First Aid for Soldiers FM 21-11

FM 21-11 First Aid for Soldiers: Chapter 3

First Aid for Special Wounds

Headquarters, Department of the Army, Washington, D.C., October 27, 1988

INTRODUCTION
*Basic lifesaving steps are discussed in Chapters 1 and 2: clear the airway/restore the breathing, stop the bleeding, protect the wound, and treat/prevent shock. They apply to first aid measures for all injuries. Certain types of wounds and burns will require special precautions and procedures when applying these measures. This chapter discusses first aid procedures for special wounds of the head, face, and neck; chest and stomach wounds; and burns. It also discusses the techniques for applying dressings and bandages to specific parts of the body.

Section I. GIVE PROPER FIRST AID FOR HEAD INJURIES

3-1. Head Injuries

A head injury may consist of one or a combination of the following conditions: a concussion, a cut or bruise of the scalp, or a fracture of the skull with injury to the brain and the blood vessels of the scalp. The damage can range from a minor cut on the scalp to a severe brain injury which rapidly causes death. Most head injuries lie somewhere between the two extremes. Usually, serious skull fractures and brain injuries occur together; however, it is possible to receive a serious brain injury without a skull fracture. The brain is a very delicate organ; when it is injured, the casualty may vomit, become sleepy, suffer paralysis, or lose consciousness and slip into a coma. All severe head injuries are potentially life-threatening. For recovery and return to normal function, casualties require proper first aid as a vital first step.

3-2. Signs/Symptoms (081-831-1000)

A head injury may be open or closed. In open injuries, there is a visible wound and, at times, the brain may actually be seen. In closed injuries, no visible injury is seen, but the casualty may experience the same signs and symptoms. Either closed or open head injuries can be life-threatening if the injury has been severe enough; thus, if you suspect a head injury, evaluate the casualty for the following:

3-3. General First Aid Measures (081-831-1000)

• Treat as a suspected neck/spinal injury until proven otherwise. (See Chapter 4 for more information.)

• Place a dressing over the wounded area. DO NOT attempt to clean the wound.

• Keep the casualty warm.

• DO NOT attempt to remove a protruding object from the head.

• DO NOT give the casualty anything to eat or drink.

(3) Spinal injury. A person that has an injury above the collar bone or a head injury resulting in an unconscious state should be suspected of having a neck or head injury with spinal cord damage. Spinal cord injury may be indicated by a lack of responses to stimuli, stomach distention (enlargement), or penile erection.

(a) Lack of responses to stimuli. Starting with the feet, use a sharp pointed object--a sharp stick or something similar, and prick the casualty lightly while observing his face. If the casualty blinks or frowns, this indicates that he has feeling and may not have an injury to the spinal cord. If you observe no response in the casualty's reflexes after pricking upwards toward the chest region, you must use extreme caution and treat the casualty for an injured spinal cord.

(b) Stomach distention (enlargement). Observe the casualty's chest and stomach. If the stomach is distended (enlarged) when the casualty takes a breath and the chest moves slightly, the casualty may have a spinal injury and must be treated accordingly.

(c) Penile erection. A male casualty may have a penile erection, an indication of a spinal injury.

CAUTION

Remember to suspect any casualty who has a severe head injury or who is
unconscious as possibly having a broken neck or a spinal cord injury! It is better to
treat conservatively and assume that the neck/spinal cord is injured rather than to
chance further injuring the casualty. Consider this when you position the casualty. See
Chapter 4, paragraph 4-9 for treatment procedures of spinal column injuries.

c. Concussion. If an individual receives a heavy blow to the head or face, he may suffer a brain concussion, which is an injury to the brain that involves a temporary loss of some or all of the brain's ability to function. For example, the casualty may not breathe properly for a short period of time, or he may become confused and stagger when he attempts to walk. A concussion may only last for a short period of time. However,if a casualty is suspected of having suffered a concussion, he must be seen by a physician as soon as conditions permit.

d. Convulsions. Convulsions (seizures/involuntary jerking) may occur after a mild head injury. When a casualty is convulsing, protect him from hurting himself. Take the following measures:

(1) Ease him to the ground.

(2) Support his head and neck.

(3) Maintain his airway.

(4) Call for assistance.

(5) Treat the casualty's wounds and evacuate him immediately.

e. Brain Damage. In severe head injuries where brain tissue is protruding, leave the wound alone; carefully place a first aid dressing over the tissue. DO NOT remove or disturb any foreign matter that may be in the wound. Position the casualty so that his head is higher than his body. Keep him warm and seek medical aid immediately.

NOTE

• DO NOT forcefully hold the arms and legs if they are jerking because this can lead to broken bones.

• DO NOT force anything between the casualty's teeth--especially if they are tightly clenched because this may obstruct the casualty's airway.

• Maintain the casualty's airway if necessary.

3-4. Dressings and Bandages (081-831-1000 and 081-831-1033)

WARNING

DO NOT attempt to clean the wound, or remove a protruding object.

NOTE

If there is an object extending from the wound DO NOT remove the object. Improvise
bulky dressings from the cleanest material available and place these dressings around the
protruding object for support after applying the field dressing.

NOTE

Always use the casualty's field dressing, not your own!

(1) Remove the dressing from the wrapper.

(2) Grasp the tails of the dressing in both hands.

(1) Remove the dressing from the wrapper.

(2) Grasp the tails of the dressing in both hands.

(5) Hold it in place with one hand. If the casualty is able, he may assist.

WARNING

(Make sure the tails remain wide and close to the front of the chin to avoid choking the
casualty.)

g. Apply a Triangular Bandage to the Head. To apply a triangular bandage to the head--

(1) Turn the base (longest side) of the bandage up and center its base on center of the forehead, letting the point (apex) fall on the back of the neck (Figure 3-10 A).

(2) Take the ends behind the head and cross the ends over the apex.

(3) Take them over the forehead and tie them (Figure 3-10 B).

(4) Tuck the apex behind the crossed part of the bandage and/or secure it with a safety pin, if available (Figure 3-10 C).

h. Apply a Cravat Bandage to the Head. To apply a cravat bandage to the head--

(1) Place the middle of the bandage over the dressing (Figure 3-11 A).

(2) Cross the two ends of the bandage in opposite directions completely around the head (Figure 3-11 B).

(3) Tie the ends over the dressing (Figure 3-11 C).

Section II. GIVE PROPER FIRST AID FOR FACE AND NECK INJURIES

3-5. Face Injuries

Soft tissue injuries of the face and scalp are common. Abrasions (scrapes) of the skin cause no serious problems. Contusions (injury without a break in the skin) usually cause swelling. A contusion of the scalp looks and feels like a lump. Laceration (cut) and avulsion (torn away tissue) injuries are also common. Avulsions are frequently caused when a sharp blow separates the scalp from the skull beneath it. Because the face and scalp are richly supplied with blood vessels (arteries and veins), wounds of these areas usually bleed heavily.

3-6. Neck Injuries

Neck injuries may result in heavy bleeding. Apply manual pressure above and below the injury and attempt to control the bleeding. Apply a dressing. Always evaluate the casualty for a possible neck fracture/spinal cord injury; if suspected, seek medical treatment immediately.

*NOTE

Establish and maintain the airway in cases of facial or neck injuries. If a neck fracture or
spinal cord injury is suspected, immobilize or stabilize casualty. See Chapter 4 for further information on treatment of spinal injuries.

3-7. Procedure

When a casualty has a face or neck injury, perform the measures below.

a. Step ONE. Clear the airway. Be prepared to perform any of the basic lifesaving steps. Clear the casualty's airway (mouth) with your fingers, remove any blood, mucus, pieces of broken teeth or bone, or bits of flesh, as well as any dentures.

b. Step TWO. Control any bleeding, especially bleeding that obstructs the airway. Do this by applying direct pressure over a first aid dressing or by applying pressure at specific pressure points on the face, scalp, or temple. (See Appendix E for further information on pressure points.) If the casualty is bleeding from the mouth, position him as indicated (c below) and apply manual pressure.

CAUTION

Take care not to apply too much pressure to the scalp if a skull fracture is suspected.

c. Step THREE. Position the casualty. If the casualty is bleeding from the mouth (or has other drainage, such as mucus, vomitus, or so forth) and is conscious, place him in a comfortable sitting position and have him lean forward with his head tilted slightly down to permit free drainage (Figure 3-12). DO NOT use the sitting position if--

• It would be harmful to the casualty because of other injuries.

• The casualty is unconscious, in which case, place him on his side (Figure 3-13). If there is a suspected injury to the neck or spine immobilize the head before turning the casualty on his side.

CAUTION

If you suspect the casualty has a neck/spinal injury, then immobilize his head/neck and
treat him as outlined in Chapter 4.

d. Step FOUR. Perform other measures.

(1) Apply dressings/bandages to specific areas of the face.

(2) Check for missing teeth and pieces of tissue. Check for detached teeth in the airway. Place detached teeth, pieces of ear or nose on a field dressing and send them along with the casualty to the medical facility. Detached teeth should be kept damp.

(3) Treat for shock and seek medical treatment IMMEDIATELY.

3-8. Dressings and Bandages (081-831-1033)

a. Eye Injuries. The eye is a vital sensory organ, and blindness is a severe physical handicap. Timely first aid of the eye not only relieves pain but also helps prevent shock, permanent eye injury, and possible loss of vision. Because the eye is very sensitive, any injury can be easily aggravated if it is improperly handled. Injuries of the eye may be quite severe. Cuts of the eyelids can appear to be very serious, but if the eyeball is not involved, a person's vision usually will not be damaged. However, lacerations (cuts) of the eyeball can cause permanent damage or loss of sight.

(1) Lacerated/torn eyelids. Lacerated eyelids may bleed heavily, but bleeding usually stops quickly. Cover the injured eye with a sterile dressing. DO NOT put pressure on the wound because you may injure the eyeball. Handle torn eyelids very carefully to prevent further injury. Place any detached pieces of the eyelid on a clean bandage or dressing and immediately send them with the casualty to the medical facility.

(2) Lacerated eyeball (injury to the globe). Lacerations or cuts to the eyeball may cause serious and permanent eye damage. Cover the injury with a loose sterile dressing. DO NOT put pressure on the eyeball because additional damage may occur. An important point to remember is that when one eyeball is injured, you should immobilize both eyes. This is done by applying a bandage to both eyes. Because the eyes move together, covering both will lessen the chances of further damage to the injured eye.

CAUTION

DO NOT apply pressure when there is a possible laceration of the eyeball. The eyeball contains fluid. Pressure applied over the eye will force the fluid out, resulting in
permanent injury. APPLY PROTECTIVE DRESSING WITHOUT ADDED
PRESSURE.

(3) Extruded eyeballs. Soldiers may encounter casualties with severe eye injuries that include an extruded eyeball (eyeball out-of-socket). In such instances you should gently cover the extruded eye with a loose moistened dressing and also cover the unaffected eye. DO NOT bind or exert pressure on the injured eye while applying a loose dressing Keep the casualty quiet, place him on his back, treat for shock (make warm and comfortable), and evacuate him immediately.

(4) Burns of the eyes. Chemical burns, thermal (heat) burns, and light burns can affect the eyes.

(a) Chemical burns. Injuries from chemical burns require immediate first aid. Chemical burns are caused mainly by acids or alkalies. The first aid is to flush the eye(s) immediately with large amounts of water for at least 5 to 20 minutes, or as long as necessary to flush out the chemical. If the burn is an acid burn you should flush the eye for at least 5 to 10 minutes. If the burn is an alkali burn, you should flush the eye for at least 20 minutes. After the eye has been flushed apply a bandage over the eyes and evacuate the casualty immediately.

(b) Thermal burns. When an individual suffers burns of the face from a fire, the eyes will close quickly due to extreme heat. This reaction is a natural reflex to protect the eyeballs; however, the eyelids remain exposed and are frequently burned. If a casualty receives burns of the eyelids/face, DO NOT apply a dressing; DO NOT TOUCH; seek medical treatment immediately.

(c) Light burns. Exposure to intense light can burn an individual. Infrared rays, eclipse light (if the casualty has looked directly at the sun), or laser burns cause injuries of the exposed eyeball. Ultraviolet rays from arc welding can cause a superficial burn to the surface of the eye. These injuries are generally not painful but may cause permanent damage to the eyes. Immediate first aid is usually not required. Loosely bandaging the eyes may make the casualty more comfortable and protect his eyes from further injury caused by exposure to other bright lights or sunlight.

CAUTION

In certain instances both eyes are usually bandaged; but, in hazardous surroundings
leave the uninjured eye uncovered so that the casualty may be able to see.

b. Side-of-Head or Cheek Wound (081-831-1033).

Facial injuries to the side of the head or the cheek may bleed profusely (Figure 3-14). Prompt action is necessary to ensure that the airway remains open and also to control the bleeding. It may be necessary to apply a dressing. To apply a dressing--

(1) Remove the dressing from its wrapper.

(2) Grasp the tails in both hands.

NOTE

When possible, avoid covering the casualty's ear with the dressing, as this will decrease
his ability to hear.

c. Ear Injuries. Lacerated (cut) or avulsed (torn) ear tissue may not, in itself, be a serious injury. Bleeding, or the drainage of fluids from the ear canal, however, may be a sign of a head injury, such as a skull fracture. DO NOT attempt to stop the flow from the inner ear canal nor put anything into the ear canal to block it. Instead, you should cover the ear lightly with a dressing. For minor cuts or wounds to the external ear apply a cravat bandage as follows:

(1) Place the middle of the bandage over the ear (Figure 3-19 A).

(2) Cross the ends, wrap them in opposite directions around the head, and tie them (Figures 3-19 B and 3-19 C).

(3) If possible, place some dressing material between the back of the ear and the side of the head to avoid crushing the ear against the head with the bandage.

d. Nose Injuries. Nose injuries generally produce bleeding. The bleeding may be controlled by placing an ice pack over the nose, or pinching the nostrils together. The bleeding may also be controlled by placing torn gauze (rolled) between the upper teeth and the lip.

CAUTION

DO NOT attempt to remove objects inhaled in the nose. An untrained person who
removes such an object could worsen the casualty's condition and cause permanent
injury.

e. Jaw Injuries. Before applying a bandage to a casualty's jaw, remove all foreign material from the casualty's mouth. If the casualty is unconscious, check for obstructions in the airway. When applying the bandage, allow the jaw enough freedom to permit passage of air and drainage from the mouth.

(1) Apply bandages attached to field first aid dressing to the jaw. After dressing the wound, apply the bandages using the same technique illustrated in Figures 3-5, 3-6, 3-7, and 3-8.

NOTE

The dressing and bandaging procedure outlined for the jaw serves a twofold purpose.
In addition to stopping the bleeding and protecting the wound, it also immobilizes a
fractured jaw.

(2) Apply a cravat bandage to the jaw.

(a) Place the bandage under the chin and carry its ends upward. Adjust the bandage to make one end longer than the other (Figure 3-20 A).

(b) Take the longer end over the top of the head to meet the short end at the temple and cross the ends over (Figure 3-20 B).

(c) Take the ends in opposite directions to the other side of the head and tie them over the part of the bandage that was applied first (Figure 3-20 C).

NOTE

The cravat bandage technique is used to immobilize a fractured jaw or to maintain a
sterile dressing that does not have tail bandages attached.

Section III. GIVE PROPER FIRST AID FOR CHEST AND ABDOMINAL WOUNDS AND BURN INJURIES

3-9. Chest Wounds (081-831-1026)

Chest injuries may be caused by accidents, bullet or missile wounds, stab wounds, or falls. These injuries can be serious and may cause death quickly if proper treatment is not given. A casualty with a chest injury may complain of pain in the chest or shoulder area; he may have difficulty with his breathing. His chest may not rise normally when he breathes. The injury may cause the casualty to cough up blood and to have a rapid or a weak heartbeat. A casualty with an open chest wound has a punctured chest wall. The sucking sound heard when he breathes is caused by air leaking into his chest cavity. This particular type of wound is dangerous and will collapse the injured lung (Figure 3-21). Breathing becomes difficult for the casualty because the wound is open. The soldier's life may depend upon how quickly you make the wound airtight.

3-10. Chest Wound(s) Procedure (081-831-1026)

NOTE

Examine the casualty to see if there is an entry and/or exit wound. If there are two
wounds (entry, exit), perform the same procedure for both wounds. Treat the more
serious (heavier bleeding, larger) wound first. It may be necessary to improvise a
dressing for the second wound by using strips of cloth, such as a torn T-shirt, or
whatever material is available. Also, listen for sucking sounds to determine if the chest
wall is punctured.

CAUTION

If there is an object extending from (impaled in) the wound, DO NOT remove the
object. Apply a dressing around the object and use additional improvised bulky
materials/dressings (use the cleanest materials available) to build up the area around the
object. Apply a supporting bandage over the bulky materials to hold them in place.

c. Open the Casualty's Field Dressing Plastic Wrapper. The plastic wrapper is used with the field dressing to create an airtight seal. If a plastic wrapper is not available, or if an additional wound needs to be treated; cellophane, foil, the casualty's poncho, or similar material may be used. The covering should be wide enough to extend 2 inches or more beyond the edges of the wound in all directions.

(1) Tear open one end of the casualty's plastic wrapper covering the field dressing. Be careful not to destroy the wrapper and DO NOT touch the inside of the wrapper.

(2) Remove the inner packet (field dressing).

(3) Complete tearing open the empty plastic wrapper using as much of the wrapper as possible to create a flat surface.

e. Apply the Dressing to the Wound (081-831-1026).

(1) Use your free hand and shake open the field dressing (Figure 3-23).

g. Seek Medical Aid. Contact medical personnel.

*WARNING

Even if an airtight dressing has been placed properly, air may still enter the chest cavity without having means to escape. This causes a life-threatening condition called tension pneumothorax. If the casualty's condition (for example, difficulty breathing, shortness of breath, restlessness, or grayness of skin in a dark-skinned individual [or blueness in an individual with light skin]) worsens after placing the dressing, quickly lift or remove, then replace the airtight dressing.

3-11. Abdominal Wounds

The most serious abdominal wound is one in which an object penetrates the abdominal wall and pierces internal organs or large blood vessels. In these instances, bleeding may be severe and death can occur rapidly.

3-12. Abdominal Wound(s) Procedure (081-831-1025)

a. Evaluate the Casualty. Be prepared to perform basic lifesaving measures. It is necessary to check for both entry and exit wounds. If there are two wounds (entry and exit), treat the wound that appears more serious first (for example, the heavier bleeding, protruding organs, larger wound, and so forth). It may be necessary to improvise dressings for the second wound by using strips of cloth, a T-shirt, or the cleanest material available.

WARNING

If there is an object extending from the wound, DO NOT remove it. Place as much of
the wrapper over the wound as possible without dislodging or moving the object. DO
NOT place the wrapper over the object.

(1) Grasp the tails in both hands.

e. Seek Medical Aid. Notify medical personnel.

Burns often cause extreme pain, scarring, or even death. Proper treatment will minimize further injury of the burned area. Before administering the proper first aid, you must be able to recognize the type of burn to be treated. There are four types of burns: (1) thermal burns caused by fire, hot objects, hot liquids, and gases or by nuclear blast or fire ball; (2) electrical burns caused by electrical wires, current, or lightning; (3) chemical burns caused by contact with wet or dry chemicals or white phosphorus (WP)--from marking rounds and grenades; and (4) laser burns.

3-14. First Aid for Burns (031-31-1007)

CAUTION

Synthetic materials, such as nylon, may melt and cause further injury.

WARNING

High voltage electrical burns may cause temporary unconsciousness, difficulties in
breathing, or difficulties with the heart (heartbeat).

WARNING

Small amounts of water applied to a dry chemical burn may cause a chemical reaction transforming the dry chemical into an active burning substance.

NOTE

After the casualty is removed from the source of the burn, he should be evaluated for conditions requiring basic lifesaving measures (Evaluate the Casualty).

b. Expose the Burn. Cut and gently lift away any clothing covering the burned area, without pulling clothing over the burns. Leave in place any clothing that is stuck to the burns. If the casualty's hands or wrists have been burned. remove jewelry if possible without causing further injury (rings, watches, and so forth) and place in his pockets. This prevents the necessity to cut off jewelry since swelling usually occurs as a result of a burn.

(1) Grasp the tails of the casualty's dressing in both hands.

(3) Hold the dressing in place with one hand and use the other hand to wrap one of the tails around the limbs or the body.

(4) Wrap the other tail in the opposite direction until the dressing is completely covered.

(5) Tie the tails into a knot over the outer edge of the dressing. The dressing should be applied lightly over the burn. Ensure that dressing is applied firmly enough to prevent it from slipping.

d. Take the Following Precautions (081-831-1007):

• DO NOT place the dressing over the face or genital area.

• For burns caused by wet or dry chemicals, flush the burns with large amounts of water and cover with a dry dressing.

• For laser burns, apply a field dressing.

• If the casualty is conscious and not nauseated, give him small amounts of water.

e. Seek Medical Aid. Notify medical personnel.

Section IV. APPLY PROPER BANDAGES TO UPPER AND LOWER EXTREMITIES

3-15. Shoulder Bandage

a. To apply bandages attached to the field first aid dressing--

(1) Take one bandage across the chest and the other across the back and under the arm opposite the injured shoulder.

(2) Tie the ends with a nonslip knot (Figure 3-35).

b. To apply a cravat bandage to the shoulder or armpit--

(1) Make an extended cravat bandage by using two triangular bandages (Figure 3-36 A); place the end of the first triangular bandage along the base of the second one (Figure 3-36 B).

(2) Fold the two bandages into a single extended bandage (Figure 3-36 C).

(3) Fold the extended bandage into a single cravat bandage (Figure 3-36 D). After folding, secure the thicker part (overlap) with two or more safety pins (Figure 3-36 E).

(4) Place the middle of the cravat bandage under the armpit so that the front end is longer than the back end and safety pins are on the outside (Figure 3-36 F).

(5) Cross the ends on top of the shoulder (Figure 3-36 G).

(6) Take one end across the back and under the arm on the opposite side and the other end across the chest. Tie the ends (Figure 3-36 H).

Be sure to place sufficient wadding in the armpit. DO NOT tie the cravat bandage too tightly. Avoid compressing the major blood vessels in the armpit.

3-16. Elbow Bandage

To apply a cravat bandage to the elbow--

a. Bend the arm at the elbow and place the middle of the cravat at the point of the elbow bringing the ends upward (Figure 3-37 A).

b. Bring the ends across, extending both downward (Figure 3-37 B).

c. Take both ends around the arm and tie them with a nonslip knot at the front of the elbow (Figure 3-37 C).

CAUTION

If an elbow fracture is suspected, DO NOT bend the elbow; bandage it in an extended position.

3-17. Hand Bandage

a. To apply a triangular bandage to the hand--

(1) Place the hand in the middle of the triangular bandage with the wrist at the base of the bandage (Figure 3-38 A). Ensure that the fingers are separated with absorbent material to prevent chafing and irritation of the skin.

(2) Place the apex over the fingers and tuck any excess material into the pleats on each side of the hand (Figure 3-38 B).

(3) Cross the ends on top of the hand, take them around the wrist, and tie them (Figures 3-38 C, D, and E) with a nonslip knot.

b. To apply a cravat bandage to the palm of the hand--

(1) Lay the middle of the cravat over the palm of the hand with the ends hanging down on each side (Figure 3-39 A).

(2) Take the end of the cravat at the little finger across the back of the hand, extending it upward over the base of the thumb; then bring it downward across the palm (Figure 3-39 B).

(3) Take the thumb and across the back of the hand, over the palm, and through the hollow between the thumb and palm (Figure 3-39 C).

(4) Take the ends to the back of the hand and cross them; then bring them up over the wrist and cross them again (Figure 3-39 D).

(5) Bring both ends down and tie them with a nonslip knot on top of the wrist (Figure 3-39 E and F).

3-18. Leg (Upper and Lower) Bandage

To apply a cravat bandage to the leg--

a. Place the center of the cravat over the dressing (Figure 3-40 A).

b. Take one end around and up the leg in a spiral motion and the other end around and down the leg in a spiral motion, overlapping part of each preceding turn (Figure 3-40 B).

c. Bring both ends together and tie them (Figure 3-40 C) with a nonslip knot.

3-19. Knee Bandage

To apply a cravat bandage to the knee as illustrated in Figure 3-41, use the same technique applied in bandaging the elbow. The same caution for the elbow also applies to the knee.

3-20. Foot Bandage

To apply a triangular bandage to the foot--

a. Place the foot in the middle of the triangular bandage with the heel well forward of the base (Figure 3-42 A). Ensure that the toes are separated with absorbent material to prevent chafing and irritation of the skin.

b. Place the apex over the top of the foot and tuck any excess material into the pleats on each side of the foot (Figure 3-42 B).

c. Cross the ends on top of the foot, take them around the ankle, and tie them at the front of the ankle (Figure 3-42 C, D, and E).