A, B, C, D

A for Airway

The head-tilt chin-lift opens the airway safely and effectively.

The complex structures of the human body leading from the lips to the lungs are often referred to simply as the patient’s “airway”. The airway of the human body is one of the more important parts to be checked when providing first aid, and is typically the first item given attention in the seriously sick or injured patient. The airway is the entrance point of oxygen and the exit point of carbon dioxide for the body. Should this become blocked, the victim will have no way to obtain fresh air, and death will eventually result.

We are normally able to keep our airway a clear path for fresh air subconsciously. Depending on the severity of the victim’s condition, an unconscious person’s airway could be blocked when their tongue relaxes and falls across their throat, blocking airflow. A common example of this is the sounds made by a snoring person. The technique used to open the airway and keep the tongue out is referred to as the “head-tilt chin-lift” technique.
For this to work properly, the patient will be placed on a flat surface, lying on their back. Kneeling at the level of the victim, the rescuer places one palm, open handed, on the victim’s forehead. The rescuer then places the index and middle finger of their other hand under the bony part of the victim’s jaw. The fingers and palm are used to gently rock the victim’s head backwards, and lift their chin upwards, extending the victim’s neck. Ideally, once you have done this, the victim’s jawline will be perpendicular to the ground.

This technique is typically not necessary for conscious victims, as they can typically maintain an open airway. Simply, if the victim is talking or has no respiratory distress, their airway is adequate.

Even if you suspect that your victim may have sustained a spinal neck injury, open the airway as normal. Life over limb – the potential for keeping the victim alive outweighs the risk of aggravating the spinal injury. If you absolutely must roll a person suspected of head, neck, or spinal injury because he or she is vomiting, choking on blood or in danger of further injury, use at least two people. Work together to keep the person’s head, neck and back aligned while rolling the person onto one side.

You may also check the victim’s mouth for visible, removable obstructions in the mouth which can obstruct airflow. The common items found obstructing the victim’s airway include partially chewed food, hard candy, and balloons. You may attempt to expel any items in the mouth which can be easily withdrawn, but do not waste time trying to remove fixed or lodged items such as dentures. Also, be alert to the status of your victim, as you could be injured if your fingers are in the mouth of a person regaining consciousness.

If a conscious victim’s airway is obstructed by a foreign object (such as someone who is choking), the object must be removed via other means. Abdominal thrustsare the standard method for conscious victims. Refer to Obstructed Airway for unconscious procedures.

Principles[edit]

Humans breathe by inhaling fresh air into the lungs, exchanging part (but not all) of the oxygen in it with unneeded carbon dioxide, and exhaling the spent air. Blood vessels located in the lungs distribute oxygen throughout the cells of the body. Human beings typically have a lung capacity of 4 to 6 liters.

When someone stops breathing, this is a life threatening condition known as respiratory arrest. Occasionally when a victim stops breathing, their breathing can restart if stimulated by a rescuer blowing air into their lungs. However, a victim in respiratory arrest is likely to fall into cardio-respiratory arrest, which means that they are no longer breathing and their heart has also stopped.

Without their lungs receiving oxygen, a victim will suffer permanent brain damage after only a few minutes. Because of this, it is crucial that rescuers provide rescue breathing (ventilation) quickly and correctly.

Checking the respiration[edit]

Regional Note
In some areas, trainers advocate calling emergency medical services as soon as you find a patient unconscious (“call first”), but the ILCOR protocol is to call EMS once you determine whether the victim is breathing or not (“call fast”). This ensures that the correct priority is given to your call. You should summon an ambulance in either case if the patient is unconscious.

After opening the victim’s airway, check to see if the victim is breathing. To do this, place your cheek in front of the victim’s mouth (about 3-5 cm away) while looking down their chest (towards their feet). If desired, you can also gently place a hand on the center of the victim’s chest. This allows you to observe whether the victim is breathing in the following ways:

1. You may Feel the victim’s breath against your cheek.
2. You may Hear the air entering or escaping your victim’s lungs.
3. You may See the chest rise and fall with each breath.
4. You may Smell the breath of the victim as they exhale.

If you have placed your hand on the victim’s chest, you may also feel their chest rise and fall against your hand. Search for these signs for 10 seconds. If there is no breathing (or it is slower than 6 times per minute), your victim is not adequately moving air in and out of their body. In order to help them, you must perform rescue breathing.

Calling For Help[edit]

If a bystander has not already summoned assistance, now is the time to make sure that emergency personnel are enroute (known as EMS, Ambulance Service, Rescue Squad, or Paramedics depending on the region). Ideally, someone else will be able to make the call while you continue aid.. If you’re alone, you must stop and call yourself.

• Europe: 112
• USA & Canada: 911
• Australia: 000
• United Kingdom: 999

You will need to give the emergency services:

• Your exact location (including apartment number, suite, building, etc.)
• The illness or injury that the victim is having (to the best of your knowledge).
• A telephone number you can be contacted back on (for instance, if they have difficulty finding you)

In some cases, the person taking your call will run through a list of questions with you in order to make sure the proper resources are sent to you. Also, some localities will give the caller instructions on what to do before help arrives.

Sometimes, the victim must be left unattended while the first aider leaves to seek help for them. If the victim is unconscious they should be left in the recovery position so they do not choke if they vomit. However, if you suspect the victim has an injury to their neck or back, they should not be moved and their head kept stationary, with two exceptions. One, if the victim is in immediate danger (such as from a fire), they should be moved regardless. Two, if the victim is unconscious, the threat of choking outweighs the potential injury to their neck or back, and they should be placed on their side anyway. There are alternative methods for safer positioning available to those with more advanced training.(See Suspected Spinal Injury for more information.)

Rescue Breaths[edit]

Regional Note
In Europe, give 5 rescue breaths for victims of: Drowning Trauma Drug overdose For other victims, begin withcompressions instead of rescue breaths.

Rescue breaths must be provided to victims in a state of respiratory arrest; do not provide them to a weakly breathing victim. If you cannot detect the breath of the victim, or they are breathing slower than once every ten seconds, begin rescue breathing.

If you have a CPR mask or other barrier device, you can use it to protect yourself and the victim from exchange of body fluids. Cheap, keyring-sized CPR masks are available in most pharmacies. Be sure to read the instructions and practice with any equipment you buy. In the event you do not have a barrier device, the rescuer should perform as best they can, given the situation and abilities. If you are uncomfortable performing direct mouth-to-mouth on a stranger, or you find blood or other bodily fluids present, you are not obligated to. You should, however, perform the chest compression portion of CPR, as it is better than doing nothing.

The 2010 CPR guidelines changed CPR so compressions are started first, after checking for breathing.

To give two rescue breaths:

• Kneel at the level of the victim, perpendicular to and facing them.
• Maintain an open airway using the head-tilt chin-lift
• Squeeze the nose of the victim with your free hand to seal it shut.
• Put your mouth on the mouth of the victim in an airtight manner, and blow into the mouth of the victim so that their chest beings to rise. Never blow forcefully, as this may cause the air to enter the stomach and not their lungs. Instead, exhale smoothly over 1-2 seconds.
• Remove your mouth, and let the victim exhale completely (watch for their chest to fall).
• Repeat the above steps for your second breath.

If your breaths do not go in easily, or the victim’s chest did not rise, the airway could have again become closed. Open the airway once again with the head-tilt chin-lift technique and try again, making sure the victim’s neck is extended and their head is rocked back fully.

Continue with CPR compressions.

Principles[edit]

Schematic of the human heart.

The human heart is an electro-mechanical pump, circulating nourishing blood throughout the body. If beating stops, the brain, lungs and even the heart itself stop receiving oxygen and perish. Rescuers can use a technique called chest compressions to squeeze the heart from outside the patient’s chest, helping to circulate blood around. When performing chest compressions during CPR, you are helping move the oxygen you delivered through rescue breathing where it is needed.

Chest compressions are often started before any other intervention in an emergency setting, because even blood that has already passed through the body has oxygen remaining to be used. Using compressions to pump that existing blood around can help buy the patient more time. This is the reason that CPR can be done “compression only”, or without rescue breathing. Once compressions start, they must continue for as long as possible.

Technique[edit]

The goal is always to compress in the center of the chest, regardless of the shape or size of the patient. This means that compressions are to performed on the sternum or breastbone of the patient, in line with the casualty’s armpits or nipple line.

Compressions for infant CPR are done with two fingers only.

• For adults (>8) – place the heel of one hand in the centre of the chest, approximately between the nipple line (on adult males – for females, you may need to approximate the ideal position of this line due to variations in breast size and shape). You may also use the bottom of the casualty’s armpits as a reference mark. Bring your other hand to rest on top of the first hand, and interlock your fingers. Bring your shoulders directly above your hands, keeping your arms straight. You should then push down firmly onto the heel of the lower hand, depressing the chest 5-6cm (2-2.5inches).
• For children (1-8) – place the heel of one hand in the centre of the chest, approximately between the nipple line. Bring your shoulder directly above your hand, with your arm straight, and perform compressions to at least one third (1/3) the depth of the chest with one arm only.
• For infants (<1yr) – Use your forefinger and middle finger only. Place your forefinger on the centre of the child’s chest between the nipples, with your middle finger immediately below it on the chest, and push downwards using the strength in your arm, compressing the chest at least one third (1/3) of its depth. For newborns and small infants, you can hold the child in your opposite arm (head in your palm, feet at your elbow) for easier access.

Give 30 compressions in a row, and then two (2) rescue breaths.

Then restart your next cycle of compressions

Making compressions effective[edit]

You MUST allow the ribs to come all the way back out after each compression, followed by a brief pause. This allows the heart’s chambers to refill. Spacing compressions too close together will lead to them being ineffective.

You are aiming for a rate of 100 compressions per minute, which includes the time to give rescue breaths. In practice, you should get just over 2 cycles of 30 compressions in along with breaths per minute.

Almost everyone compresses the chest too fast – Experience shows that even well trained first aiders tend to compress the heart too fast. The rate you are aiming for is only a little over one per second. The best equipped first aid kits should include a Metronome with an audible ‘beep’ to match your speed to. Many public access defibrillators have these included in their pack. If one is not available, count the number of compressions with the word ‘and’ between them. When you press down on the chest, say the number, when the chest rises say ‘and’. this way, you will be saying ‘one-and-two-and-three…’

The patient should be on a hard surface – If the patient is in bed or a similar cushioned area, moving them to the floor will help assure you are compressing their chest and not the mattress or couch cushions. If moving the casualty is impractical, a hard, flat board can be placed behind them to make compressions more effective.

Keep your arms straight – A lot of television and films show actors ‘performing CPR’ bending their elbows. This is not effective – you should always keep your arms straight, with your elbows locked and directly above your hands.

It often helps to count out loud – You need to try and get 30 compressions per cycle, and it helps to count this out loud or under your breath. In such a stressful situation, you will be anxious and unable to count out loud for the duration, but ensure you keep counting, even if it’s in your own mind.

If you lose count, don’t stop, just estimate – It is important to carry on once you’ve started, so if you lose count, don’t panic, and simply estimate when 30 compressions is over, and do 2 breaths, then start over counting again. Avoid any interruptions in CPR.

You are likely to break ribs – When performing compressions, especially on the elderly, you may find yourself breaking the patient’s ribs. This often feels like flicking the finger of one hand against the palm of another. This is to be expected during CPR, and you should carry on regardless. It is a sign that you are performing good, strong compressions. Oftentimes the cracking sound you will hear is just the cartilage of the ribs and sternum breaking, and not the bones themselves. If bystanders are concerned about injury to the patient, you may want to remind them of the life over limb principle and assure them that it is a normal occurrence, and what you are doing is critically important.

Chest compressions are tiring – This is especially true if you are performing both rescue breathing and compressions by yourself. Studies show that the efficacy of CPR drops when one rescuer performs compressions for an extended time. Hospital emergency rooms switch personnel performing compressions often for this reason. If you are with someone else trained in CPR, rotate between compressions and rescue breaths

When to Stop[edit]

You should continue giving the patient CPR until:

• The casualty starts breathing spontaneously – This occurs very infrequently, and does not include gasping, called agonal breathing. Patients are also likely to make sighing noises or groans as you perform chest compressions – this is just the sound of air trapped in the lungs being forced out, and you should not stop CPR if these noises are heard.
• The patient vomits – This is an ACTIVE mechanism, meaning the patient moves and actively vomits. Not to be confused with regurgitation, where stomach contents make their way passively in to the mouth. If the casualty vomits, roll them to their side, clear the airway once they’re done vomiting and reassess ABCs. Vomit is obviously undesirable for the person performing CPR. Attempt to clear the mouth with your fingers (preferably while wearing a barrier device) and continue CPR. If you are without barrier device and feel uncomfortable giving rescure breaths, give chest compressions only.
• Qualified help arrives and takes over. This could be a responder with a defibrillator, the ambulance service or a doctor. DO NOT STOP until instructed to. They are likely to require time to set up their equipment and evaluate the patient (as you did at first) and you should continue with CPR until instructed to stop. The emergency medical personnel are used to working around people, and may do things like place defibrillator patches while you continue. By continuing CPR, you are keeping the medical personnel free to perform other tasks.
• You are unable to continue – CPR is physically very demanding, and continued periods can be exhausting. Try to change places frequently with another trained rescuer to lessen the chance of exhaustion.
• You put yourself in danger by continuing – Hazards may change, and if your life is endangered by a new hazard, you should stop CPR. If possible, remove the patient from the hazardous situation as well, but never at the risk of your own life or health.

Deadly Bleeding[edit]

Best Practice
If the gauze or dressing becomes saturated, DO NOT take the gauze away. Apply more gauze as necessary, only professional medical personnel should remove dressings. This includes anything the victim may have applied. Add, never take away.

CPR without enough blood is useless, so a check for deadly bleeding should be included in your primary survey whenever possible.

If your victim is breathing, then you should continue your primary assessment with a check for deadly bleeding.

If your victim isn’t breathing, then you’ll be doing CPR; a bystander or second trained first aider may be able to perform this check while you continue resuscitation.

Assessment[edit]

With gloved hands check the victim’s entire body for bleeding, starting with the head. Stick your hands behind or underneath the victim and remove them, repeating this process every couple of inches until you have reached the victim’s heels. If your hands are bloody when you withdraw them, then you’ve found bleeding. An injury on the head or neck, may indicate a spinal injury, in which case you should keep the victim’s head and neck stationary. Be thorough. Blood will seek the lowest level, and a blood soaked sock could be from a knee laceration. Also, hair conceals blood surprisingly well — make sure you check the scalp thoroughly.

Caution
Remember that about 80% of life-threatening bleeding can be controlled adequately using direct pressure alone and the application of a tourniquet may result in the loss of the limb.

 

Treatment[edit]

The key element in treating severe bleeding is the application of firm, direct pressure to the wound, using sterile gauze or other dressing. If the wound is in a limb, raising it above the heart can help, though this should not be done if there is a risk of disturbing fractures, or if it causes much pain to the victim.

You may also consider using pressure points to control major bleeding: press down on an artery that is between the heart and the wound to slow blood from flowing to the wound. Two easily found ones are on the underside of the bicep area, and the underside of the thigh area of the leg.

Tourniquets may also be useful in controlling massive bleeding such as an amputation. This is not a standard procedure and should only be used as an ABSOLUTE last resort when the victim will die without it. Also, once a tourniquet is applied, it is only removed by a physician.