1 Acute Abdomen
Symptoms:
- Severe abdominal pain
- Guarding
- Vomiting
Do NOT give food or drink.
Seek emergency care.
87.2 Gastrointestinal Bleeding
Signs:
- Vomiting blood
- Black tarry stools
Lay patient flat and seek urgent help.
Chapter 88: Renal and Genitourinary Emergencies
88.1 Acute Urinary Retention
Severe lower abdominal pain with inability to urinate.
Requires hospital catheterization.
88.2 Kidney Stones
Severe flank pain radiating to groin.
Provide comfort and urgent referral.
Chapter 89: Dermatological Emergencies
89.1 Severe Allergic Rash
May progress to anaphylaxis.
Monitor airway closely.
89.2 Stevens-Johnson Syndrome (Awareness Level)
Severe skin reaction often medication-related.
Immediate hospital care required.
Chapter 90: Integrated Emergency Algorithms
90.1 ABCDE Systematic Approach
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
Used in trauma and medical emergencies.
90.2 Pediatric Assessment Triangle
- Appearance
- Work of breathing
- Circulation to skin
Rapid visual assessment tool.
PART 9 – Advanced Cardiovascular Physiology, Complex Trauma, Burn Science, Radiation Disasters & Psychological Trauma
Chapter 91: Advanced Cardiovascular Physiology in Emergencies
Understanding cardiovascular collapse enhances rapid recognition.
91.1 Cardiac Output and Perfusion
Cardiac output (CO) = Stroke Volume × Heart Rate
Perfusion failure may result from:
- Pump failure (cardiogenic shock)
- Volume loss (hypovolemic shock)
- Obstruction (pulmonary embolism, tension pneumothorax)
- Severe vasodilation (septic or anaphylactic shock)
In first aid settings, recognition relies on:
- Altered mental status
- Weak or absent pulse
- Pale, cold, clammy skin
- Delayed capillary refill
91.2 Electrical Instability and Sudden Cardiac Death
Sudden cardiac death often results from ventricular fibrillation.
Early CPR and defibrillation are critical components of the “Chain of Survival,” emphasized by the American Heart Association.
Public access defibrillation programs significantly improve survival rates.
Chapter 92: Mechanical Complications of Trauma
92.1 Compartment Syndrome
Increased pressure within muscle compartments compromises blood flow.
Signs:
- Severe pain out of proportion
- Tight swollen limb
- Decreased sensation
Urgent hospital intervention required.
92.2 Flail Chest
Occurs when multiple rib fractures cause a segment of chest wall to move independently.
Signs:
- Paradoxical chest movement
- Respiratory distress
First aid:
- Support breathing
- Rapid transport
92.3 Internal Hemorrhage in Blunt Trauma
May present with:
- Abdominal rigidity
- Distension
- Hypotension
Maintain supine position and monitor continuously.
Chapter 93: Advanced Burn Management
Burns are classified by depth and total body surface area (TBSA).
93.1 Pathophysiology of Severe Burns
- Massive fluid loss
- Electrolyte imbalance
- Risk of infection
- Hypothermia
93.2 Rule of Nines (Adult)
Estimates burn surface area:
- Head: 9%
- Each arm: 9%
- Each leg: 18%
- Anterior trunk: 18%
- Posterior trunk: 18%
93.3 Chemical Burns
Management:
- Remove contaminated clothing
- Irrigate with copious water
- Avoid neutralizing agents
93.4 Electrical Burns
May cause:
- Deep tissue injury
- Cardiac arrhythmias
Always monitor for cardiac complications.
Chapter 94: Radiation & Nuclear Disaster Deep Dive
Radiological emergencies may result from industrial accidents or warfare.
Global response coordination may involve the World Health Organization.
94.1 Acute Radiation Syndrome (ARS)
Stages:
- Prodromal (nausea, vomiting)
- Latent phase
- Manifest illness
- Recovery or death
94.2 First Aid in Radiation Exposure
- Remove from contaminated area
- Remove clothing
- Wash exposed skin
- Avoid spreading contamination
Professional radiological response teams must be activated.
Chapter 95: Advanced Psychological Trauma Management
Emergencies affect mental health profoundly.
95.1 Acute Stress Reaction
Symptoms:
- Anxiety
- Tremors
- Disorientation
First Aid:
- Calm reassurance
- Provide safe environment
- Encourage slow breathing
95.2 Post-Traumatic Stress Disorder (Awareness)
May develop weeks to months after event.
Symptoms:
- Flashbacks
- Nightmares
- Avoidance behavior
Referral to mental health services is important.
95.3 Provider Psychological Protection
First aid providers may develop:
- Compassion fatigue
- Burnout
- Secondary trauma
Peer debriefing and mental health support are essential.
Chapter 96: Long-Term Rehabilitation Awareness
While first aid is immediate care, understanding long-term outcomes is valuable.
96.1 Post-Stroke Rehabilitation
May involve:
- Physical therapy
- Speech therapy
- Occupational therapy
96.2 Post-Trauma Recovery
Focuses on:
- Mobility restoration
- Psychological support
- Chronic pain management
Chapter 97: Research & Evidence-Based Updates in Emergency Care
Evidence-based practice improves outcomes.
97.1 CPR Compression Depth and Rate Research
Current recommendations:
- Rate: 100–120 compressions per minute
- Depth: 5–6 cm in adults
Guidelines are periodically updated by the European Resuscitation Council and the American Heart Association.
97.2 Tourniquet Safety Research
Modern studies confirm that properly applied tourniquets reduce mortality in severe limb trauma.
Chapter 98: Ethical Case Analysis – Pandemic Resource Allocation
During pandemics:
- Ventilator scarcity
- ICU bed shortages
- Medication limitations
Ethical allocation often follows public health frameworks endorsed by global agencies such as the World Health Organization.
Chapter 99: Integrated Advanced Case Simulation
Scenario: Multi-Victim Road Traffic Accident
Victims:
- Unconscious with no breathing
- Severe leg hemorrhage
- Walking wounded
Triage:
- Victim 1 → Immediate CPR
- Victim 2 → Tourniquet
- Victim 3 → Minor category
Demonstrates prioritization principles.
Chapter 100: Comprehensive Review and Integration
This textbook has covered:
- Foundations of first aid
- Basic and advanced life support
- Trauma and medical emergencies
- Pediatric and obstetric care
- Toxicology
- Disaster medicine
- Ethical frameworks
- Public health systems
- Psychological first aid
- Research developments
Core Principles to Remember
- Ensure scene safety.
- Follow structured assessment (ABCDE).
- Prioritize airway, breathing, and circulation.
- Control life-threatening bleeding immediately.
- Activate emergency services early.
- Provide reassurance and psychological support.
- Continue skill training regularly.
