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Then pull up the chin. Stretch the other arm out as pictured. The subsequent treatment of an unconscious person is described in 6. Quickly check the carotid neck pulse by placing the tips of the two fingers of one hand into the groove between the windpipe and the large muscle at the side of the neck.

The carotid pulse normally is a strong one; if it cannot be felt or is feeble, there is insufficient circulation. Spontaneous breathing may occur as a result of this simple measure. Place the patient in a face-up position on a hard surface. Put one hand beneath the patient's neck and the other hand on the forehead.

Lift the neck with the one hand, and apply pressure to the forehead with the other to tilt the head backward. This extends the neck and moves the base of the tongue away from 10 the back of the throat. The head should be maintained in this position during the entire artificial respiration and heart compression procedure. If only one rescuer is available the head should be fixed in the shown position by means of a rolled blanket or similar object pushed under the patient's shoulders. If the airway is still obstructed any foreign material in the mouth or throat should be removed immediately with the fingers.

Breathing If the patient does not resume adequate, spontaneous breathing promptly after his head has been tilted backward; the mouth-to-mouth or mouth-to-nose method or other techniques should give artificial respiration.

Regardless of the method used, preservation of an open airway is essential. Pinch together the patient's nostrils with the thumb and index finger to prevent air from escaping. Continue to exert pressure on the forehead with the palm of the hand to maintain the backward tilt of the head. Then continue the procedure. If adequate respiration is taking place, the chest should rise and fall.

If in the right position, the patient's exhalation will be felt on your cheek. Repeat this procedure 10 to 12 times a minute, once every 5 seconds, for adults and children over 4 years. A foreign body should be suspected if you are unable to inflate the lungs, despite proper positioning and a tight air-seal around the mouth or nose.

Use the other hand to lift up the patient's lower jaw to seal the lips. Repeat quickly 4 times. Alternative method of artificial respiration Silvester method In some instances, mouth-to-mouth respiration cannot be used.

For instance, certain toxic and caustic materials present a hazard to the rescuer. The mouth-to-mouth method should be avoided if the casualty has corrosive burns around his mouth or if he has ingested or inhaled any toxic substance, but especially one of the following: Cyanide Tables and Hydrogen sulphide Table Hydrocarbons Table Petroleum and petroleum products Table Chlorinated hydrocarbons Table This section describes an effective alternative method of artificial respiration, the Silvester technique.

However, this method is much less effective than those previously described, and it should only be used when "mouth-to-mouth" technique cannot be used. Raise his shoulders on a cushion, folded jacket or in some other way.

Head fully back. Shoulders raised on clothing etc. If necessary, turn his head to one side to clear out the mouth. Grasp his wrists, cross them over the lower part of his chest. Release the pressure and, with a sweeping movement, draw the patient's arms backwards and outwards as far as possible.

Repeat this procedure rhythmically 12 times per minute. Keep the mouth clear. Artificial respiration should be continued for 2 hours if necessary; longer if there are signs of life. Unless circulation is restored the brain will be without oxygen and the person will suffer cerebral damage within 4 to 6 minutes, and may die.

Artificial respiration will bring oxygen-containing air to the lungs of the victim. From there, oxygen is transported with circulating blood to the brain and to other organs, and the effective heart compression will - for some time - artificially restore the blood circulation, until the heart starts beating.

For this reason, artificial respiration is always required whenever heart compression is used. Effective heart compression requires sufficient pressure to depress the patient's lower sternum about 4 to 5 cm in an adult. For heart compression to be effective, the patient must be on a firm surface. If he is in bed, a board or improvised support should be placed under his back. However, chest compression must not be delayed to look for a firmer support. Kneel close to the side of the patient and place only the heel of one hand over the lower half of the sternum.

Avoid placing the hand over the tip of the breastbone xiphoid process which extends down over the upper abdomen. Pressure on the xiphoid process may tear the liver and lead to severe internal bleeding. Feel the tip of the sternum and place the heel or the hand about 4 cm towards the head of the patient. Your fingers must never rest on the patient's ribs during compression. This increases the possibility of rib fractures. Depress the sternum 60 times per minute for an adult when two rescuers are used.

This is usually rapid enough to maintain blood flow, and slow enough to allow the heart to fill with blood. The compression should be regular, smooth, and uninterrupted, with compression and relaxation being of equal duration. Under no circumstances should compression be interrupted for more than 5 seconds. Circulation a. The most effective artificial respiration and heart compression are achieved by giving one lung inflation quickly after each five-heart compressions 5 : 1 ratio.

The compression rate should be 60 per minute for two rescuers. One rescuer performs heart compression while the other remains at the patient's head, keeps it tilted back, and continues rescue breathing artificial respiration. Supplying the breaths without any pauses in heart compression is important, because every interruption in this compression results in a drop of blood flow and blood pressure to zero.

Single rescuer A single rescuer must perform both artificial respiration and artificial circulation using a 2 ratio. The head should be kept in the shown position by means of a rolled blanket or similar object pushed under the patient's shoulders. Two very quick lung inflations should be delivered after each chest compression, without waiting for full exhalation of the patient's breath. A rate equivalent to 80 chest compressions per minute must be maintained by a single rescuer in 19 order to achieve 50 to 60 actual compressions per minute because of the interruptions for the lung inflations.

Checking effectiveness of heart compression: pupils and pulse Check the reaction of the pupils: a pupil that narrows when exposed to light indicates that the brain is receiving adequate oxygen and blood. If the pupils remain widely dilated and do not react to light, serious brain damage is likely to occur soon or has occurred already.

Dilated but reactive pupils are a less serious sign. The carotid neck pulse should be felt after the first minute of the heart compression and artificial respiration, and every 5 minutes thereafter.

The pulse will indicate the effectiveness of the heart compression or the return of a spontaneous effective heartbeat see 5. Terminating heart compression Deep unconsciousness, the absence of spontaneous respiration, and fixed, dilated pupils for 15 to 30 minutes indicate cerebral death of the patient, and further efforts to restore circulation and breathing are usually futile.

Place patient on his back on a hard surface. Step 1 Airway If patient is unconscious, open the airway; thereafter make sure it stays open. Step 2 Breathing If patient is not breathing, begin artificial respiration; mouth-tomouth or mouth-to-nose respiration. It should be felt again after the first minute of artificial respiration and checked every 5 minutes thereafter. If it does not, check to make sure the patient's head is tilted as far back as possible.

If necessary, use fingers to clear airway. Step 3 Circulation If pulse is absent, begin heart compression. If possible, use two rescuers. Don't delay. One rescuer can do the job.

Pupils or eyes should be checked during heart compression. A pupil that constricts on exposure to light shows that the brain is getting adequate blood and oxygen, 5. The function of the airway is to ensure a clear passage between the lips and the back of the throat. Then, with the head fully back, slide the airway gently into the mouth with the outer curve of the airway towards the tongue.

This operation will be easier if the airway is wetted. If there is any attempt by the patient to gag, retch or vomit, it is better not to proceed with the insertion of the airway. If necessary, try again later to insert it. Head tilted right back 22 Continue to slide the airway in until the flange of the airway reaches the lips. If necessary tape one or both lips so that the end of the airway is not covered by them. Continue to keep the jaws upward and the head fully back so that the airway will be held in place by the teeth or gums and by its shape.

As the patient regains consciousness, he will spit out the airway. He should remain in the unconscious position under constant observation until he is fully conscious. If he relapses into unconsciousness it may be necessary to reinsert the airway if breathing is still difficult. It is very important that a casualty who shows signs of pulmonary oedema should be placed in this position. It should be given only where specifically advised in this Guide or on the instruction of a doctor giving advice by radio.

This drug should be given with caution it there is shortness of breath. It depresses breathing activity if too much is given, or the casualty is sensitive to it. You may be advised by the doctor to give naloxone hydrochloride, which counteracts these side effects of morphine. It has many causes other than those arising from chemical poisoning. Later it may become slow and stop.

Unconsciousness may follow this. If they become large and do not react to light, life is in danger. If the patient becomes increasingly breathless, finds difficulty in lying flat, and coughs up a lot of frothy sputum, he may be beginning to suffer from pulmonary oedema see 6. Apart from immediate asphyxia, this is the most serious and dangerous complication of many types of poisoning. The patient may develop pulmonary oedema at any time up to 48 hours after the initial poisoning. However, the patient may recover but then begins to feel unwell again.

Give oxygen continuously see 8. Give furosemide frusemide 80 mg by mouth at once. If there is no improvement after 30 minutes, give a further 40 mg by mouth. This is a serious condition, and every effort should be made to get medical help on board, or transfer the patient to hospital if there is no rapid improvement in the symptoms and signs after treatment or if unconsciousness persists for more than a few minutes. Patients who have had pulmonary oedema should be kept in bed at rest for a minimum of 48 hours after they appear to be completely recovered, even if the illness has been slight.

If the sputum becomes green or yellow following an attack of pulmonary oedema, the patient may be developing bronchitis or pneumonia.

This should be treated as described see 6. There are two forms, acute i. In mild cases there is little fever, but in severe cases the temperature is raised to about In a day or two the cough becomes looser, phlegm sputum is coughed up; at first sticky, white and difficult to bring up, later greenish yellow, thicker and more copious.

The temperature begins to return to normal. The patient is usually well in about a week to ten days, but this period may often be shortened if antibiotic treatment is given. These symptoms distinguish bronchitis from pneumonia see 6. The absence of pain distinguishes bronchitis from pleurisy see 6.

General treatment The patient should be put to bed and placed in the nigh sitting-up position see 5. A container should be provided for the sputum, which should be inspected. Smoking should be discouraged. Specific treatment Give soluble aspirin mg every 4 hours by mouth.

This is sufficient treatment for milder cases with a temperature of up to If the temperature is higher than Note: If the patient has a known allergy to any of the penicillin group of drugs, of which ampicillin is one, give 2 co-trimoxazole tablets by mouth every 12 hours for 5 days.

Co-trimoxazole must not be given to a woman who is pregnant or might be pregnant. Subsequent management The patient should remain in bed until the temperature has been normal for 48 hours. Examination by a doctor should be arranged at the next port.

Chronic bronchitis This is usually found in men past middle age who are aware of the diagnosis. Exposure to dust, fumes and tobacco smoke predisposes to the development of chronic bronchitis. Sufferers usually have a cough of long standing. Superimposed on his chronic condition, a patient may also have an attack of acute bronchitis, for which treatment see 6. If this occurs, the temperature is usually raised and there is a sudden change from clear, sticky or watery sputum to thick yellow sputum.

Anyone with chronic bronchitis should seek medical advice on reaching his homeport. The onset may be rapid over a period of a few hours after inhalation or ingestion of a chemical. The onset may be delayed, however, for 2 or 3 days, or it may occur as a complication of bronchitis see 6. This may be localized to one side of the chest. The temperature is usually as high as Provide a beaker for sputum in order to examine its appearance.

Encourage the patient to drink because he will be losing a lot of fluid both from breathing quickly and from sweating. If this is not effective, give mg every 4 hours. Patients who have had pneumonia should be kept in bed until they are feeling better and their temperature, pulse and respiration are normal.

Increasing activity and deep breathing exercises help to get the lungs functioning normally after the illness. Patients who have had pneumonia should not be allowed back on duty until they have seen a doctor.

The condition is usually a complication of serious lung diseases such as pneumonia, but may follow inhalation of toxic gases or fumes. In a typical case arising during the course of pneumonia, the breathing movements rub the inflamed pleural surfaces together, causing severe chest pain which is usually felt in the armpit or breast 31 area. It is described as a stabbing or tearing pain which is made worse by breathing or coughing and relieved by preventing movement of the affected side.

Occasionally the hand placed over the site of pain can feel the rubbing. A doctor at the first opportunity, even if recovered, should see all cases of pleurisy. Pleural effusion fluid round the lungs In a few cases of pleurisy the inflammation causes fluid to accumulate between the pleural membranes at the base of a lung. This complication should be suspected if the patient remains ill but the chest pain becomes less and chest movement on the affected side is diminished in comparison with the unaffected side.

General treatment If pneumonia is present, treat as described in 6. Otherwise, confine the patient to bed. If there is difficulty in breathing, put the patient in the high sitting-up position see 5. This may be caused by either failure of the heart see 6. The symptoms and signs of this condition are described below. If it is not treated adequately, this may be a progressive and fatal condition.

It is important to recognize this condition, since it may initially be confused with fainting attacks syncope. Syncope is a temporary failure of the blood circulation due to fright, pain or a nervous shock and is seldom serious.

The signs and symptoms are very similar to those of a circulatory collapse. Note: Other causes of circulatory collapse, such as severe injuries and bleeding, should be excluded before a diagnosis of poisoning is made. With these measures, the patient will recover completely within a few minutes.

There are a number of chemicals, which affect the heart directly, but some may cause a lack of oxygen in the body, which results in the same effect. Heart failure may occur within a few hours of chemical poisoning and may be relatively rapid in onset. However, it may also develop gradually over a period of 24 to 48 hours. The patient may recover with treatment, but occasionally the heart failure may be persistent.

It should be remembered that a patient in the older age group might have a poor heart and already be under treatment. The breathing is usually rapid and shallow. If the heart failure is severe, or sudden in onset, pulmonary oedema may develop see 6.

See diagnosis and treatment of kidney failure in 6. Oedema is the name given to the presence of an abnormal collection of fluid in the tissue under the skin. Its presence can be confirmed by gently pressing the tip of one finger on to the affected part for 10 seconds.

When the finger is taken away 34 a dent will be seen in the skin. In heart failure, the swelling first appears in the feet and ankles and spreads up the legs. If the patient is in bed, the oedema will collect under the skin overlying the lower part of the spine. If the coma is very deep and lasts for a long while, it indicates a severe degree of poisoning.

Remember that there are many other causes for unconsciousness apart from poisons. The most immediate danger to life is from failure of, or obstruction to, breathing. If the degree of consciousness is lighter he may, however, stir or groan. Check for signs of asphyxia see 6. Pulmonary oedema see 6. Bronchitis and pneumonia see 6. Heart failure see 6. These should be treated in the appropriate way as described according to the diagnosis.

Keeping the air passage clear is essential, and requires the patient to be kept in the unconscious position. Unconscious patients must never be left unwatched in case they move, vomit, have a fit or fall out of their bunk. They must be turned from one side to the other at least every 3 hours to prevent bedsores. Turn the patient gently and roll him smoothly from one side to the other. The head must always be kept back with a chin-up position when actually turning, and at no time must the head be allowed to bend forwards with the chin sagging.

This is both to help to keep a clear air passage and to prevent neck injuries. Check the breathing and that the Guedel airway is securely in place as soon as you have turned the person.

Make sure that all limb joints are neither fully straight nor fully bent. Ideally they should all be kept in mid-position. Place pillows under and between the bent knees and between the feet and ankles. Use a bed-cage a large stiff cardboard box will make a good improvised cage to keep the bedclothes from pressing on the feet and ankles.

Check that elbows, wrists and fingers are in a relaxed midposition 36 after turning. Do not pull, strain or stretch any joint at any time. Make quite sure that the eyelids are closed and that they remain closed at all times, otherwise preventable damage to the eyeball can easily occur.

Irrigate the eyes every 2 hours by opening the lids slightly and pouring some saline solution gently into the corner of each eye in such a way that the saline will run across each eye and drain from the other corner. A saline solution can be made by dissolving one level teaspoonful of salt in half a litre one pint of boiled water, which has been allowed to cool After 12 hours of unconsciousness further problems will arise. Unconscious people must be given nothing by mouth in case it chokes them and they suffer from obstructed breathing.

Because fluids cannot be given by mouth the fluid should be given per rectum see 6. An input-output chart will be necessary and the instructions given under fluid balance in 6. A container connected by tubing to a condom over the penis should be used to collect the urine. The mouth, cheeks, tongue and teeth should be moistened every 3 to 4 hours, using a small swab moistened with water. Carry out mouth care every time the person is turned.

After 48 hours or unconsciousness move The limb joints at least once a day. All the joints in all the limbs should be moved very gently in such away da to put each joint through a full range of movement, provided that other considerations such as fracture do not prevent this. Watch that the exercise of the arms does not interfere unduly with the patient's breathing. Do the job systematically. Begin on the side of the patient, which is most accessible. Start with the fingers ana thumb, then move the wrist, the elbow and the shoulder.

Now move the toes, the foot and the ankle. Then bend the knee and move the hip round. Next, turn the patient, if necessary with the help of another person, and move the joints on the other side.

Remember that unconscious patients may be very relaxed and floppy - so do not let go of their limbs until you have placed the limbs safely back on the bed. Hold the limbs firmly but not tightly and do everything slowly and with the utmost gentleness. Take your time in moving each joint fully before going on to the next. They usually occur when there is severe irritation of the brain There is a variation in severity from twitching of the muscles to general heaving of the body or most severe a maintained general spasm of all muscles The latter condition endangers life by restricting the breathing.

Convulsions may occur at any time after poisoning and recur several times. The more frequent and longer the attacks, the greater the danger to life.

For a few chemical poisons, there are specific treatments for the fits they cause. These will be given in the appropriate tables of section 9.

General management Prevent the patient from hurting himself in the convulsive stage. Never restrain him forcibly, as this may cause injury, but remove hard objects and surround him with pillows, clothing or other soft material. As opportunity arises, put the handle of a spoon, or other hard object, wrapped in a handkerchief or piece of cloth, between his teeth at the side of the mouth to prevent the tongue being bitten. After the fit is over, let him sleep it off as he may be rather confused and dazed when he comes round.

Reassure him, and do not leave him until you are sure he is aware of his surroundings, and knows what he is doing. This can occur either as a direct result of the chemical on the brain, e. Diagnosis If the mental Confusion State is due to a direct action of the chemical on the brain, the patient will develop the signs and symptoms within 15 to 30 minutes after exposure.

The patient may be disorientated as to the date, time and place, and be 38 unable to speak coherently. He may be unable to recognize friends or to perform simple tasks, which he does in everyday life.

On occasions, the patient may appear drowsy and can only be roused with difficulty. In severe cases, he may become unconscious see 6. Some chemicals may cause confusion with mental agitation and aggressive violent behaviour.

If there has been no improvement after 30 minutes, give a further 50 mg intramuscularly. They may also be absorbed, and cause general poisoning symptoms see 4. The more severe corrosive chemicals, e. Remember that other illnesses, e. Treatment Emergency first aid as described in section 8 should be given first. Repeat every 2 hours until relief is obtained. If the vomited matter is green with bile, this may suggest a paralysis of the gut. This causes peritonitis, which is an inflammation of the thin layer of tissue the peritoneum which covers the intestines and lines the inside of the abdomen.

The onset of peritonitis may be assumed when there is a general worsening of the condition of a patient already seriously ill following ingestion of corrosive chemicals. It commences with severe pain all over the abdomen - pain which is made worse by the slightest movement The abdomen becomes hard and extremely tender, and the patient draws up his knees to relax the abdominal muscles. Vomiting occurs and becomes progressively more frequent, large quantities of brown fluid being brought up without any effort The temperature is raised up to The pallid anxious face, the sunken eyes and extreme general weakness all confirm the gravely ill state of the patient.

It is almost always affected in poisoning, but may also be severely damaged by certain chemicals, e. Injury to the liver does not show itself until two to three days after poisoning.

Rapid and progressive failure of the liver causes increasing drowsiness followed by loss of consciousness and death after some days.

Liquids should include at least 2 teaspoonfuls of glucose in a glass of water every 2 hours. In addition he may be given plenty of bread, soft drinks and sweet tea. Food with a high protein content red meats, fish, chicken, eggs, and milk should be avoided. The illness is likely to take some days to resolve and normally a long period of convalescence is advised, during which no alcohol should be taken.

If there is a rapid onset of the symptoms and signs, associated with drowsiness or coma, then the damage is likely to be severe. In severe poisoning, kidney failure may develop after 24 hours, and if it does not improve, the patient may die after 7 to 14 days.

Diagnosis The volume of urine passed, if any, should be measured and recorded every 2 hours. There will be only a small amount of urine passed in a period of 24 hours, usually less than ml. If no urine is passed at all, or less than ml is passed in 6 hours, check whether the bladder is overfull retention see 6. If it is not full then kidney failure is present. The chemical, causing a persistent desire to pass urine may irritate the bladder. It may be painful to pass urine and there may be staining with blood.

Treatment It is important in all types of of chemical poisoning, where kidney failure may occur, to promote a good urine output, preferably more than 2 litres in 24 hours.

The following indicates the amount of fluid to be given for the appropriate amount of urine produced. This indicates true kidney failure. This should continued until the urine output increases to over mi in 6 hours, or medical advice has been obtained to the contrary. Note: Any substantial increase in fluids taken by mouth which does not result in the production of a similar volume of urine in the following 6 to 12 hours is dangerous and the above criteria must be applied.

Fluid restriction Allow the patient to drink a quantity of water equal to the total urine passed the previous day, plus ml over the next 24 hours. If the cabin temperature is greater than 25 C, give an additional ml of water. It is important to look for any signs of waterlogging oedema in the body, which may indicate heart failure see 6. It is also possible for this to occur in a 43 conscious patient. It is an important cause of not passing urine, and should be distinguished from kidney failure.

If retention is present the bladder becomes increasingly distended, with the patient complaining of pain if he is conscious. The bladder can be felt in the lower abdomen as a rounded, tender swelling above the pubic bone and, in severe cases, can extend upward as far as the navel. Fluid intake An average daily intake of fluids from food and drink is about 2.

In temperate climates it is possible to manage for a short time on as little as 1 litre just under 2 pints. In hot climates, where there is a large fluid loss through sweating, an intake of 6 litres per day may be necessary. Fluid loss Body fluid is lost through unseen perspiration, obvious sweating, the breath, the urine and the faeces. At least 2. In any illness where fluid balance is likely to be a problem, a fluid chart recording the amount of fluid intake and fluid loss should be started.

During the first hour period the fluid intake should normally be 0. After the first hour period the fluid intake and loss should balance over the day, taking into account loss due to sweating, etc. If the patient cannot take fluid by mouth for any reason, such as unconsciousness, persistent vomiting or burns to the mouth and throat, it may become necessary to give fluid by rectum to maintain fluid balance.

Giving fluid by rectum To prepare the bed, place two pillows, one on top of the other, across the middle of the undersheet. Protect the pillows with a width of rubber or plastic sheeting covered by a wide clean towel. Allow the ends of the sheeting and towel to hang over the side of the bed to drain any possible leakage. The patient should be placed lying on his left side with his buttocks raised on the pillows and with his right knee flexed.

He should be made comfortable but only one pillow should be allowed to support his head so that the tilt can be maintained. A sheet should then cover him, leaving only the buttocks exposed. The buttocks should be separated gently, then a catheter 26 French gauge well lubricated with petroleum jelly vaseline should be passed, slowly and gently, through the anus into the rectum for a distance of about 23 cm 9 inches. After the catheter has been inserted, its external end should be taped to the skin in a convenient position to attach to a tube and drip set.

Give ml 6 fl oz of water slowly through the tube taking about 10 to 15 minutes to drip the water in. This amount will usually be retained. Leave the catheter in position and block its end with a spigot, or small cork, or compression clip Give the patient a further ml of water every 4 hours. This should give a fluid intake of about ml 1 litre per day. However, if any overflow occurs the amount given must be reduced.

The rectum will not retain large amounts of fluid and fluid must be retained in order to be absorbed. Occasionally the rectum will not accept fluid readily, especially if it is loaded with faeces. Smaller quantities at more frequent intervals should be tried in these cases. Patient on side with right knee flexed Clip Rectal tube Plastic or rubber sheeting Towel 45 Careful observation will show whether the fluid is being retained.

Aim to give at least 1 litre of fluid per day if possible. Giving fluid by rectum should be continued until the patient can safely take fluid by mouth, or medical assistance becomes available.

With the patient naked sponge him all over, using long strokes, with tepid or cold water. Because this treatment causes rapid cooling of only parts of the body, it is important that the thermometer remains in position under the tongue for 4 minutes so that the temperature recorded is that of the body as a whole.

There should not be any ice in the mouth while the temperature is being recorded. If the brain centre, which controls body temperature, is damaged, heat regulation may be upset for many days.

Patients thus affected sometimes need to be surrounded by ice packs or to have frequently changed cold water bottles placed around them. Read the section on fluid balance see 6. These are very similar to burns from fire or electricity except that the chemical may be absorbed through the skin, causing general symptoms of poisoning. Some chemicals may be absorbed even if the skin surface is intact see 4. The aim is to limit the areas of burned akin exposed at any one time to lessen both the risk of infection and the seepage of fluid.

Clean the skin around the edges of the burn with soap, water and swabs. Clean away from the burn in every direction. DO NOT use cotton wool or other linty material for cleaning, as it is likely to leave bits in the burn. Flood the area with clean, warm, boiled water from a clean receptacle to remove debris. With a swab soaked in boiled warm water, dab gently at any remaining dirt or foreign matter in the burned area.

Be gentle, as this will inevitably cause pain. Now apply a covering of absorbent material to absorb any fluid leaking from the burn, e. This is held in place by a suitable bandage - tubular dressings or crepe bandage are useful for limbs and elastic net dressings for other areas.

Re-dress such areas as above. If there is severe pain, not relieved by the paracetamol, give morphine sulphate 7. Fluorescein staining Staining the eye with fluorescein will highlight any area of corneal or conjunctival damage. Pull the lower eyelid downwards and draw the fluorescein paper strip, which contains the dye, gently across the inner moist surface of the lower lid with the patient looking upwards.

This wipes the dye off the strip onto the lid and when the patient blinks a couple of times the dye spreads over the eye. Wipe any excess dye off the eyelids. Any area of corneal or conjunctival damage will attract the dye and be stained green. For further treatment see 8. If the affected area is left untreated, death of the tissue gangrene may well occur.

Give paracetamol mg by mouth. If this is not effective give morphine as directed see 5. These maybe present at a distance from the main site of the fire, and may have no odour. Self-contained breathing apparatus should be used in approaching chemical fires. Inhalation of fumes may result in rapid collapse and unconsciousness, which should be treated as in 6.

Particularly produced in smouldering fires. Treatment The main danger from fume exposure is asphyxia see 6. If burns are present as a result of the fire, they should be treated as for chemical burns see 6. The main danger is from nitrogen oxides Table , Certain metal alloys, in particular those containing zinc or cadmium, give off fumes causing characteristic symptoms known as "metal fume fever".

These symptoms usually resolve spontaneously without any treatment over the following 12 hours. Pulmonary oedema, however, may occur as a very rare complication see 6. If the patient is removed from any further exposure there are no lasting effects or recurrence. Contact with explosives does not normally cause a medical problem from the chemicals themselves, unless they are in a decomposed state, when they may produce fumes, particularly of nitrogen oxides Table , which may be inhaled. Either or both of these may be important.

The chemical effect on persons may be apparent more or less immediately. The effects of chemicals could be either poisoning or burns. They should be treated as appropriate to the chemical as described in section 9 chemical tables. The external radiation hazard may result when the material is separated from its shielding, or when the shielding is destroyed, whereas the contamination, inhalation and ingestion hazards may result if the containment for the material is violated.

In these cases, immediately undertake appropriate first aid before any other procedure. In case of disturbed respiration, use breathing assistance equipment if available, otherwise use mouth-to-mouth or mouth-to-nose artificial respiration.

These activities are unlikely to result in significant contamination of individuals handling a contaminated person. Cotton or similar material is adequate. Heavy protective gear and breathing apparatus are not required unless dictated by the presence of fire or chemical hazards. Place items in plastic bag or sealed box, label, and hold in a secure area that is not near occupied space until assistance from a radiation expert is available to evaluate them.

Treat major, but less than life-threatening, injuries at this time. Mild detergents, including the use of soft brushes, may be used during showering and care should be taken to prevent the spread of contaminated washing water.

Do not abrade the skin. Save swabs and nose blows, treat as if contaminated. Rinse mouth thoroughly. Also, store any towels, blankets, brushes, etc. Remove contaminated clothing and shoes immediately. Wash oft the chemical immediately with copious quantities of water for at least 10 minutes. Continue for a further 10 minutes if there is any evidence of chemicals still on the skin.

If there is no evidence of a chemical burn, check in the relevant chemical table to see whether absorption of the chemical through the intact skin is possible, causing general symptoms of poisoning see 4. If such a possibility does exist, the patient should be kept under close observation for a period of not less than 24 hours, or longer if specified in the relevant technical table. Give half a cup of water every 10 minutes to help replace fluid loss if the bum is other than small in area.

Keep the eyelids widely apart, as illustrated. This must be done thoroughly for 10 minutes, timed by the clock. If there is any doubt whether the chemical has been completely removed, repeat the eyewash for a further 10 minutes. If severe pain is experienced, physical restraint of the patient may be necessary in order to be certain of effective treatment.

For treatment of pain, give 2 paracetamol tablets by mouth every 4 hours until the pain has been relieved. If there is very 53 severe pain, give morphine sulphate 7. Stain the eye with fluorescein. This will prevent the eyelid sticking to the eyeball. Put the ointment into the eye every 2 hours and cover the eye with a dry gauze pad. Hold in place securely by using sticking plaster. Treatment should be continued for 24 hours after the eye is no longer inflamed, and is white.

Check that the casualty is breathing. Tilt the head firmly backwards as far as it will go to relieve obstructed breathing. Listen for breathing with ear over nose and mouth. Breathing and conscious The patient may be conscious, but having difficulty in breathing.

If the breathing does not improve despite these measures, then asphyxia 6. Oxygen is essential to life. It is given for treatment when the body is unable to get enough oxygen from the air because of damage to the lungs or because of other causes such as asphyxia see 6.

Oxygen should be given only where advised in this Guide. The accidents where a patient may require oxygen can be divided into two stages: Stage 1 - During rescue from the place of an accident During this time the patient should be connected to the portable oxygen apparatus through a mask placed over his face. The oxygen valve should be turned on and oxygen administered until the patient is transferred to the ship's sickbay. If a portable oxygen apparatus is not available, air may be given by use of a selfcontained breathing apparatus fitted with a separate airline.

Stage 2 - The patient is in the ship's sick-bay The procedure should be followed as set out below: The unconscious patient 1 2 3 Ensure that a clear airway has been established see 5. Ensure that it remains securely in place. Check that the equipment is correctly assembled according to manufacturer's instructions and that sufficient oxygen is contained in the cylinder.

Connect the mask to the flowmeter, using the tubing provided, and set the flowmeter to 4 litres per minute. This should be continued until the patient no longer has difficulty in breathing and has a healthy colour. The conscious patient 1 2 3 4 5 Ask the patient whether he usually suffers from severe difficulty in breathing with a chronic cough, i. The appropriate mask, as above, should be placed over the patient's mouth and nose and secured to remain correctly in place.

The patient should be placed in the high sitting-up position see 5. Oxygen therapy should be continued until the patient no longer has difficulty in breathing and has a healthy colour. The patient should be kept warm in bed in all circumstances until he has recovered. If severe pain and vomiting occur, see 6. Remember that vomit may be inhaled into the lungs, causing difficulty in breathing; if this occurs, treat as for inhalation see 8. Arsine gas is produced if these chemicals are in contact with acids Table Signs and symptoms Treatment Skin contact There is irritation with redness.

In severe cases, blisters may form. Skin contact Emergency treatment: see 8. If general symptoms occur, give These chemicals may be absorbed through the intact skin, causing general symptoms of poisoning similar to those produced by inhalation or ingestion see below. This is particularly true of arsenic tribromide and arsenic trichloride. Eye contact Eye contact Severe irritation with pain and redness of the eyes may occur. Emergency treatment: see 8.

Inhalation Inhalation There may be a dry mouth, difficulty in breathing and a persistent cough. In more severe cases, there may be a blue discoloration of the skin with shortness of breath. Pulmonary oedema and convulsions can occur. Pulmonary oedema: see 6.

Ingestion Ingestion There may be abdominal pain with Emergency treatment: see 8. In more severe cases, convulsions can occur. Symptoms similar to those of inhalation see above may occur. Convulsions: see 6. If general symptoms occur, give dimercaprol as described for ingestion see below.

If general symptoms occur, give dimercaprol mg intramuscularly every 6 hours for the first day, every 8 hours on the second day, and then twice a day for 3 days.

Signs and symptoms Skin contact There will be severe irritation and redness. Chemical burns can occur. These chemicals are absorbed through the intact skin, and may produce symptoms similar to those of inhalation see below.

Eye contact There will be severe irritation and redness. Treatment Skin contact Emergency treatment: see 8. Inhalation Inhalation In mild cases, there will be a cough, shortness of breath, nausea and vomiting. Severe exposure may produce breathlessness with frothy sputum pulmonary oedema.

In severe cases, weakness, convulsions and unconsciousness may occur. Ingestion There will be abdominal pain with vomiting. In severe cases, weakness, unconsciousness and convulsions can occur. Ingestion Emergency treatment: see 8. Inhalation of vapours of the metal may cause toxic symptoms shortly after exposure. Mercury compounds are highly toxic, and may particularly damage the kidneys and nervous system. They can accumulate in the body. Signs and symptoms Treatment Skin contact Mild irritation of the skin can occur.

These chemicals may be absorbed through the intact skin, causing symptoms similar to those of inhalation and of ingestion see below. Eye contact Eye contact Mild irritation may occur. Inhalation Inhalation There may be a headache with increased salivation, and red painful gums.

Kidney failure can develop after a few hours. Kidney failure: see 6. Ingestion Ingestion There may be a metallic taste, pain in the stomach and severe vomiting and diarrhoea. Circulatory collapse and kidney failure Emergency treatment: see 8. Circulatory collapse: see 6. They accumulate in the body after exposure.

Signs and symptoms Treatment Skin contact Skin contact Symptoms only occur after prolonged Emergency treatment: see 8. Eye contact Eye contact No symptoms are likely to occur. Inhalation and ingestion Inhalation and ingestion Abdominal pain and constipation may occur. There may be a headache, followed by drowsiness, unconsciousness and convulsions in severe cases. Kidney failure can occur, after 2 or 3 days.

If the casualty becomes unconscious or drowsy, or has convulsions, send to hospital ashore as soon as possible. They do not act in the same way as other lead compounds. Symptoms and signs may be delayed for up to one week following exposure.

Signs and symptoms Treatment Skin contact Skin contact Irritation of the skin may occur. These compounds are easily absorbed through the intact skin, causing symptoms similar to those of inhalation see below.

Eye contact Eye contact Redness and irritation may occur. Inhalation Inhalation There will be a sudden onset of nausea, vomiting and headache with apathy, and mental confusion. More severe cases may develop severe agitation with violent aggressive behaviour.

Convulsions and death can occur. Ingestion Ingestion This may produce signs similar to those of inhalation, except there is often burning in the stomach followed by severe vomiting. Acute mental disturbance: see 6.

They are generally toxic to the whole body. Death may occur after severe poisoning. Signs and symptoms Treatment Skin contact A rash may occur. Eye contact Eye contact Irritation and redness may occur. Inhalation Inhalation There may be excessive salivation, lethargy, difficulty in breathing and a cough with pain in the chest.

More severe poisoning will cause shortness of breath with frothy sputum pulmonary oedema. These signs may not develop for 4 to 10 hours after exposure. Kidney failure and liver failure may occur. Liver failure: see 6. Ingestion Ingestion There may be nausea, vomiting, diarrhoea and headache. Kidney failure and liver failure can occur two or three days after exposure.

Eye contact Eye contact Mild redness and irritation may occur. Inhalation Inhalation Inhalation of the dust may cause a mild Emergency treatment: see 8. Bronchitis: see 6. Ingestion Ingestion Nausea, diarrhoea and vomiting will occur. A staggering walk may develop followed by severe weakness and, rarely, convulsions.

They are irritants of the lungs and skin, but there is a wide variation in response to exposure between individuals. Signs and symptoms Treatment Skin contact Skin contact There may be redness and irritation following exposure.

Severe itching and small blisters may occur later. Eye contact Eye contact Severe irritation with redness may occur, as well as swelling of the eyelids. Inhalation Inhalation There may be acute shortness of breath with frothy sputum pulmonary oedema. This indicates the development of either bronchitis or pneumonia. Pneumonia: see 6. Ingestion Ingestion This rarely occurs, but may cause nausea and vomiting.

If they come into contact with acids, stibine gas is produced, which is extremely toxic Table Antimony pentachloride and antimony trichloride reacts with water, forming hydrochloric acid, which acts as a corrosive Table Antimony pentafluoride reacts with water, forming hydrogen fluoride, which is severely corrosive Table Signs and symptoms Treatment Skin contact Skin contact There may be redness and severe irritation with small septic blisters forming after a few hours.

Chemical burns may occur. Eye contact Eye contact There may be severe redness and pain followed by darkening of the whites of the eyes, and deterioration of vision. Inhalation Inhalation Shortness of breath with a cough, chest Emergency treatment: see 8. This may persist and become a chemical bronchitis. Nausea and vomiting may occur. Ingestion Ingestion There may be nausea, vomiting and severe diarrhoea.

In severe circulatory collapse can occur. They may be generally toxic to the whole body when ingested. Vanadium oxytrichloride, vanadium tetrachloride, and vanadium trichloride react with water, forming hydrochloric acid, which is corrosive Table Minor accidents involving chemicals do not usually cause severe effects provided that the appropriate first aid measures are taken.

Although the number of reported serious accidents is small, accidents involving those chemicals which are toxic or corrosive may be dangerous, and must be regarded as being potentially serious until either the affected person has completely recovered, or medical advice to the contrary has been obtained. Chemical irritation and secondary infection of the lungs: productive cough sticky white, yellow or green phlegm [sputum]. It gives likely signs, symptoms, treatment and other advice as per the effect of goods under that table.

It suggests treatment in case of skin contact, eye contact inhalation and ingestion. The procedures for the treatment are also mentioned. You must be logged in to post a comment. Previous post: Refrigerated Cargoes.

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Remember that unconscious patients may be very relaxed and floppy - so do not let go of their limbs until you have placed the limbs safely back on the bed.

Hold the limbs firmly but not tightly and do everything slowly and with the utmost gentleness. Take your time in moving each joint fully before going on to the next. They usually occur when there is severe irritation of the brain There is a variation in severity from twitching of the muscles to general heaving of the body or most severe a maintained general spasm of all muscles The latter condition endangers life by restricting the breathing.

Convulsions may occur at any time after poisoning and recur several times. The more frequent and longer the attacks, the greater the danger to life. For a few chemical poisons, there are specific treatments for the fits they cause.

These will be given in the appropriate tables of section 9. General management Prevent the patient from hurting himself in the convulsive stage.

Never restrain him forcibly, as this may cause injury, but remove hard objects and surround him with pillows, clothing or other soft material. As opportunity arises, put the handle of a spoon, or other hard object, wrapped in a handkerchief or piece of cloth, between his teeth at the side of the mouth to prevent the tongue being bitten.

After the fit is over, let him sleep it off as he may be rather confused and dazed when he comes round. Reassure him, and do not leave him until you are sure he is aware of his surroundings, and knows what he is doing.

This can occur either as a direct result of the chemical on the brain, e. Diagnosis If the mental Confusion State is due to a direct action of the chemical on the brain, the patient will develop the signs and symptoms within 15 to 30 minutes after exposure.

The patient may be disorientated as to the date, time and place, and be 38 unable to speak coherently. He may be unable to recognize friends or to perform simple tasks, which he does in everyday life. On occasions, the patient may appear drowsy and can only be roused with difficulty. In severe cases, he may become unconscious see 6. Some chemicals may cause confusion with mental agitation and aggressive violent behaviour. If there has been no improvement after 30 minutes, give a further 50 mg intramuscularly.

They may also be absorbed, and cause general poisoning symptoms see 4. The more severe corrosive chemicals, e. Remember that other illnesses, e. Treatment Emergency first aid as described in section 8 should be given first.

Repeat every 2 hours until relief is obtained. If the vomited matter is green with bile, this may suggest a paralysis of the gut.

This causes peritonitis, which is an inflammation of the thin layer of tissue the peritoneum which covers the intestines and lines the inside of the abdomen. The onset of peritonitis may be assumed when there is a general worsening of the condition of a patient already seriously ill following ingestion of corrosive chemicals. It commences with severe pain all over the abdomen - pain which is made worse by the slightest movement The abdomen becomes hard and extremely tender, and the patient draws up his knees to relax the abdominal muscles.

Vomiting occurs and becomes progressively more frequent, large quantities of brown fluid being brought up without any effort The temperature is raised up to The pallid anxious face, the sunken eyes and extreme general weakness all confirm the gravely ill state of the patient. It is almost always affected in poisoning, but may also be severely damaged by certain chemicals, e. Injury to the liver does not show itself until two to three days after poisoning. Rapid and progressive failure of the liver causes increasing drowsiness followed by loss of consciousness and death after some days.

Liquids should include at least 2 teaspoonfuls of glucose in a glass of water every 2 hours. In addition he may be given plenty of bread, soft drinks and sweet tea.

Food with a high protein content red meats, fish, chicken, eggs, and milk should be avoided. The illness is likely to take some days to resolve and normally a long period of convalescence is advised, during which no alcohol should be taken. If there is a rapid onset of the symptoms and signs, associated with drowsiness or coma, then the damage is likely to be severe.

In severe poisoning, kidney failure may develop after 24 hours, and if it does not improve, the patient may die after 7 to 14 days. Diagnosis The volume of urine passed, if any, should be measured and recorded every 2 hours.

There will be only a small amount of urine passed in a period of 24 hours, usually less than ml. If no urine is passed at all, or less than ml is passed in 6 hours, check whether the bladder is overfull retention see 6.

If it is not full then kidney failure is present. The chemical, causing a persistent desire to pass urine may irritate the bladder. It may be painful to pass urine and there may be staining with blood.

Treatment It is important in all types of of chemical poisoning, where kidney failure may occur, to promote a good urine output, preferably more than 2 litres in 24 hours.

The following indicates the amount of fluid to be given for the appropriate amount of urine produced. This indicates true kidney failure. This should continued until the urine output increases to over mi in 6 hours, or medical advice has been obtained to the contrary. Note: Any substantial increase in fluids taken by mouth which does not result in the production of a similar volume of urine in the following 6 to 12 hours is dangerous and the above criteria must be applied.

Fluid restriction Allow the patient to drink a quantity of water equal to the total urine passed the previous day, plus ml over the next 24 hours.

If the cabin temperature is greater than 25 C, give an additional ml of water. It is important to look for any signs of waterlogging oedema in the body, which may indicate heart failure see 6.

It is also possible for this to occur in a 43 conscious patient. It is an important cause of not passing urine, and should be distinguished from kidney failure. If retention is present the bladder becomes increasingly distended, with the patient complaining of pain if he is conscious.

The bladder can be felt in the lower abdomen as a rounded, tender swelling above the pubic bone and, in severe cases, can extend upward as far as the navel. Fluid intake An average daily intake of fluids from food and drink is about 2. In temperate climates it is possible to manage for a short time on as little as 1 litre just under 2 pints. In hot climates, where there is a large fluid loss through sweating, an intake of 6 litres per day may be necessary.

Fluid loss Body fluid is lost through unseen perspiration, obvious sweating, the breath, the urine and the faeces. At least 2. In any illness where fluid balance is likely to be a problem, a fluid chart recording the amount of fluid intake and fluid loss should be started.

During the first hour period the fluid intake should normally be 0. After the first hour period the fluid intake and loss should balance over the day, taking into account loss due to sweating, etc. If the patient cannot take fluid by mouth for any reason, such as unconsciousness, persistent vomiting or burns to the mouth and throat, it may become necessary to give fluid by rectum to maintain fluid balance.

Giving fluid by rectum To prepare the bed, place two pillows, one on top of the other, across the middle of the undersheet. Protect the pillows with a width of rubber or plastic sheeting covered by a wide clean towel. Allow the ends of the sheeting and towel to hang over the side of the bed to drain any possible leakage. The patient should be placed lying on his left side with his buttocks raised on the pillows and with his right knee flexed.

He should be made comfortable but only one pillow should be allowed to support his head so that the tilt can be maintained. A sheet should then cover him, leaving only the buttocks exposed. The buttocks should be separated gently, then a catheter 26 French gauge well lubricated with petroleum jelly vaseline should be passed, slowly and gently, through the anus into the rectum for a distance of about 23 cm 9 inches. After the catheter has been inserted, its external end should be taped to the skin in a convenient position to attach to a tube and drip set.

Give ml 6 fl oz of water slowly through the tube taking about 10 to 15 minutes to drip the water in. This amount will usually be retained. Leave the catheter in position and block its end with a spigot, or small cork, or compression clip Give the patient a further ml of water every 4 hours. This should give a fluid intake of about ml 1 litre per day. However, if any overflow occurs the amount given must be reduced.

The rectum will not retain large amounts of fluid and fluid must be retained in order to be absorbed. Occasionally the rectum will not accept fluid readily, especially if it is loaded with faeces. Smaller quantities at more frequent intervals should be tried in these cases. Patient on side with right knee flexed Clip Rectal tube Plastic or rubber sheeting Towel 45 Careful observation will show whether the fluid is being retained.

Aim to give at least 1 litre of fluid per day if possible. Giving fluid by rectum should be continued until the patient can safely take fluid by mouth, or medical assistance becomes available. With the patient naked sponge him all over, using long strokes, with tepid or cold water. Because this treatment causes rapid cooling of only parts of the body, it is important that the thermometer remains in position under the tongue for 4 minutes so that the temperature recorded is that of the body as a whole.

There should not be any ice in the mouth while the temperature is being recorded. If the brain centre, which controls body temperature, is damaged, heat regulation may be upset for many days. Patients thus affected sometimes need to be surrounded by ice packs or to have frequently changed cold water bottles placed around them.

Read the section on fluid balance see 6. These are very similar to burns from fire or electricity except that the chemical may be absorbed through the skin, causing general symptoms of poisoning. Some chemicals may be absorbed even if the skin surface is intact see 4.

The aim is to limit the areas of burned akin exposed at any one time to lessen both the risk of infection and the seepage of fluid. Clean the skin around the edges of the burn with soap, water and swabs. Clean away from the burn in every direction. DO NOT use cotton wool or other linty material for cleaning, as it is likely to leave bits in the burn.

Flood the area with clean, warm, boiled water from a clean receptacle to remove debris. With a swab soaked in boiled warm water, dab gently at any remaining dirt or foreign matter in the burned area.

Be gentle, as this will inevitably cause pain. Now apply a covering of absorbent material to absorb any fluid leaking from the burn, e.

This is held in place by a suitable bandage - tubular dressings or crepe bandage are useful for limbs and elastic net dressings for other areas. Re-dress such areas as above. If there is severe pain, not relieved by the paracetamol, give morphine sulphate 7. Fluorescein staining Staining the eye with fluorescein will highlight any area of corneal or conjunctival damage.

Pull the lower eyelid downwards and draw the fluorescein paper strip, which contains the dye, gently across the inner moist surface of the lower lid with the patient looking upwards. This wipes the dye off the strip onto the lid and when the patient blinks a couple of times the dye spreads over the eye. Wipe any excess dye off the eyelids. Any area of corneal or conjunctival damage will attract the dye and be stained green. For further treatment see 8. If the affected area is left untreated, death of the tissue gangrene may well occur.

Give paracetamol mg by mouth. If this is not effective give morphine as directed see 5. These maybe present at a distance from the main site of the fire, and may have no odour. Self-contained breathing apparatus should be used in approaching chemical fires. Inhalation of fumes may result in rapid collapse and unconsciousness, which should be treated as in 6. Particularly produced in smouldering fires. Treatment The main danger from fume exposure is asphyxia see 6.

If burns are present as a result of the fire, they should be treated as for chemical burns see 6. The main danger is from nitrogen oxides Table , Certain metal alloys, in particular those containing zinc or cadmium, give off fumes causing characteristic symptoms known as "metal fume fever". These symptoms usually resolve spontaneously without any treatment over the following 12 hours. Pulmonary oedema, however, may occur as a very rare complication see 6.

If the patient is removed from any further exposure there are no lasting effects or recurrence. Contact with explosives does not normally cause a medical problem from the chemicals themselves, unless they are in a decomposed state, when they may produce fumes, particularly of nitrogen oxides Table , which may be inhaled.

Either or both of these may be important. The chemical effect on persons may be apparent more or less immediately. The effects of chemicals could be either poisoning or burns. They should be treated as appropriate to the chemical as described in section 9 chemical tables. The external radiation hazard may result when the material is separated from its shielding, or when the shielding is destroyed, whereas the contamination, inhalation and ingestion hazards may result if the containment for the material is violated.

In these cases, immediately undertake appropriate first aid before any other procedure. In case of disturbed respiration, use breathing assistance equipment if available, otherwise use mouth-to-mouth or mouth-to-nose artificial respiration. These activities are unlikely to result in significant contamination of individuals handling a contaminated person.

Cotton or similar material is adequate. Heavy protective gear and breathing apparatus are not required unless dictated by the presence of fire or chemical hazards. Place items in plastic bag or sealed box, label, and hold in a secure area that is not near occupied space until assistance from a radiation expert is available to evaluate them. Treat major, but less than life-threatening, injuries at this time. Mild detergents, including the use of soft brushes, may be used during showering and care should be taken to prevent the spread of contaminated washing water.

Do not abrade the skin. Save swabs and nose blows, treat as if contaminated. Rinse mouth thoroughly. Also, store any towels, blankets, brushes, etc. Remove contaminated clothing and shoes immediately.

Wash oft the chemical immediately with copious quantities of water for at least 10 minutes. Continue for a further 10 minutes if there is any evidence of chemicals still on the skin. If there is no evidence of a chemical burn, check in the relevant chemical table to see whether absorption of the chemical through the intact skin is possible, causing general symptoms of poisoning see 4.

If such a possibility does exist, the patient should be kept under close observation for a period of not less than 24 hours, or longer if specified in the relevant technical table. Give half a cup of water every 10 minutes to help replace fluid loss if the bum is other than small in area. Keep the eyelids widely apart, as illustrated.

This must be done thoroughly for 10 minutes, timed by the clock. If there is any doubt whether the chemical has been completely removed, repeat the eyewash for a further 10 minutes. If severe pain is experienced, physical restraint of the patient may be necessary in order to be certain of effective treatment.

For treatment of pain, give 2 paracetamol tablets by mouth every 4 hours until the pain has been relieved. If there is very 53 severe pain, give morphine sulphate 7. Stain the eye with fluorescein. This will prevent the eyelid sticking to the eyeball. Put the ointment into the eye every 2 hours and cover the eye with a dry gauze pad. Hold in place securely by using sticking plaster. Treatment should be continued for 24 hours after the eye is no longer inflamed, and is white.

Check that the casualty is breathing. Tilt the head firmly backwards as far as it will go to relieve obstructed breathing. Listen for breathing with ear over nose and mouth.

Breathing and conscious The patient may be conscious, but having difficulty in breathing. If the breathing does not improve despite these measures, then asphyxia 6. Oxygen is essential to life. It is given for treatment when the body is unable to get enough oxygen from the air because of damage to the lungs or because of other causes such as asphyxia see 6.

Oxygen should be given only where advised in this Guide. The accidents where a patient may require oxygen can be divided into two stages: Stage 1 - During rescue from the place of an accident During this time the patient should be connected to the portable oxygen apparatus through a mask placed over his face. The oxygen valve should be turned on and oxygen administered until the patient is transferred to the ship's sickbay.

If a portable oxygen apparatus is not available, air may be given by use of a selfcontained breathing apparatus fitted with a separate airline. Stage 2 - The patient is in the ship's sick-bay The procedure should be followed as set out below: The unconscious patient 1 2 3 Ensure that a clear airway has been established see 5.

Ensure that it remains securely in place. Check that the equipment is correctly assembled according to manufacturer's instructions and that sufficient oxygen is contained in the cylinder.

Connect the mask to the flowmeter, using the tubing provided, and set the flowmeter to 4 litres per minute. This should be continued until the patient no longer has difficulty in breathing and has a healthy colour. The conscious patient 1 2 3 4 5 Ask the patient whether he usually suffers from severe difficulty in breathing with a chronic cough, i. The appropriate mask, as above, should be placed over the patient's mouth and nose and secured to remain correctly in place.

The patient should be placed in the high sitting-up position see 5. Oxygen therapy should be continued until the patient no longer has difficulty in breathing and has a healthy colour. The patient should be kept warm in bed in all circumstances until he has recovered.

If severe pain and vomiting occur, see 6. Remember that vomit may be inhaled into the lungs, causing difficulty in breathing; if this occurs, treat as for inhalation see 8. Arsine gas is produced if these chemicals are in contact with acids Table Signs and symptoms Treatment Skin contact There is irritation with redness. In severe cases, blisters may form. Skin contact Emergency treatment: see 8.

If general symptoms occur, give These chemicals may be absorbed through the intact skin, causing general symptoms of poisoning similar to those produced by inhalation or ingestion see below.

This is particularly true of arsenic tribromide and arsenic trichloride. Eye contact Eye contact Severe irritation with pain and redness of the eyes may occur. Emergency treatment: see 8.

Inhalation Inhalation There may be a dry mouth, difficulty in breathing and a persistent cough. In more severe cases, there may be a blue discoloration of the skin with shortness of breath. Pulmonary oedema and convulsions can occur. Pulmonary oedema: see 6. Ingestion Ingestion There may be abdominal pain with Emergency treatment: see 8.

In more severe cases, convulsions can occur. Symptoms similar to those of inhalation see above may occur. Convulsions: see 6. If general symptoms occur, give dimercaprol as described for ingestion see below. If general symptoms occur, give dimercaprol mg intramuscularly every 6 hours for the first day, every 8 hours on the second day, and then twice a day for 3 days. Signs and symptoms Skin contact There will be severe irritation and redness.

Chemical burns can occur. These chemicals are absorbed through the intact skin, and may produce symptoms similar to those of inhalation see below. Eye contact There will be severe irritation and redness. Treatment Skin contact Emergency treatment: see 8. Inhalation Inhalation In mild cases, there will be a cough, shortness of breath, nausea and vomiting.

Severe exposure may produce breathlessness with frothy sputum pulmonary oedema. In severe cases, weakness, convulsions and unconsciousness may occur. Ingestion There will be abdominal pain with vomiting. In severe cases, weakness, unconsciousness and convulsions can occur. Ingestion Emergency treatment: see 8. Inhalation of vapours of the metal may cause toxic symptoms shortly after exposure.

Mercury compounds are highly toxic, and may particularly damage the kidneys and nervous system. They can accumulate in the body. Signs and symptoms Treatment Skin contact Mild irritation of the skin can occur.

These chemicals may be absorbed through the intact skin, causing symptoms similar to those of inhalation and of ingestion see below. Eye contact Eye contact Mild irritation may occur. Inhalation Inhalation There may be a headache with increased salivation, and red painful gums.

Kidney failure can develop after a few hours. Kidney failure: see 6. Ingestion Ingestion There may be a metallic taste, pain in the stomach and severe vomiting and diarrhoea. Circulatory collapse and kidney failure Emergency treatment: see 8. Circulatory collapse: see 6. They accumulate in the body after exposure. Signs and symptoms Treatment Skin contact Skin contact Symptoms only occur after prolonged Emergency treatment: see 8.

Eye contact Eye contact No symptoms are likely to occur. Inhalation and ingestion Inhalation and ingestion Abdominal pain and constipation may occur. There may be a headache, followed by drowsiness, unconsciousness and convulsions in severe cases. Kidney failure can occur, after 2 or 3 days. If the casualty becomes unconscious or drowsy, or has convulsions, send to hospital ashore as soon as possible.

They do not act in the same way as other lead compounds. Symptoms and signs may be delayed for up to one week following exposure. Signs and symptoms Treatment Skin contact Skin contact Irritation of the skin may occur. These compounds are easily absorbed through the intact skin, causing symptoms similar to those of inhalation see below.

Eye contact Eye contact Redness and irritation may occur. Inhalation Inhalation There will be a sudden onset of nausea, vomiting and headache with apathy, and mental confusion. More severe cases may develop severe agitation with violent aggressive behaviour. Convulsions and death can occur. Ingestion Ingestion This may produce signs similar to those of inhalation, except there is often burning in the stomach followed by severe vomiting. Acute mental disturbance: see 6. They are generally toxic to the whole body.

Death may occur after severe poisoning. Signs and symptoms Treatment Skin contact A rash may occur. Eye contact Eye contact Irritation and redness may occur. Inhalation Inhalation There may be excessive salivation, lethargy, difficulty in breathing and a cough with pain in the chest. More severe poisoning will cause shortness of breath with frothy sputum pulmonary oedema.

These signs may not develop for 4 to 10 hours after exposure. Kidney failure and liver failure may occur. Liver failure: see 6. Ingestion Ingestion There may be nausea, vomiting, diarrhoea and headache. Kidney failure and liver failure can occur two or three days after exposure. Eye contact Eye contact Mild redness and irritation may occur.

Inhalation Inhalation Inhalation of the dust may cause a mild Emergency treatment: see 8. Bronchitis: see 6. Ingestion Ingestion Nausea, diarrhoea and vomiting will occur. A staggering walk may develop followed by severe weakness and, rarely, convulsions.

They are irritants of the lungs and skin, but there is a wide variation in response to exposure between individuals. Signs and symptoms Treatment Skin contact Skin contact There may be redness and irritation following exposure.

Severe itching and small blisters may occur later. Eye contact Eye contact Severe irritation with redness may occur, as well as swelling of the eyelids. Inhalation Inhalation There may be acute shortness of breath with frothy sputum pulmonary oedema.

This indicates the development of either bronchitis or pneumonia. Pneumonia: see 6. Ingestion Ingestion This rarely occurs, but may cause nausea and vomiting. If they come into contact with acids, stibine gas is produced, which is extremely toxic Table Antimony pentachloride and antimony trichloride reacts with water, forming hydrochloric acid, which acts as a corrosive Table Antimony pentafluoride reacts with water, forming hydrogen fluoride, which is severely corrosive Table Signs and symptoms Treatment Skin contact Skin contact There may be redness and severe irritation with small septic blisters forming after a few hours.

Chemical burns may occur. Eye contact Eye contact There may be severe redness and pain followed by darkening of the whites of the eyes, and deterioration of vision. Inhalation Inhalation Shortness of breath with a cough, chest Emergency treatment: see 8. This may persist and become a chemical bronchitis. Nausea and vomiting may occur.

Ingestion Ingestion There may be nausea, vomiting and severe diarrhoea. In severe circulatory collapse can occur. They may be generally toxic to the whole body when ingested. Vanadium oxytrichloride, vanadium tetrachloride, and vanadium trichloride react with water, forming hydrochloric acid, which is corrosive Table Signs and symptoms Treatment Skin contact Skin contact There may be redness and irritation only.

Eye contact Eye contact There may be irritation with mild redness. Inhalation Inhalation The casualty may complain of a metallic taste, and on occasions the tongue may become green after a few days. There is often a cough with difficulty in breathing and audible wheezing shortly after exposure. Rarely, severe shortness of breath with frothy sputum pulmonary oedema can occur.

Wheezing - If wheezing, administer oxygen and give two puffs of salbutamol micrograms per puff and five puffs of beclomethasone 50 micrograms per puff every 15 minutes by spacer device for the first hour. Hospital required. Then give two puffs four times a day of both salbutamol and beclomethasone if symptoms persist.

Ingestion Ingestion There may be nausea and vomiting, with a metallic taste in the mouth. The symptoms and signs may develop slowly over two or three days. If ingestion has occurred, the casualty should be transferred ashore for further treatment, since death may occur up to five weeks later. Signs and symptoms Treatment Skin contact Skin contact Mild irritation of the skin may occur. It is absorbed through the intact skin and may cause symptoms similar to those of ingestion.

If these occur, treat as for ingestion. Eye contact Eye contact Mild redness and irritation will occur. Inhalation Inhalation This rarely occurs, but may cause signs Emergency treatment: see 8. Ingestion Ingestion There will be nausea, abdominal pain and vomiting. Occasionally there may be blood in the vomit. After 2 or 3 days, progressive weakness, difficulty in walking and "pins and needles" in the legs and arms may develop. Increasing mental disturbance and confusion may follow.

Liver failure and kidney failure can occur. A characteristic sign is the progressive loss of hair, which may be rapid. Convulsions can occur. Give two sachets 10 g of activated charcoal dispersed in ml 1 pint of water, followed by three doses of one sachet 5 g in ml of water at intervals of 20 minutes.

Bleeding: see 6. Zinc chloride is particularly toxic and may cause severe chemical burns. Zinc resinate is not as toxic. Signs and symptoms Treatment Skin contact Skin contact There may be severe chemical bums of the skin with pain and redness. Eye contact Eye contact Severe pain, redness and irritation will occur. There may be chemical burns of the eye in serious cases. Inhalation There will be a cough, sneezing and copious sputum production. There may be severe difficulty in breathing, with tightness and pain in the chest.

Severe breathlessness with frothy sputum pulmonary oedema can occur. Bronchitis may develop after 2 or 3 days in less severe cases. Ingestion Ingestion This is unlikely to occur, but will produce swelling of the linings of the throat with nausea and vomiting. Circulatory collapse may occur. Emergency treatment: collapse: see 6.

They are particularly toxic after ingestion. Signs and symptoms Treatment Skin contact Skin contact There may be severe pain with redness. Chemical burns can occur in severe cases. Eye contact Eye contact There may be severe irritation with redness and pain.

Inhalation Emergency treatment: see 8. There is usually a persistent cough with Emergency treatment: see 8. Inhalation sneezing, soreness of the throat and aching in the muscles, which develops 2 or 3 hours after exposure.

These often resolve spontaneously within 24 hours. Ingestion Ingestion There may be burning in the throat, with nausea, diarrhoea and vomiting. Blood may be present in the vomit or diarrhoea. In severe cases, liver and kidney damage can occur. Convulsions are a rare complication. They are extremely toxic if ingested in sufficient quantities. Signs and symptoms Treatment Skin contact Skin contact There may be severe pain with redness and chemical burns of the skin.

If the chemical is not removed promptly, progressive painful ulcers will occur. Eye contact Eye contact There may be redness and pain. Chemical burns of the eye can occur in serious cases.

Inhalation Inhalation There may be difficulty in breathing, with chest pain and wheezing. In more severe cases, shortness of breath with Emergency treatment: see 8. Hospital treatment may be required. If wheezing continues after the first hour, continue with oxygen and give two puffs of salbutamol and five puffs of beclomethasone by spacer device every two hours for the next 12 hours, while awaiting medical advice.

Occasionally, blood may be present in the vomit or faeces. In severe cases, Emergency treatment: see 8. In addition to this, the compounds may be corrosive, particularly lithium hydroxide, causing severe chemical burns of the skin. Signs and symptoms Treatment Skin contact Skin contact There may be redness and irritation. Permanent damage to the eyes may occur. Inhalation Inhalation There may be difficulty in breathing, with Emergency treatment: see 8.

In more severe cases, shortness of breath with frothy sputum pulmonary oedema can occur. Agitation, confusion and unconsciousness may develop even if there is no difficulty in breathing. Ingestion Ingestion There is often nausea, vomiting and confusion.

In severe cases, there may be blurring of vision, muscle twitching, confusion and progressive unconsciousness. There may be no smell or taste in the mouth as a warning of their presence. If severe symptoms do occur, the casualty should be transferred ashore since the period of illness and recovery is prolonged.

Signs and symptoms Treatment Skin contact Skin contact There will be redness and irritation. These compounds may be absorbed through the intact skin, producing symptoms similar to those of inhalation see below. Eye contact Eye contact There may be redness and irritation. Inhalation Inhalation Initial symptoms can include nausea, headache, dizziness and vomiting. These may improve, but after 12 to 36 hours the casualty may develop difficulty in breathing, with chest pain and a cough.

In severe cases, weakness and breathlessness with frothy sputum pulmonary oedema can occur. Convulsions may rarely occur. Ingestion Ingestion There will be nausea and vomiting. Shortness of breath with frothy sputum pulmonary oedema and circulatory collapse may occur.

Give dimercaprol mg intramuscularly every 6 hours for the first day, every 8 hours on the second day, and then twice a day for 3 days. They are mainly a hazard because they ignite spontaneously in air, and are explosive, causing burns. They may produce toxic fumes after ignition. Signs and symptoms Treatment Skin contact Skin contact There may be redness and pain with chemical burns of the skin. Severe chemical burns can occur. Inhalation Inhalation There may be severe shortness of breath, which can progress in severe cases to breathlessness with frothy sputum pulmonary oedema.

Convulsions may occur. Ingestion Ingestion This is unlikely to occur, but there will be severe burning of the mouth and throat with pain. This may be followed by nausea and vomiting. In addition, they are irritants of the skin and lungs. Selenium hexafluoride and hydrogen selenide are gases, and are extremely toxic if inhaled. Signs and symptoms Treatment Skin contact Skin contact There may be redness and irritation of the skin.

Eye contact Emergency treatment: see 8. There may be redness and irritation. Chemical bums can occur in severe cases.

There may be a metallic taste in the mouth and a garlic odour to the breath. Muscle pains with a mild fever can occur a few hours after exposure. In severe cases, shortness of breath with frothy sputum pulmonary oedema may develop.

Occasionally, wheezing and shortness of breath may occur. Ingestion Ingestion There will be nausea and vomiting, occasionally with blood. Black faeces may be passed, indicating bleeding from the gut. Liver and kidney failure may develop after 2 or 3 days. Eye contact Eye contact There will be redness and irritation. The vapour causes a gritty feeling in the eyes, redness and watering, and the casualty may notice the appearance of rings around lights.

Inhalation Inhalation In low concentrations, there will be a cough, slight breathlessness and watering of the eyes, with a headache. In severe cases, shortness of breath with frothy sputum pulmonary oedema may occur. Kidney damage is a late complication. Kidney failure may occur in severe cases.

They may burn spontaneously on contact with air, and the vapour released is highly irritating to the lungs. If the contact is prolonged, a deep, painful chemical burn will be produced. Keep the injured part of the body under water or covered with wet dressings and remove the phosphorus with a spoon, spatula or tweezers. Eye contact Eye contact There will be severe pain and redness with chemical bums if the solid is in contact with the eyes.

The fumes cause redness and irritation, and occasionally chemical burns in severe exposure. Inhalation Inhalation There will be a cough with shortness of breath and chest pain.

Rarely, shortness of breath with frothy sputum pulmonary oedema may occur. The chemical may be absorbed into the body, producing nausea and vomiting, a garlic odour of the breath, and loss of appetite. Liver failure can occur. Ingestion Ingestion This is unlikely to occur. There will be Emergency treatment: see 8. In severe cases, blood may be vomited.

Symptoms similar to those of inhalation can occur see above. Persistent vomiting: see 6. If they are brought into contact with acids or water, hydrogen phosphide phosphine is produced, which is a highly toxic gas Table Small septic blisters may form. Inhalation Inhalation There may be a garlic odour to the breath with dizziness and muscle pains.

There is often a cough with shortness of breath, nausea, vomiting and diarrhoea. Ingestion Ingestion There may be nausea, vomiting and diarrhoea, with excessive thirst. They have a strong foul odour. Signs and symptoms Treatment Skin contact Skin contact There may be extreme irritation with a rash and blisters.

They are absorbed through the intact skin, causing symptoms similar to inhalation see below. Eye contact Eye contact There may be severe irritation.

Inhalation Inhalation In mild cases, there may be nausea, headache, lethargy and drowsiness. In more severe cases there will be general muscular weakness, difficulty in speaking, unsteadiness in walking, loss of consciousness and occasionally convulsions. Death may occur. Rarely, there may be severe agitation with aggressive behaviour.

Liver and kidney failure can occur. Ingestion Ingestion This is unlikely to occur, but if it does, may produce severe nausea and vomiting followed by unconsciousness.

Liver and kidney failure can develop as late complications. If exposure occurs, treatment must be given immediately, since death may occur very rapidly. Nitrites contain cyanide and therefore act in the same way. Signs and symptoms Treatment Skin contact Skin contact There may be irritation and pain. These chemicals are absorbed through the intact skin, producing similar signs to those of inhalation and ingestion see below.

If general symptoms occur, treat as described for inhalation and ingestion see below. Eye contact Eye contact There may be irritation and redness. Inhalation and ingestion Inhalation and ingestion There may be chest pain with shortness of breath, anxiety and rapid loss of consciousness.

If the patient is conscious, he should be placed flat on his back, and rest within 30 minutes. The patient may have a smell of bitter almonds on his breath. If the patient is unconscious, place in the unconscious position and insert a Guedel airway see 5. Start artificial respiration by the Silvester method see 5. If the breathing and pulse are present, break an ampoule of amyl nitrite 0.

This should be repeated with a further ampoule at 3-minute intervals, using up to five ampoules. They have a corrosive action. Inhalation Inhalation There may be shortness of breath with a cough and chest pain.

More severe cases may develop shortness of breath with frothy sputum pulmonary oedema. Similar symptoms to those of ingestion may occur see below. Ingestion Ingestion There may be nausea and vomiting with a burning sensation in the mouth. In more severe cases, there is pallor of the skin, a weak pulse, sweating and circulatory collapse.

Some may be extremely toxic because, on contact with water and acids, they produce hydrogen sulphide Table , which has a strong foul odour. Chemical burns can occur rarely. Inhalation Inhalation There will be burning of the mouth and Emergency treatment: see 8. In severe cases, breathlessness with frothy sputum pulmonary oedema may develop.

Rarely, convulsions can occur. Ingestion Ingestion This will produce nausea and vomiting, headache and difficulty in breathing. In severe cases, there may be trembling of the hands and legs, loss of consciousness, circulatory collapse and convulsions. They particularly damage the kidneys if ingested. Signs and symptoms Treatment Skin contact Skin contact There may be redness and chemical burns of the skin.

Eye contact Eye contact There may be pain and redness. Chemical bums can occur. Inhalation Inhalation There may be shortness of breath with a cough. In more severe cases, symptoms similar to those of ingestion may develop see below. Ingestion Ingestion There may be abdominal pain and vomiting followed by weakness and convulsions. Circulatory collapse can occur. If there is severe poisoning, kidney failure may develop.

Silver nitrate has a corrosive action, and may produce chemical burns of the eyes and skin. They are absorbed through the intact skin, producing symptoms similar to those of inhalation and ingestion see below. In more severe cases there may be a weak pulse and circulatory collapse. Loss of consciousness, convulsions and death may occur Emergency treatment: see 8.

The nitrites may cause blueness of the skin and mouth cyanosis , with a reddish-brown discoloration of the urine. This is due to damage of the blood cells methaemoglobinaemia. Also give 1 g of ascorbic acid by mouth and repeat every 4 hours for 24 hours. They are mild irritants. Signs and symptoms Treatment Skin contact Skin contact There may be mild redness and irritation. Eye contact There may be mild redness and irritation. Inhalation Inhalation There may be slight shortness of breath with a cough, and soreness of the throat.

Ingestion Ingestion There may be nausea and vomiting only. Some are corrosive to skin, mouth, throat and lungs. The liquids may ignite spontaneously, causing burns of the skin. Signs and symptoms Treatment Skin contact Skin contact There may be severe pain and redness. They are absorbed through the intact skin, causing symptoms similar to those of inhalation see below. Eye contact Eye contact There may be severe pain and redness. Inhalation Inhalation The onset of symptoms may be delayed for up to 24 hours.

Mild exposure causes lethargy, confusion, headache and a feeling of constriction in the chest. More severe exposure may give slurred speech, drowsiness, trembling of the hands with muscle spasms, unconsciousness and convulsions.

Breathlessness with frothy pulmonary oedema may occur. Ingestion Ingestion There may be nausea and vomiting. Symptoms similar to those of inhalation may occur see above. They also affect the nervous system. Chloral and chloracetaldehyde are particularly toxic, causing rapid loss of consciousness. Chemical burns rarely occur. Inhalation Inhalation Mild exposure will cause a cough, with shortness of breath. Prolonged exposure can cause breathlessness with frothy sputum pulmonary oedema.

This may be delayed in onset. Bronchitis can develop as a complication. More severe cases may lose consciousness and occasionally develop convulsions. Emergency treatment: Convulsions: see 6. They cause depression of the nervous system and symptoms similar to those of "drunkenness".

The features of alcohol intoxication are well known, and are described with appropriate medical treatment in the IMGS. Signs and symptoms Treatment Skin contact Skin contact There may be mild irritation. Eye contact Eye contact There may be mild irritation and redness. Inhalation Inhalation There may be shortness of breath, with a cough. They can be absorbed through the lungs, producing symptoms similar to those of ingestion see below. Ingestion Ingestion There may be mental confusion, a staggering walk and slurred speech.

In more severe cases, there is a loss of consciousness and, rarely, convulsions. Signs and symptoms Treatment Skin contact Skin contact There will be mild redness and irritation.

It may be absorbed through the intact skin, producing symptoms similar to those of ingestion see below. If general symptoms occur, treat described for ingestion see below.

Eye contact Eye contact There may be mild irritation and redness only. Inhalation Inhalation It is absorbed through the lungs, and Emergency treatment: see 8.

Mild shortness of 1 breath may occur. Ingestion Ingestion The patient will initially appear to be "drunk". There then may be a delayed period of 18 to 48 hours after which nausea, vomiting, abdominal pain and confusion may occur. The vision may deteriorate and blindness can occur in severe cases. There may be muscle weakness with "pins and needles" in the arms and legs.

It is intended to provide advice necessary for initial management of chemical poisoning and diagnosis within the limits of the facilities available at sea. The MFAG itself gives general information about the particular toxic effects likely to be encountered. The treatment recommended in this Guide is specified in the appropriate tables and more comprehensive in the appropriate sections of the Appendices. However, differences exist between countries on certain types of treatment and where these differences occur they are indicated in the relevant national medical guide.

Treatments in this guide cater for the accidental human consequences of the carriage of dangerous goods at sea. Accidental ingestion of toxic substances during voyage is rare. The guide does not cover ingestion by intention. Minor accidents involving chemicals do not usually cause severe effects provided that the appropriate first aid measures are taken.