Transcript What to do
First Aid Eduard Kasal, MUDr., Ph.D., Assoc. Prof. Department of Anaesthesiology and Intensive Care Medicine 2014 First aid • It is better to know first aid and not to need it than to need it and not to know it. • A delay… can mean the difference between life and death. However • most injuries do not require life-saving efforts First aid Definition: … is the immediate care given to an injured or suddenly ill person. … also includes the things that people can do for themselves. …is one of those things you need to know – but never want to use… First aid …most people do not know first aid. … even if they know it, they may panic in an emergency. First aid Legal considerations • before giving first aid, a first aid provider should have the victim´s consent (permission) • expressed consent – conscious mentally competent person of legal age • implied consent – an unresponsive victim in a life-threatening condition – “implied“ consent First aid Legal considerations Bystander = a vital link between the emergency medical services and the victim. Decision to help Czech Republic: everybody is obligated to provide first aid adequate to his knowledge and possibilities… Refusal to provide first aid • extra-legal • a new testimony legalized – driving away from the place of traffic accident = crime First aid Legal considerations Foreigners • are obligated to abide with laws of the country Basic Life Support First Aid Background Approximately 700,000 cardiac arrests per year in Europe Outcome: Survival to hospital discharge presently approximately 5-10 - 14% Bystander CPR = vital intervention before arrival of emergency services Early resuscitation and prompt defibrillation (within 1-2 minutes) can result in >60% survival Chain of survival CardioPulmonary Resuscitation Definition: CPR is an emergency first-aid procedure that is used to maintain respiration and blood circulation in a person, whose breathing and heartbeats have suddenly stopped, (one or more vital functions failed ). CardioPulmonary Resuscitation Three basic vital functions: Breathing Circulation Consciousness CardioPulmonary Resuscitation History 1. Peter Safar - Professor of Pittsburgh University presented in 1968 small book “Cardiopulmonary Resuscitation” …. 2. Guidelines 2000 3. Guidelines 2005 Many changes of almost all algorithms used for several tens of years… Publication of new guidelines does not mean, that CPR provided in accordance with previous guidelines is not effective and not correct, but we should follow them as possible… www.erc.edu Basic life support CardioPulmonary Resuscitation “Thoracic pump theory“ the chest compression propels blood out of the thorax by increasing intrathoracic pressure … the time of the chest compression and decompression should be equal Pressure should be completaly released Hands should remain in the contact with the chest CardioPulmonary Resuscitation Theoretical background Oxygene content In atmospheric air - 21% In alveoli - 14,5% Expired air – diluted by air from the airways (dead space) - 16 – 18 % O2 Provided that there is an adequate amount of expired air reaching the victim's lungs, oxygen delivery will be sufficient to ensure that the victim's haemoglobin will be over 80% saturated with oxygen. Theoretical background Cardiac arrest 1. Asystole 2. Ventricular fibrillation Most cardiac arrest victims have an electrical malfunction of the heart heart´s pumping function abruptly ceases 3. Pulseless ventricular tachycardia = Fast ventricular contractions without haemodynamc effect Signs of the both = identical!!! Differential dg: only ECG Theoretical background At best chest compressions provide only 30% of normal perfusion brain + heart Time! Time! Time! Time! Time! Time! Time! Time! Failure of the circulation 3 - 5 minutes irreversible cerebral damage. Chances of successful CPR - restoration of spontaneous circulation (ROSC) decreases by 10% with each minute following sudden cardiac arrest… Cause of cardiac arrest and emergency system activation Adults • Ischemic heart disease - AMI- with/or ventricular fibrillation (> 80%) Children • Suffocation or choking with hypoxemia or asphyxia. Ventricular fibrillation is rare in children (only 5-8%) Cause of cardiac arrest and emergency system activation different approach to the emergency system activation. Adults electric defibrillator is necessary as soon as possible; therefore, if telephone is available and you are alone: 1. call for help, then 2. start with CPR Children 1. start CPR immediately for 1 minute to provide some tissue oxygenation 2. then call for help Emergency telephone number 155, 112 in the Czech Republic Indication of CPR to victims with unexpected cardiac arrest in otherwise healthy individuals … = to those, who can be described as having ”heart too good to die” Indication of CPR • • • • • • • • • malignant arrhythmia acute myocardial infarction (AMI) pulmonary embolism intoxication electrocution drowning acute suffocation severe trauma stroke and alike CPR is not indicated signs of definitive biological death witnessed information, that cardiac arrest had happened 15 or more minutes before the rescuer arrived (time assessment in the stressing situation is not precise) terminal stage of incurable disease (generalised malignant disease…) an evident trauma without chance to survive (catastrophic head injury) “living will” - only in countries when constitution accepts it DNR - “Do not attempt resuscitation” has been written in the file (incurable disease after all available therapy failed) execution Age of the patient is not restriction of CPR Outcome after CPR Ventricullar fibrilation – better than asystole - in case of immediate CPR Special emphasis Soon defibrilation 1 minute 5 minutes 7 minutes 10 - 12 minutes - survival - 90%, - survival - 50%, - survival - 30% - survival - 2 – 5%. CPR outcome • In first 4 minutes – brain damage is unlikely, if CPR started • 4 – 6 minutes – brain damage possible • 6 – 10 minutes – brain damage probable • > 10 minutes – severe brain damage certain Cells of the brain cortex • Most sensitive for the stop of pefusion and oxygenation Without perfusion and oxygenation irreversibly damaged after 3-5 minutes Signs of cardiac arrest (Guidelines 2000) 1. Unconsciousness in several seconds 2. Respiratory arrest ( apnea) or the last gasps (1-3 minutes after cardiac arrest) 3. Pulse-less on large ( major) arteries (carotid or femoral artery) 4. Changed general appearance (colour changes, face changes…) 5. Pupils dilation (mydriasis) – not reliable Signs of cardiac arrest (Guidelines 2005) 1. 2. 3. Unconsciousness No reactivity Absence of normal breathing Basic conditions for CPR 1. 2. 3. 4. 5. 6. Rescuer’s safety = the first priority To assess the risk of trauma, intoxication, infection … a victim position: supine on to his/her back on the firm flat surface to make effective chest compressions victim´s position in relation to rescuer´s position CPR during transfer ??? Rescuer’s safety The rescuer should never place him/herself or others at more risk than the victim • • before starting resuscitation – assess the risks of ongoing traffic, falling masonry, electrocution, toxic fumes and poisons risk of infections transmission • bloodborne infections (hepatitis B and C, HIV) - can be transmitted by blood and other body solutions, excretes • airborne infections (TBC and several infectious diseases - herpetic, meningococcal etc. - can be transmitted by mouth-to-mouth breathing Rescuer’s safety • Always: protect yourself !!! • personal protective equipment (gloves) • barrier protective devices • Moth – to - barrier protective devices breathing Personal Protective Equipment Can control the risk of exposure to bloodborne pathogens –prevents an organism from entering the body (medical exam gloves, eye protection, mask) All human blood and body fluids should be considered infectious Mouth-to-mouth barrier devices Can prevent air-borne pathogens transmission Not documented case of disease transmission But…should be used whenever possible CardioPulmonary Resuscitation Barrier devices S – tube Face shields (resuscitation veil ) Pocket face mask + one-way valve Handkerchief Towel Stop CPR if Victim starts to breathe normally Medical assistance arrives and instructs you to stop CPR You are physically exhausted Stop CPR if: When CPR has been performed for 20 minutes without restoration of the spontaneous circulation It can be stopped earlier, when: rescuer is physically exhausted when signs of biological death develop (postmortal rigidity, post-mortal cooling and gravity-dependent livid stains) ??? CardioPulmonary Resuscitation Safar´s algorithm of CPR stressing conditions an inadequate situation assessment Airways Breathing Circulation Drugs ECG BLS ? ALS New resuscitation alphabet – in adults Algorithm of CPR EKG Circulation Airways Breathing Drugs BLS ALS BLS sequence Kneel by the side of the victim BLS sequence Shake shoulders Ask “Are you all right?” BLS sequence If he responds • Leave as you find him • Find out what is wrong • Reassess regularly BLS sequence Unresponsive Shout for help BLS sequence Unresponsive Shout for help Open airway BLS sequence Unresponsive Shout for help Open airway Check breathing BLS sequence Look, listen and feel for NORMAL breathing No breathing – apnea Gasps (agonal breathing) Agonal breathing Occurs shortly after heart stops in up to 40% of cardiac arrests Described as barely, heavy, noisy or gasping breathing Recognise as a sign of cardiac arrest Do not confuse agonal breathing with NORMAL breathing BLS sequence Unresponsive Shout for help Open airway Check breathing Call 155 (112) BLS sequence Unresponsive Shout for help Open airway Check breathing Call 112 30 chest compressions Chest compression Place the heel of one hand in the centre of the chest Place other hand on top Interlock the fingers Compress the chest Rate 100 min-1 Depth 4-5 cm Equal compression : relaxation When possible (2 or more rescuers) change CPR operator every 2 min. to prevent fatigue Chest compression Place the heel of one hand in the centre of the chest Place other hand on top Interlock fingers Compress the chest Rate 100 min-1 Depth 4-5 cm Equal compression : relaxation When possible (2 or more rescuers) change CPR operator every 2 min. to prevent fatigue Chest compression Place the heel of one hand in the centre of the chest Place other hand on top Interlock fingers Compress the chest Rate 100 min-1 Depth 4-5 cm Equal compression : relaxation When possible (2 or more rescuers) change CPR operator every 2 min. to prevent fatigue Chest compression Unresponsive Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths 2 rescue breaths Pinch nose Place and seal your lips over the victim´s mouth Blow until the chest rises Takes about 1 second Allow chest to fall Repeat (10 – 12 times per minute) B) Breathing expired air resuscitation - several techniques: - Mouth-to-mouth breathing - Mouth-to-nose breathing - Mouth-to-mouth + nose breathing ( small children) - Mouth-to the barrier device ( to protect the rescuer) - Mouth to tracheostomy Self-inflating bag CardioPulmonary Resuscitation Artificial breath during expired air resuscitation Volum = normal breathing volum Volum = 6-7 ml/ kg bw = 500 ml Breath duration in adults = 1 second Expiration – passive Check the chest rise during rescue breath Self-infalting bag Capacity 1500 ml 1 way valve Volume controlled by compression Breathing by atmospheric air Oxygene source - conection Oxygene reservoir – 100% O2 Continue CPR CPR Continue 30 : 2 Ratio 30 : 2 One uniform ratio • always in adults • in children in the prehospital CPR • in children when the rescuer is alone Defibrillation Defibrillation Automated External Defibrilators (AEDs) A new generation of “smart“ defibrilators Advanced computer technologies Ability to interprete heart (ECG) rhythm Ability to determine whether defibrilation is required Delivery of electric shock Guides the operator through every action Provides voice and message prompts Legal aspects AEDs Easier than CPR Readily available on places with haevy people concentration, where can be probably used once during 2 years Extendes beyon healthcare prefessional personnel to trained citizens Switch on AED AEDs will automatically switch themselves on when the lid is opened Attach pads to casualty’s bare chest Analyse rhythm – do not touch victim Shock indicated – stand clear Rescuer giving defibrilation shock • is responsible for his safety • is responsible for the safety of other people surronding the victim Immediately resume CPR Need new picture 30 : 2 Give CPR every moment, when AED is not available, always if AED is not available within 5 minutes Need new picture 30 : 2 If victim starts to breathe normally place him in recovery position Need new picture CPR should not usually be abandoned after 20 minutes: in case of the victim´s hypothermia in case of persistent ventricular fibrillation = AED indicates defibrilation shock Responsibility during CPR Precordial chest thumps Indication: wittnessed cardiac arrest (patient´s collapse) adults only within 20 sec. Only experienced rescuers Contraindications: uknown time of cardiac arrest chest injury children A. Airway management A) Head tilted backward Chin lift Triple manouvre ??? „A“ • head titlted backward • chin lift Jaw thrust • suspected cervical spine injury • experienced rescuer ( anaesthesiologist) Lower jaw pulled forward A. Airway management 1. Unconscious patient – tongue tilt the head backward + lift the chin 2. Conscious patient - foreign body airway obstruction choking - partial airway blockade encourage the victim to cough add several hits to his/her back Cough is much more effective than any other manoeuvre. A. Airway management 1. Foreign body airways obstruction 2. Potentially treatable Mostly during eating Commonly witnessed event Oportunity for early intervention Can cause mild (partial) or severe (comlete) airway obstruction 3. 4. 5. 6. Heimlich manoeuvre (several thrusts (5)) pregnant ladies, children A. Airway management Signs of mild (partial) large airways obstruction Suffocation Difficult intensive inspiration Neck and thorax soft tissues retraction Hoarse (croupy) sounds accompanying inspiration (noisy breathing) Barking cough A. Airway management Signs of severe or complete large airways obstruction Difficult intensive inspiratory effort Powerful breathing movements Neck and thorax soft tissues retraction No breathing phenomena hearable Patients non-cooperation, restlessness, convulsions, coma, blue skin color Equipment for airway management C: Circulation Diagnosis: • Signs of functional circulation (breathing, coughing, movement, skin condition, responsiveness, pulse) • Pulse-less on large ( major) arteries – only experienced rescuers Compression-only CPR “Top-less” Reluctance of rescuers to perform mouthto-mouth breathing on strangers Unwilling person to breathe… Unability to perform …(vomiting, bleeding, trauma, unskilled rescuer…) Chest compressions only Better some resuscitation than no resuscitation Compression-only CPR New recommendation of AHA Witnessed collapse of the patient First 10 minutes Contraindications: Children Sudden cardiac arrest due to choking CPR in children Who is an infant? 0 – 1 year Landmark between child and adult: puberta Who is a child? 1 - puberta CPR in children Differencies: Cause of cardiac arrest –choking, trauma Activation of emergency system Hypoxia developes faster – high metabolic rate Ventricular fibrillation – rare Primary cardiac arrest uncommon, Precordial thump is contraindicated Length of CPR = identical Chain: Choking- hypoxia – hypercapnia – apnoea – bradycardia – cardiac arrest Trauma CPR in children A) The most often cause of vital functions failure = choking Foreign body airway obstruction Infectious diseases afecting throat by swelling ( epiglotitis, acute suffocating LTB, croup) Trauma CPR in children Sequence of action Rescuers with no knowledge of pediatric resuscitation may use the adult sequence with the exception that they should start with 5 initial breaths followed by 30 compressions 30 : 2 for 1 minute than call 155 (112) but Generally prefered ratio in children = 15:2 (in-hospital CPR, 2 rescuers) CPR in children “A“ Identical with adults More often inflamation throat diseases with swelling and suffocation Foreign bodies!!! Small toys and toys that can be dismantled for small parts!!! CPR in children “B“ Look, listen and feel no more than 10 s Volum 6-7 ml /kg bw Blow steadily over 1 – 1.5 sec. To make the chest visibly rise Start with 5 breaths Paediatric size of self-inflating bag Adult self-inflating bag??? Start with 5 breaths in adults with choking as well !!!! CPR in children “C“ Look for signs of circulation (movements, coughing, skin colour, breathing…) Check the pulse (if you are an experienced health provider) no more than 10 s Lower third of the sternum (1 finger above xiphoid process) One third of the depth of the chest 100 compressions per min. CPR in children C) Technique of chest compressions Rate of chest compressions Algorithm of CPR: 2:15 1 rescuer: 2:30 Infants: 1:3 CPR in children 2 : 15 2 : 30 CPR in children Chest compressions in infants CPR in children Chest compressions in children BLS in children FBAO • back blows • chest thrusts • abdominal compression All manouevres intrathoracic pressure expulsion of FB out from the airways 50% of cases – more than 1 manouevre is necessary Complications during CPR Gastric distension –often in children Prevention: avoid overinflating the lungs appropriate volum making the chest rise Rib fractures Prevention: correct hand´s position do not remove hands from the chest wall prevent “dancing on the chest“) Gastric content (or other fluids) aspiration Prevention: prevent gastric distension recovery position in unconscious victims Children suffocation disease Croup: laryngotracheobronchitis age 1-3 years, viral origin accompanbies influenza, children infection diseases, winter or early spring season barking cough not sore throat no special position swalloving problems intercostal retractions not so fast progression of suffocation Dysfonia, afonia Children suffocation disease Epiglottitis age 3-7 years, bacterial origin air hunger anxiety sitting position, hyperextended head severe sore throat swallowing problems, salivation Severe inspiratory dyspnea with stridor Mortality 10% !!! underestimated Children suffocation disease Both situations Transfere to the hospital, where anaesthesiologist or intensivist is available as soon as possible !!!! Not to a general practicioner www.erc.edu First aid in special situations Bleeding = escaped blood from the blood vessels Hemorrhage – large amount of bleeding in a short time External bleeding –seen blood coming from an open wound –outside the body - often overestimated Internal bleeding – inside the body - often underestimated Bleeding 3 kinds according to its source: 1. Arterial • • • • • • • bright red colour under pressure, comes out in spurts the most serious fast rate large blood loss less likely to clot (clot only when blood flow is slow) dangerous : it must be controlled Bleeding 3 kinds according to its source: 2. Venous • dark red colour • low pressure • blood flow steadily • it is easier to control • most veins collaps when cut but • bleeding from deep veins can be as massive as arterial bleeding !!! Bleeding 3 kinds according to its source: 3. Capillary bleeding • • • • • • oozing out, leaking most common blood oozes usually not serious easily controlled often it clots and stops itself 4. Mixed bleeding Bleeding - clinical symptoms Depend on - the quantity of the blood loss - the rapidity of the blood loss !!! Sudden loss of a large quantity of blood results in shock: - skin - cold, pale - pulse - weak, fast - mental disorders, fear, unconscioussness Bleeding What to do? the first aid is the same reagardless of the type of bleeding most important = to controll bleeding External bleeding Steps: 1. Protect yourself (exam gloves or improvizations) 2. Manual control of external haemorrhage 3. Expose the wound (remove or cut clothing) to find the source 4. Place sterile pad or clean cloth and apply direct pressure (fingers, palm, hand) = pressure over the wound 5. If bleeding from arm or leg – elevate extremity above the heart level + pressure over the wound External bleeding Steps: 6. If bleeding continues – continue + apply pressure against the bone at pressure points ( brachial or femoral points ???) 7. Use pressure bandage – you have free hands for help to other victims 8. For application of direct pressure – use ring pad 9. Tourniquets – rarely on the extremities – it can damage nerves and vessels !!! 10.When you need it – use wide, flat materials and write the time of application !!! Internal bleeding skin is not broken blood is not seen difficult to detect can be life threatening traumatic and nontraumatic origin What to look for? “Swelling“ on extremities in case of trauma Contussion of the skin Painful, rigid, tender abdomen Vomiting or coughing up blood Black stools or stool with bright red blood Internal bleeding What to do? 1. 2. 3. Steps: Check ABCs Expect vomiting – keep the victim on his/her left side Treat for shock: Elevate legs Cover the victim to keep him/her warm Do not give a victim anything to eat and drink (prevention of lung aspiration, can cause complications during surgery) Splinting extremities bleeding pain prevents nerve and vessels injury Internal bleeding Loss of blood - long bones fractures: • Pelvis 2 – 5 L • Femur (tigh) 1 – 2,5 L • Shin bones 1 – 1,5 L • Arm ( humerus) 0,5 – 1 L • Forearm – 0,5 L Shock Definition: Circulatory system failure when insufficient amounts of blood is provided for different parts of body (insuficient perfussion) Three components: 1. Heart pump failure 2. Network of pipes (vessels) enlargement 3. Adequate volume of circulated fluids fluid loss - blood - plasma - extracellullar fluids (vomit, diarrhoea, sweatting, urine…) Damage of any of these components can produce conditions known as shock. Shock What to look for? 1. 2. 3. 4. 5. 6. 7. 8. Altered mental status, restlessness Pale, cold, clammy skin, livid lips Limited perfussion of peripheral parts of the body Capilary refil phenomenon – nail beds Nausea and vomiting Rapid breathing Rapid weak pulse or pulseless on peripheral arteries Unresponsiveness, when shock is severe BP < 60 mm Hg Shock What to do? 1. Treat life-threatening injuries 2. Lay the victim on his/her back 3. Raise the victim´s legs ( if no evident injury) – drain of blood from legs to the heart 4. Prevent body heat loss (blankets) 5. Splintig of long bones fractures 6. Seek immediate medical attention Shock What to do? 6. ABC 7. In case of severe shock - prevent peroral intake nausea + vomiting inhaling foreign material into the lungs complications during surgery 8. Oxygene … Bruises (suffusions) = a form of internal bleeding, but not life threatening Allergy, anaphylaxis Definition: A powerful reaction to substances (eaten, injected, contacted…) Reaction antigene + antibody. Anaphylaxis = severe allergic reaction Characteristics: Occurs within minutes or seconds Fast progression Can cause death if not treated immediatelly Common cause: Medications, food + food additives, insect stings, plant and flowers pollen, parfumes… Allergy, anaphylaxis What to look for ? Fast development Sneezing, coughing, wheezing Shortness of breath Suffocation (swelling in the throat, tongue, mouth, neck = Quincke oedema…) Tightness in the chest Increased pulse rate Dizzines Nausea + vomiting Diarrhoea Anaphylactic shock Urtica with skin itching (pruritus), blisters, quickly spreading exanthema Allergy, anaphylaxis What to do? Immediatelly interrupt the contact with allergene Check ABCs Seek immediate medical attention Help the victim to use epinephrine, if he/she is provided with Strangulation Removing the body from the noose - prevention of body fall and other injuries Suspected injury of - the brain - cervical spine, larynx, cervical vessels (thrombosis of the carotid artery, of the jugular vein) What to look for? - Status of vital functions What to do? ABC stabilize head against movement seek medical attention admission to the hospital ICU Seizures (convulsions) Seizure (convulsions, crumps) - is a burst of electrical activity from the brain that results in involuntary movements, loss of consciousness (LOC), or both. Basic classification generalised - always LOC - convulsive - tonic or combination of tonic with - clonic convulsions (seizures) urinary incontinence or tongue biting may occur nonconvulsive - absence, myoclonic partial - no LOC Seizures (convulsions) Risk factors: Serum electrolyte disturbances - Na <120 or >160 mmol/l, Ca<1mmol/l, Mg<0,5mmol/l Drugs - amphetamine, cocaine, ethanol, TCAs CNS infection - meningitis, encephalitis Miscellaneous - CNS tumour - hypertensive encephalopathy - severe hypoxemia - Head injury Seizures (convulsions) Clinical signs: Seizures have abrupt onset and last 1-5 minutes the period of altered mental status can last up to 30 minutes Status epilepticus - defined as seizures lasting >30 minutes or two or more seizures without lucid interval in between. Seizures (convulsions) What to do? Restrain the victim as necessary to protect from self- injury and from secondary injury - cars and traffic on the road, sharp objects in the proximity of the patient Bring the patient gently into recovery position to prevent aspiration in the case of vomiting - rough treatment could provoke other paroxysm ABC as soon as the seizures stop Call for help and arrange transport to the hospital Near drowning Drowning is death from asphyxia secondary to submersion in a liquid (usually water) or within 24 hours of submersion. Near drowning is survival of suffocation secondary to submersion in a liquid. Mechanisms of near drowning with aspiration - aspiration of water and vomitus in fresh water loss of surfactant – fast absorbtion to the circulation in see water flooding of alveoli hypoxemia (80-90%) no aspiration – laryngospasm spastic closure of glottis (vocal cords) hypoxemia (in 10-20%) = dry drowning. Near drowning What to do? Extrication of the victim from the water - very dangerous - protect yourself !!! ABCs - the earliest as possible - Airways + oxygenation + ventilation The airway should be checked for foreign material and vomitus Prevent additional hypothermia Seek for medical attention Heat stroke Heat stroke - defined as a heat injury + altered mental status in consequence of failure of the body temperature control. Rectal (core) body temperature is above 40°C - usually there is a history of exposure to exercise or increased temperature and humidity. Causes: high ambient or environmental temperature increased endogenous heat production decreased ability to dissipate heat Heat stroke Risk factors - extremes of age (infants and the elderly) dehydration alcoholism, medication (atropine) Mortality is high because of the risk of multi-organ failure Clinical signs: hyperpyrexia altered mental status lack of or minimal sweating ataxia neurological deficit – paralysis (hemiplegia, Babinsky reflex) Heat stroke What to do? ABC Reduction of core temperature – water should be - sprayed on undressed patient with breeze from fans or - wrap the patient in wet packsheet till the temperature falls to 38,5°C, then stop the cooling Continuation of cooling could cause the uncontrolled drop of body temperature. Cold water immersion or air-cooling Seek medical attention Heat cramps Heat cramps - are painful, involuntary contractions of skeletal muscles that mostly involve the calves, thighs, and shoulders. Causes - the same as those for heat stroke The main risk factor - is the replacement of sweating losses with plain (hypotonic) water. The hypo-osmolality can lead to the brain edema with the cramps. What to do? Give to the patient the glass with salt water one half of the glass every 15 min. Massage the muscles to relieve the spasm Seek medical attention Cold injury - hypothermia Shivering Besides goose pimples - as a part of “cold stress reaction“ protective reaction = an early response to cold stress Shivering is able to increase the basal metabolism rate two-to five fold Heart oxygene and energetic consumption is increased by 500% It is operative between 30-37°C Cold injury - hypothermia Clinical signs: gradually deteriorating mental status incoordination confusion lethargy coma body is cold to touch, dysarthria Tachycardia bradycardia - ventricular fibrillation occurs at temperatures 28°C Hypertension hypotension Tachypnea (↑rate of breathing) bradypnea (↓ rate of breathing) Hyperreflexia areflexia – fixed and dilated pupils with coma at temperature below 22°C Asystole - at 22º C Cold injury - hypothermia Cause - is the exposure of the person to the low environmental temperature. Hypothermia is supported by the wind and high humidity. Classification mild hypothermia core temperature - 32-35°C moderate hypothermia - 28-32°C severe hypothermia < 28°C Risk factors : extremes of age (infants and elderly) accompanying diseases and bad status of health alcohol intoxication and drug overdose Cold injury - hypothermia What to do? In mild hypothermia: Transport patient to the warm environment and give him warm fluids (but no alcohol) In severe hypothermia: ABC Transport the patient to the warm environment, undresse him and remove the rings and all thing, that can constrict lower and upper extremities and limit the perfusion Avoid movements with the patient´s body parts Seek medical attention Cold injury - frostbite Frostbite - a cold-related contact injury characterised by freezing of tissues Most often affected parts of body = peripheral - face, ears, nose, hands, feet, penis and scrotum Most cases - in soldiers, winter outdoor enthusiasts, e.g. mountain climbers Cold injury - frostbite Pathophysiology - cold exposure leads to ice crystal formation cellular dehydration protein denaturation inhibition of DNA synthesis abnormal cell wall permeability damage to capillaries pH changes Cold injury - frostbite Degree of injury 1st-degree injury - erythema, oedema, waxy appearance, hard white plaques, and sensory deficit 2nd-degree injury - erythema, edema, and formation of clear blisters 3rd-degree injury - presence of blood-filled blisters 4th-degree injury - full-thickness damage affecting muscles, tendons, and bones Cold injury - frostbite What to do? Examine vital functions, start ABC when necessary Replace wet clothing with dry, soft clothing to minimise further heat loss. Remove constricting clothing. Initiate rewarming of affected area as soon as possible. Avoid rubbing affected area with warm hands or snow, as this can cause further injury. Transport patient to the warm environment and give him warm fluids. Active re-warming of the frost-bitten part via immersion in circulating clear water at 40-41°C Dry sterile dressing of the frostbite Seek medical attention Open wounds - types Abrasion - the top level of skin is removed = painful - (nerve endings) Laceration - skin is cut with jagged, irregular edge Incision - smooth edges (surgery) - bleeding depends on the depth, the location and the size of the wound Punctures - deep narrow wounds (nail, knife), the object may remain impaled in the wound Amputation , avulsion - the cutting or tearing off of a body part – finger, toe, hand, foot, arm or leg Open wounds - what to do Protect yourself - use medical gloves if possible or several layers of gauze or clean cloth and apply pressure on the wound (your bare hand should be used only as a last resort) Expose the wound - to see where the blood is coming from Control the bleeding Do not clean large extremely dirty or life threatening wounds. Let hospital emergency department personnel to do the cleaning Do not scrub a wound Open wounds - wound care Shallow wounds should be cleaned to prevent infection - risk of restarting of bleeding by disturbing the clot For severe bleeding, leave the pressure bandage in place until medical attention. To clean a shallow wound - wash inside the wound with soap and water - irrigate the wound with water from a faucet (tap) - for a wound with a high risk for infection (animal bite, very dirty or ragged wound or a puncture) seek medical attention for wound cleaning Cover the area with a sterile dressing Open wounds - amputation Control the bleeding Treat the victims shock Recover the amputated part, take it with the victim - - it does not need to be cleaned - wrap it with a dry sterile gauze or clean cloth and put it in the plastic bag - keep it cool, but do not freeze Seek medical attention immediately - 18 hours is the maximum time allowable for a part that has been cooled properly. Muscles without blood lose viability within six hours. Open wounds - impaled objects What to do Expose the area - remove or cut away clothing surrounding the injury Do not remove or move an impaled object - movement of any kind could produce additional bleeding and tissue damage Control any bleeding with pressure around the impaled object Shorten the object if necessary - stick or trunk of the tree, wooden or iron bar.. Burns and scalds Rank among the most serious and painful injuries. Can be classified thermal (heat) burns - contact with hot objects, flammable vapor, steam or liquid chemical - acids, alkalis and organic compounds (petroleum, kerosene…) electrical - severity of injury depends on the type of current, the voltage, the area of body exposed and the duration of contact Burns and scalds 1st-degree burns (superficial): surface (outer layer) of the skin is affected characteristics - redness, mild swelling, tenderness and pain 2nd-degree burns: affect partial thickness of the skin characteristics - blistering and swelling, severe pain 3rd-degree burns: penetrates the entire thickness of the skin and deeper tissues characteristics - no pain, skin looks waxy or pearly grey or charred Burns and scalds - what to do? Stop the burning ! Check ABCs Determine the depth (degree) of the burn Determine the extend of the burn - rule of nine - how much body surface area is affected by burns - head 9%, complete arm 9%, front torso 18%, back 18%, each leg 18%, victims hand excluding the fingers and the thumb, represents about 1% of victims body surface Determine which parts of the body are burned - burns of the face, hands, feet and genitals are more severe Seek medical attention Calculation of the burned surfice extent Anterior and posteror part of the trunk Burns and scalds - what to do in case of 1st and small 2nd-degree burns Aim of the care - reduce pain - protect against infection - prevent evaporation Cooling - immerse the burned area in cold water - apply cold until the part is pain free (10-45 minutes) Sterile bandage or clean cloth Fluids orally ??? Analgesia Shock treatment Burns and scalds - what not to do Do not remove clothing stuck to the skin - pulling will further damage the skin Do not forget to remove jewellery as soon as possible - swelling could make jewellery difficult to remove later Do not apply cold to more than 20% of an adult´s body surface (10% for children) - widespread cooling can cause hypothermia. Burn victims lose large amount of heat and water evaporation) Do not apply ointment, butter or any other coatings on a burn except of sterile dressing or clean cloth Do not break any blisters - intact blisters serve as excellent burn dressings Burns and scalds - what to do in case of large 2nd and 3rd-degree burns Do not apply cold because it may cause hypothermia Cover the burn with a dry, nonsticking dressing or a clean cloth Treat the shock by elevating the legs and keeping victim warm with a clean sheet or blanket Seek medical attention Chemical burns - what to do Immediately remove chemical by flushing the area with water - brush dry powder chemicals from the skin before flushing (water may activate a dry chemical) - protect yourself Remove contaminated clothing and jewellery while flushing the water Flush for 20 minutes all chemical burns (skin, eyes) Cover the burned area with a dry, sterile dressing or clean pillowcase or sheet Seek medical attention immediately for all chemical burns Chemical burns - what not to do Do not apply water under high pressure - it will drive the chemical deeper into the skin Do not neutralize a chemical even if you know which chemical is involved - heat may be produced, resulting in more damage. Some product labels for neutralizing may be wrong. Save the container or label for the chemical´s name. Electric current injury Effects of electricity on the body are determined by 7 factors: type of current - skin offers greater resistance to direct current than alternating current amount of current pathway of current duration of contact area of contact resistance of the body voltage - high voltage accident (>1000 V) is regularly accompanied with burns, while low voltage (<1000 V) injury causes electric damage, most often arrhythmia. Electric current injury Both high and low voltage electric currents can adversely influence vital functions - unconsciousness, breathing paralysis and severe cardiac dysrhythmias (mostly ventricular fibrillation). Heating by electrical current is the major mechanism of tissue damage in electrical trauma. In high voltage accidents, the victims usually do not continue to hold the conductor - they are often thrown away from the electric circuit and thus acquire traumatic injuries (e.g. fracture, brain haemorrhage). Low voltage = heart injury High voltage = thermal injury Electric current injury - what to do Make sure the area is safe - unplug, disconnect or turn off power, if not possible, call for help Check ABCs - remember - ventricular fibrillation !!! - start CPR If the victim fell, check for a spinal injury Seek medical attention immediately, victims with cardiac dysrythmias need in hospital observation for 48 72 hrs Electrical injuries with burns (high voltage) - cover them by sterile dressing, victims usually require burn centre care Head injuries Mechanism of injury – motor vehicle crashes, falls, hits, gunshots and stab wounds, mortality rate 30-50% The main types of head injury - scalp wounds - scull fractures - basilar, linear and comminuted - intracranial lesions - contusion, subarachnoid haemorrhage, subdural hematoma, epidural hematoma - diffuse brain injury – concussion, diffuse axonal injury Scull fracture is always associated with the brain injury In case of suspicion of the brain injury, the patient has to be hospitalised, examined and monitored for at least 48 hours. Diffuse brain injury Concusion Diffuse axonal injury Concusion Is a brief, temporary interruption of neurological function folloving head trauma Concussion – clinical features Headache Nausea, vomiting Tachycardia Amnesia for the event Unconsciousness – short lasting Concussion - treatment ABCs Treatment for scalp wounds, aplication of pressure dressings to prevent hemorrhage Seek medical attention Transport to the hospital for diagnostics Admision to the hospital for monitoring, observation (mental status, consciousness assessment, pupils, …) Head injuries - what to do When the patient is unconscious ABC - monitor vital functions. By the application of airway management (head position tulted backward) keep in mind the possibility of cervical spine injury. Examine the head gently and cover the external injuries with sterile dressings (bandage) - don’t press on the wound, stabilize the victims neck against movement Examine the state of pupils - size, similarity, reaction on the light Examine also the thorax, abdomen and extremities When the circulation and breathing are stable bring the patient into recovery (stable -side) position (beware of cervical spine injury) and monitor vital functions. Call for help Head injuries - what to do When the patient is conscious: Bring the patient into supine position with a little elevated head if there is no suspicion of cervical spine injury Treat the wounds in the same way as above Call for help Keep in mind, that even if the patient is conscious, the status of consciousness can alter due to the brain injury or intracranial bleeding and therefore all the time monitor the mental status of the victim. Eye injuries - penetrating eye injuries Result when a sharp object (knife, needle) penetrates the eye Seek immediate medical attention - any penetrating eye injury should be managed in the hospital Stabilize any protruding object with bulky dressings or clean cloth Cover the undamaged eye Do not wash out eye with water Do not try to remove an object stuck in the eye Do not press on an injured eyeball or penetrating object Eye injuries - chemical burns of the eye Chemical burn of the eyes are extremely sight-threatening Alkalis cause greater damage than acids - they penetrate deeper and continue to burn longer Damage can happen in 1 to 5 minutes - the chemical must be removed immediately What to do - use your fingers to keep the eye as wide as possible - flush the eye with water immediately - irrigate from the nose side of the eye towards the outside, to avoid flushing material into other eye - loosely bandage both eyes with cold, wet dressings Seek immediate medical attention Nose injuries - nosebleeds Two types - anterior - most common (90%) - posterior - serious and requires medical attention Nose injuries - nosebleeds What to do Place victim in a seated position Keep his/her head tilted slightly forward so blood can run out, not down the back of the throat, which can cause choking, nausea or vomiting Pinch (or have victim pinch) all the soft parts of the nose together between thumb and two fingers for 5 minutes Apply an ice pack over the nose and cheeks Seek medical attention - if the bleeding continues or you suspect a broken nose or posterior nosebleed Spinal injuries Spinal injuries are often associated with head injuries The head may have been moved suddenly in one or more directions, damaging the spine What to look for - painful movement of the arms or legs - numbness, tingling, weakness or burning sensation in the arms or legs - loss of bowel or bladder control - paralysis of the arms or legs Spinal injuries What to do Stabilize the victim against any movement - to stabilize head against movement - place heavy objects on each side of the head Check ABCs Transfere the patient by 3 – 4 pairs of hands Transfere patient on the vacuum matrace or on the board Seek medical attention Chest injuries All chest injury victims should be rechecked for ABC Broken ribs - main symptom is pain by breathing, coughing and movements What to do help the victim find comfortable position stabilize the ribs using pillow or other soft object fixed by bandage over the injured area some victims find comfort by lying on the injured side seek medical attention Chest injuries - what to do Impaled object in chest Stabilize the object in place with bulky (wide) dressing Do not try to remove an impaled object - bleeding and air in the chest cavity can result Seek medical attention Chest injuries Sucking chest wound - results when a chest wound allows air to pass into and out of the chest cavity with each breath Chest injuries Pneumothorax open - persisting opening to the chest closed - no external communication tension (valve) - air can enter pleural cavity during inspiration and cannot escape during expiration Chest injuries Air entered into pleural cavity – results in Pneumothorax Collaps of the lung + increasing intrapleural pressure mediastinum shift to the healthy side stopped venous return to the heart cardiac arrest Pneumothorax – clinical features Sudden onset chest pain Chest wall deformity Crepitus Agitation Air hunger Tachycardia Hypotension Pneumothorax - treatment ABCs is priority Immobilization Transport to the hospital Pneumothorax What to do Cover the wound immediately Seal the wound with anything available to stop air from entering the chest cavity plastic wrap or plastic bag, if not available, you can use your gloved hand Seek medical attention urgently !!! Pleural puncture should be done as soon as possible Pneumothorax (PNO) What to do Always change the open pneumothorax into the closed Plastic bag – place on the chest wound and fix it by adhesive tape (plaster) from 3 sides with the fourth side free (pocket) Abdominal trauma clinical features Nausea Vomiting Dyspnea Heartburn Abdominal pain Abdominal distension Abdominal trauma clinical features Ecchymoses over the abdomen Presence of open penetrating wounds Abdominal tenderness Hypotension tachycardia Abdominal trauma - treatment ABCs is priority Immobilization Monitoring of vital signs Transport to the hospital Abdominal injuries Blow to the abdomen - observe for pain, tenderness, muscle tights, or rigidity What to do - place the victim in a comfortable position and expect vomiting check general condition – shock can develope do not give any food and drink seek medical attention Penetrating wound - expect internal organs to be damaged What to do - if the penetrating object is still in place, stabilize the object and control bleeding, seek medical attention do not try to remove the object Abdominal injuries Protruding abdominal organs - what to do Position - the victim with the head and shoulders slightly raised, and knees bent and raised Cover protruding organs with the (moist) sterile dressing or clean cloth Place towel lightly over the dressing to help maintain warmth Seek medical attention Do not try to reinsert protruding organs into the abdomen - you could introduce infection or damage the intestines Do not give anything to eat or drink Pelvic injuries If you suspect broken pelvis, press the sides of the pelvis gently downward and squeeze them inward at the iliac crests (upper point of the hips) - broken pelvis will be painful What to do Treat the victims shock Place padding between victims thighs, then tie the knees and ankles together Keep the victim on a firm surface - do not move the victim Seek medical attention Bone, joint and muscle injuries Fractures - closed fractures - skin is intact - open fractures - skin over the fracture is damaged or broken What to look for: D-O-T-S • Deformity – abnormal position • Open wound • Tenderness • Swelling Bone, joint and muscle injuries What to do: Determine what happened and the location of the injury Gently remove clothing covering the injured area Examine the area by looking and feeling for D-O-T-S Check – C-S-M - circulation, sensation, movement First aid: R-I-C-E procedures (rest, ice, compression, elevation) Use a splint to stabilize the fracture – 1 jount above and 1 joint under broken bone !!! Seek medical attention Bone, joint and muscle injuries Joint injuries - the most frequently affected are shoulders, elbows, fingers, hips, knees and ankles Signs and symptoms Deformity (main sign) Pain Swelling Bone, joint and muscle injuries What to do: • Check – C-S-M - circulation, sensation, movement • First aid: R-I-C-E procedures - rest, ice, compression, elevation • Use a splint to stabilize the joint in the position in which it was found • Do not try to put displaced parts into their normal position - nerve and blood vessel damage could result • Seek medical attention Poisoning Most often causes – ingestion - drugs, alcohol, or both of them, toxic food (mushrooms) or fluids inhalation - narcotics and carbon monoxide or other toxic gases intravenous, transcutaneous or intramuscular application of drugs in addict people Clinical sings - polymorphous - mostly altered mental status - altered vital functions - Convulsions Poisoning Evaluation of vital functions – examine ABCs followed by history + physical examination. History is of primary importance, but at altered mental status may be difficult Obtain as much information as possible from the patient, from the family and from anyone else who was at the scene. Poisoning The most important questions What poison is involved? How much was taken? By what route was the poison taken (e.g. by mouth, iv., i.m., skin exposure)? When was it taken? What else was taken with it? (combination of drugs and ethanol) Poisoning Besides vital functions are regularly examined, observe: Pupillary size - mydriasis - (atropine, cocaine, ethanol), - miosis (opiates, organophosphates and barbiturates) Oral examination - the odour of the breath is diagnostic clue hydration (opiates, atropine vs. organophosphates, strychnine) Examination of the skin - marks of i.v. drugs use, cyanosis, red skin colour (due to cyanide or carbon monoxide) dry skin (atropine, anticholinergics drugs) Poisoning Call for help and transport the patient to the hospital Monitor vital function during the transport - ABCs Bring with the patient to hospital all drugs, empty blisters and boxes of the drugs that are present at the scene. Provoke vomiting in co-operative person Don't give any fluids and do not provoke the vomiting in people with altered state of consciousness. Poisoning - specific antidotes Specific poisonings antidotes: Ethyleneglycol alcohol Methylalcohol alcohol Alkali juice or vinegar or lemon Acid milk ? Be careful !!! Children suffocation disease Croup: laryngotracheobronchitis - age 1-3 years - barking cough - intercostal retractions Epiglottitis - age 3-7 years, sore throat - air hunger - anxiety - sitting position, hyperextended head - swallow problems, salivation Children suffocation disease Large airways obstruction Inspiratory stridor Soft tisues af the neck and chest (intercostal) retractions Noisy breathing Hoarseness “Cock“ voice Children suffocation disease What to do Very urgent life-threatening disease !!! Death from suffocation can develop within tens of minutes or several hours from normal healthy status !!! Organize transfer to the hospital (emergency, anaesthesiology, ICU) as soon as possible by prehospital emergency services !!! Children suffocation disease What to do Before transfer: Could weather can help Take the child outside Aply cold compress on the neck (Prieznitz) Assure inhalation of air with high humidity Chest pain Several causes Always think about heart attack first Medical care at the onset of a heart attack is vital to survive Seek medical atention immediatelly Heart attack Signs and symptoms Uncomfortable pressure Squeezing or pain in the center of the chest lasting more than a few minutes or going away and coming back Pain spreading to the shoulders, neck or arms Chest discomfort, nausea, shortness of breath Not always typical signs Heart attack What to do Call emergency medical servis or get to the nearest hospital The least painful position (sittin with legs up and bent at the knees) Give Nitroglycerin tablets or spray (dilates coronary arteries) – Caution: possible hypotension Avoid Nitroglycerin application if patient used VIAGRA within last 48 hours If unresponsive victim – check ABC and start CPR Stroke (Brain attack) Blood vessels rupture – bleeding or blood vessels plugged Nerve cells dies within minutes Transient attack – closely associated with strokes short duration from minutes to several hours (mini- strokes) serious warning sign of a potential stroke Stroke (Brain attack) What to look for Weakness, paralysis Decreased vision Speaking or understanding problems Dizziness or loss of ballance Severe headache Differentiate pupils from “Pupils equal and reactive for light“ Stroke (Brain attack) What to do If victim unresponsive – ABC Call emergency medical servis If breathing – recovery position Supine position with slightly elevated head and shoulders ( neutral position) Do not give anything to drink and eat (restricted swallowing, throat paralysis, tendency to vomit…) Diabetic emergencies Diabetes mellitus (DM) Definition: condition, in which insulin is either lacking or inefective. Insulin = a hormon produced by pancreas. Role of insulin: helps the body to use energy from food. It takes sugar from the blood and carries it into cells to be used. In Diabetes: No insulin sugar remains in the blood body cells must rely on fat as fuel. Blood sugar is a major body fuel. Diabetic emergencies If blood sugar cannot be used in cells: blood sugar level increases overflows into the urine increased urine production Dehydration Loss of unused important source of fuel Diabetes mellitus will develop Diabetic emergencies 2 types of DM Type I (juvenile-onset) = insulin dependent External insulin is required to allow sugar to pass from the blood into cells Type II. (adult - onset) = insulin-non-dependent Not dependent on external insulin If insulin level is low known problems as discussed above Diabetic emergencies The body is continuously balancing sugar and insulin. Much insulin + not enough sugar low blood sugar (insulin shock) Much sugar + not enough insulin high blood sugar (diabetic coma) Both low and high blood sugar = life threatening situation ( coma) Diabetic emergencies Low blood sugar = hypoglycemia Causes: • • • • • delayed food long fasting exercise alcohol combination Diabetic emergencies Low blood sugar = hypoglycemia Signs: • • • • • • • • sudden onset poor coordination anger, bad temper pale colour confusion, desorientation sudden hunger excessive sweating unconsciousness – hypoglycemic coma Diabetic emergencies Low blood sugar = hypoglycemia What to do: • give sugar or sweet juice or glucose tablets if patient is awake • if no efect, repeat it • seek immediate medical attention • provide ABCs Diabetic emergencies High blood sugar = hyperglycemia Causes: • inactivity • • • • • • insuficient insulin forgotten application of insulin before eating overeating (inadequate ingurgitation of food) illness stress combination Diabetic emergencies High blood sugar = hyperglycemia Signs • • • • • • • • • gradual onset drowsiness extreme thirst frequent urination of high volume flushed skin vomiting fruity breath odor haevy deep breathing unconsciousness - coma Diabetic emergencies High blood sugar = hyperglycemia What to do: • If you are not sure whether victim has high or low blood sugar, give the person food or drink with sugar • If you do not see improvement, seek medical care Or: • Check blood sugar by glucometer • Help the patient to apply insulin in case of high blood sugar Emergencies during pregnancy Try to remain calm and considerate of the mother during stressful situation What to look for? • • • • • • • vaginal bleeding cramps in lower abdomen swelling of the face or fingers severe continuous headache dizziness or fainting uncontrolled vomiting baby Emergencies during pregnancy What to do • keep quiet • place sanitary napkin or any sterile or clean pad over the opening of vagina • replace bload-soaked pads and save them together with all tisues that are passed • arrange immediate transfere to a medical facility • place a woman partly on her left side in case of discomfort, collaps, dizziness, faint or try to shift pregnant abdomen gently to the patient´s left side (release the pressure on the vena cava inferior-increased venous return to the heart) Emergencies during pregnancy What to do during bustling (fast) delivery • • • • • • • • • try to be quiet try to co-operate with delivering lady protect the baby´s head if child is delivered, place him between mother´s thighs and cover him with dry blanket congratulate to the mother thank her for her co-operation wait for the end of funis (umbilical cord) pulsation close it by tape seek medical attention Acute psychic (mental) disorders • • • • • • • • • psychiatric disease alcohol intoxication opioid intoxication (heroin) marihuana intoxications – overdose (joints) intoxications by stimulationg drugs (extasis) organic diluents (toluen) cocain overdose (crack) haluconogens (LSD, crystal joints…) rarely mental disorders in lactation but change of behaviour can be caused also by: •lack of oxygen - hypoxemia •rescuer’s personality and look •development of shock state •head injury •cervical spine injury Acute psychic (mental) disorders What to do • • • • • • very difficult situation risk of auto and heteroagresivity risk of suicidal attemts calm, trustful approach needed patience to listen to the patient direct isntructions to undergo the therapy … • use of physical limitations – delicate situation – only in cases with risk of autoagressivity and risk of exposure of the patient or his neighbourhood • seek emergency medical services to secure safe transfer to the hospital Animal bites What to do • dogs – similar to other injuries – often face, extremities, risk of bleeding • snakes – toxins -neurotoxins -cardiotoxins -clotting disorders -cytotoxic and hydrolytic effect not all snake bite has toxic risks (rat snake) First aid: • calm down the patient • immobilisation of extremity • not invasive therapeutic procedures • shock therapy • ABC • immediate transfer to the hospital Animal bites What to do • spiders – danger very rarely – arachnophobia toxins – neurotoxic therapy as snakes • scorpions – very painful bite - rarely very high toxicity - vegetative neurotoxicity therapy as snakes • insects – most danger is hornet (yellow jacket) bee – 100 bites = lethal dosis pain, swelling, alergic reactions therapy – cooling, antiallergic therapy neck bites – swelling, airways obstruction ABC Web-side address: http://www.lfp.cuni.cz Study Actual study information Study information, sekce Medical studies in English