Bushcraft and Outdoor Skills - First Aid Part 2


	Airway Management, Rescue Breaths & CPR

SECTION 2 – AIRWAY MANAGEMENT , RESCUE BREATHS & CPR

CLEARING THE AIRWAY
An unconscious casualty has no control over his or her muscles, including the muscles that control the tongue. The relaxed tongue will fall backwards across the airway, and cause an obstruction. If a breathing unconscious casualty remains on his or her back, the risk of airway obstruction is increased. An unconscious casualty may also have material in the mouth such as food, blood or vomit, which may obstruct the airway. It is vital that if such material is present it is removed as soon as possible.

The diagram below shows, both the normal position of the tongue during breathing and the position of the tongue when it has obstructed the airway.

REMEMBER: It may not be the tongue that is obstructing the airway; it could be a foreign body.

The clearing of the airway in an unconscious casualty takes precedence over any other injury or illness, and this includes spinal injuries. In most situations the airway can be managed with the use of backward head tilt and jaw thrust. In the event that the airway is obstructed by a foreign body, then the airway should be cleared with the casualty lying on their side to avoid accidental inhalation of obstructions.

Roll casualty onto side
Place your hand on the forehead and gently tilt the head back
Support and lift the chin to open the airway
Lift the jaw forward to open the mouth
Remove any visible obstruction from the casualty’s mouth
Remove dislodged or loose dentures
Leave well fitting dentures in place

Jaw thrust
In some instances involving injuries or illness, the casualty's airway may be difficult to open. An alternative method of airway maintenance is the jaw thrust.

Apply pressure with the fingers behind the angle of the jaw.
Thrust the jaw gently forward and up, opening the airway.

RESCUE BREATHS

During normal breathing, without physical exertion, a person breathes in approximately 21% oxygen. The body uses between 4-5% of this amount for its normal functions.
So during expiration a person breathes out approximately 16% oxygen. To breathe into another person as a means of supplementing their oxygen supply is essential for a non breathing casualty. Immediate rescue breaths are necessary to prevent the brain suffering from tissue damage, which can occur within 3-4 minutes.

There are 5 methods of providing breathing assistance to a casualty, which are listed below.

Mouth-to-Mouth where the breather seals the casualty’s mouth with their own mouth, pinches the nose closed, and then blows air into the casualty’s mouth. The most common of all methods.

Mouth-to-Nose is used where the casualty has sustained facial injuries that preclude using the mouth. The rescuer closes the casualty’s mouth, covers the nose with their mouth, breathes gently, then releases the casualty’s jaw to allow exhalation.

Mouth-to-Nose-&-Mouth is the preferred method when resuscitating a child, as the rescuer’s mouth can cover and seal the child’s nose and mouth.

Mouth-to-Stoma is used for resuscitating a casualty who breathes through a stoma, an opening in the neck, through which the casualty normally breathes. The rescuer breathes through the stoma directly into the airway while blocking the nose and mouth. Casualties who have a stoma often wear a scarf or fabric filter over the stoma. Be alert for the presence of a stoma under such wrappings.

Mouth-to-Mask is the most desirable method for rescue breaths as it lessens the risk of cross-infection and is more acceptable to many people than mouth-to-mouth. Masks come in various forms but they are used similarly.

Indications for rescue breaths: The following are indications which should lead the first aider into performing rescue breathing on the casualty.

Not breathing, or is only making occasional gasps or weak attempts at breathing.
Unconscious collapse.
Cyanosis (blue colour).

Procedure for rescue breaths:

Always send someone for help if you have not already done so.
If you are alone with an adult casualty, leave them immediately you realise they are not breathing and go to telephone for an ambulance, then return and give 2 rescue breaths.
Turn the casualty onto their back if not already in this position.
Give 2 slow effective breaths.
Ensure the chest rises with each breath, take no more than 10 seconds to do this.
Ensure the head is tilted, carryout a jaw thrust.
Pinch the soft part of the casualty’s nose closed, open the mouth maintaining jaw thrust.
Take a deep breath to fill your lungs with oxygen, and place your lips around the casualty’s mouth, making sure that you have a good seal.
Blow steadily into the casualty’s mouth whilst watching the chest.

Ø Adults and older children - take about 2 seconds to make the chest rise as in normal breathing.

Ø Younger children and infants - take about 1 -1.5 seconds to make the chest rise as in normal breathing.

Maintaining head tilt and jaw thrust, take your mouth away from the casualty and watch for the chest to fall.
Repeat the sequence as above, giving at least two effective breaths in all.
If you have difficulty achieving an effective breath, re-check the casualty’s mouth and remove any obstruction.
Re-check that there is adequate head tilt and jaw thrust, check circulation.

If Circulation Present:

Continue rescue breaths until the casualty starts breathing on their own.
Adults and older children - give 10 breaths per minute
Younger children and infants - give 20 breaths per minute
If the casualty starts to breathe normally on their own but remains unconscious, turn them into the recovery position
Observe and reassess the casualty’s vital signs regularly

If Circulation absent - Commence CPR

Slow breaths are used for an adult and older child. When breathing into a young child ensure that you modify the force of the breaths. If delivered too forcefully, the air will be directed into the stomach, which may cause the child to vomit.
The method to be employed for infants is "frog breathing" or "puffing", where the rescuer fills his or her mouth with air and "puffs" it into the infant;s mouth. There will be adequate pressure and volume to satisfy the lung's requirements, but not enough to impact on the stomach.

Rescue breaths are continued until the casualty begins breathing on their own, until the rescuer is relieved by medical aid, or until the casualty deteriorates into full cardiac arrest at which point the rescuer delivers cardiopulmonary resuscitation (CPR).

During rescue breaths, stop inflation once there is visible rise of the chest. Do not over inflate!

CARDIOPULMONARY RESUSCITATION:
The term Cardiopulmonary resuscitation (CPR) means Rescue Breaths used in conjunction with External Cardiac Compressions (ECC) when a casualty is in cardiac arrest – There is not beating of the heart, which is preventing Oxygen from being sent around the body. Rescue breathing provides oxygen to the casualty’s lungs and blood whilst external cardiac compressions, when applied correctly, pumps the oxygenated blood around the body. Effective CPR can sustain a casualty until more expert medical treatment is available. Cardiac arrest may be caused by heart attack, lack of oxygen (hypoxia ), choking, electrocution, drug overdose, drowning, trauma (bleeding), or other medical condition - however the first aid treatment is the same, CPR!

Indications which will lead you to performing CPR:

Unconsciousness.
No normal breaths, although there may be brief irregular, ‘gasping’ breaths.
No signs of circulation.

To maximize effectiveness of CPR and to avoid damage to the ribs and organs such as the lungs and the liver, it is particularly important that the first aider hands are positioned correctly. Using your middle and index fingers, find the lower rib edge nearest to you. Keep your fingers together and slide them upwards to the point where the ribs join the breastbone (sternum). This point is called the Xiphoid Process. With your middle finger on this point, place your index finger on the sternum itself.

Once you have the correct location you need to compress the chest the appropriate depth depending on age of the casualty.

15 years or older	9 – 14 years	1 to 8 years	Newborn to 1 year
2 hands	2 hands	1 hand	2 fingers
4-5 cm	4-5 cm	1/3 depth of chest	1/3 depth of chest

Adults and Older Children:
Locate the Xiphoid Process. Slide the heel of your other hand down the sternum until it reaches your index finger. This should be the middle of the lower half of the sternum. The second hand is positioned over the first and the wrist is gripped for stability. Lift the fingers to ensure that pressure is not applied over the casualty's ribs. Ensure that there is no pressure exerted over the upper abdomen or bottom tip of the sternum. An alternative is for the fingers of the second hand to entwine or interlock the first. Position yourself directly above the casualty's chest and, with your arms straight, press down on the sternum with two hands between 4-5 cm. Release all the pressure without losing contact between the hand and sternum. Compress at a rate of about 100 times a minute (a little less than two compressions a second).

Younger Children
Locate the Xiphoid Process. Slide the heel of your other hand down the sternum until it reaches your index finger. This should be the middle of the lower half of the sternum. Lift the fingers to ensure that pressure is not applied over the casualty?s ribs. Ensure that there is no pressure exerted over the upper abdomen or bottom tip of the sternum. Position yourself directly above the casualty?s chest and, with your arms straight, press down on the sternum with one hand approximately 1/3 the depth of the chest. Release all the pressure without losing contact between the hand and sternum. Compress at a rate of about 100 times a minute (a little less than two compressions a second).

Infants
Locate the Xiphoid Process. Slide two fingers of your other hand down the sternum until it reaches your index finger. This should be the middle of the lower half of the sternum. Ensure that there is no pressure exerted over the upper abdomen or bottom tip of the sternum. Position yourself directly above the casualty?s chest and press down on the sternum with two fingers approximately 1/3 the depth of the chest. Release all the pressure without losing contact between the hand and sternum. Compress at a rate of about 100 times a minute (a little less than two compressions a second).

Procedure for CPR:

Ensure the safety of all those at the scene
Check the casualty’s response, if you are alone with an adult casualty, leave them immediately you realise they are not breathing and go to telephone for an ambulance, then return and give 2 rescue breaths
Check the airway is open & clear, if obstructed roll the casualty and open and clear the airway
check breathing.
If no breathing, give 2 slow effective breaths, ensuring that the chest rises with each breath, taking no more than 10 seconds to do this.
Check circulation.

If no signs of circulation:

Locate correct compression point, use your middle and index fingers to find the lower rib edge nearest to you.
Keep your fingers together and slide them upwards to the point where the ribs join the sternum.
Place your index finger on the sternum.
Place (hand, hands or fingers) on the sternum beside your index finger depending on age of casualty.

Adult	Older Child	Younger Child	Infant
2 hands	2 hands	1 hand	2 fingers

Position yourself directly above the casualty's chest, with your arms straight, press directly down on the sternum.

Adult	Older Child	Younger Child	Infant
4-5 cm	4-5 cm	1/3 depth of chest	1/3 depth of chest
15 compressions	15 compressions	5 compressions	5 compressions
100 per minute	100 per minute	100 per minute	100 per minute

Give effective breath(s)

Adult	Older Child	Younger Child	Infant
2 effective breaths	2 effective breaths	1 effective breath	1 effective breath

Return your hands quickly to the correct position on the chest and then give the next compressions
Repeat effective breaths
Repeat cycles (Compressions: Breathing).
If the first aiders wish to change over as they become tired, this should be done as quickly as possible.

The following points regarding two-person CPR should be noted.

The first priority is to summon help. This may mean that one rescuer has to start CPR alone whilst the other leaves to find a telephone.
First aiders should work from opposite sides of the casualty, this allows each aider to view what the other is doing.
A ratio of 15 compressions to two inflations should be used.
At the end of each series of 15 compressions, the first aider responsible for breaths should already be positioned ready to give two inflations with the least possible delay.

Only stop CPR if:

The scene becomes unsafe.
Another trained first aider arrives and takes over.
Qualified help arrives and takes over.
The casualty shows signs of recovery.
You become physically unable to continue.

If for any reason rescue breaths can not be given, chest compressions should still be administered as some oxygen will still be circulated with compressions alone.