Approach and assessment

Danger

Approach with care, making sure that there is no continuing danger either to yourself or the casualty. Be aware of hazards from electricity, gas, traffic, masonry, etc.

Response

Assess whether or not the casualty is conscious. Carefully shake his shoulders and ask loudly "What's happened?" or "Are you all right?" or give a command such as "Open your eyes". An unconscious casualty will not respond.

Shout for help

If someone else is nearby ask him to wait as you might need his assistance. If you are alone, shout loudly to try and attract attention but do not leave the casualty.

Airway

In an unconscious casualty the tongue may fall back to block the airway. By tilting the head back and lifting the chin forward the tongue is drawn away from the back of the throat.

Unless you can assess him fully in the position in which you find him, turn the casualty onto his back. Place one hand on his forehead and gently tilt his head back. (Keep your thumb and index finger free to close the nose if rescue breathing is required).

Remove any visible obstruction from his mouth (leave well-fitting dentures in place).

Then lift the chin using two fingertips of your other hand under the point of the chin. This will open the airway.

In casualties with suspected neck injuries, try and avoid head tilt, using chin lift to clear the airway. The first priority, however, is to obtain a clear airway and some degree of head tilt may be unavoidable. Neck injuries can happen as a result of:

• head injury

• road accidents

• falls from heights

• dives into shallow water

• accidents involving rugby scrums

• horse riding falls.

Breathing

LOOK, LISTEN and FEEL for up to 10 seconds

Keeping the airway open check whether the casualty is breathing normally by looking for chest movement, listening at the mouth for breath sounds and feeling for breath on your cheek. Look, listen and feel for 10 seconds before deciding that breathing is absent.

There may be several reasons why the casualty has stopped breathing. These include:

• lying unconscious on his back with a blocked airway

• heart attack

• injury to the head or chest

• poisoning (drugs, toxic gases etc)

• drowning

• choking

Circulation

Once you have given 2 rescue breaths, assess the casualty for signs of a circulation by again looking, listening and feeling for normal breathing, coughing or movement.
Check for signs of a circulation for no more than 10 seconds.

If there are no signs of a circulation, or you are at all unsure, assume that the heart has stopped. This is called cardiac arrest.

The casualty will be unconscious and may appear very pale, grey or bluish in colour. An artificial circulation will have to be provided by chest compression. If the circulation stops then breathing will stop also; casualties with cardiac arrest will need both rescue breathing and chest compression, a combination known as cardiopulmonary resuscitation (CPR).

CPR will "buy time" for the casualty by allowing blood containing oxygen to be circulated around the body preventing damage to vital organs such as the brain. It will not "bring the casualty back to life" which is why it is important that the ambulance is called as quickly as possible. Ambulance personnel will be able to use a machine called a "defibrillator" designed to deliver an electric shock to the heart, which may be able to start it beating again.

Action plan for resuscitation of adults

Casualty is responsive and breathing:

1. Leave him in the position you found him (unless this is dangerous).

2. Get help if necessary.

3. Keep checking his condition.

Rescue breathing

This is usually given by the "mouth to mouth" method.

Turn the casualty onto his back, if he is not already in this position, and kneel by him. Keep the airway clear (head tilt and chin lift) and pinch his nose closed. With your other hand keep the chin lifted and allow his mouth to open. Take a breath, place your mouth completely over the mouth of the casualty, making a firm seal, and breathe steadily into the casualty.

Each breath should be sufficient to cause the chest to rise as in normal breathing; take about 2 seconds.

Maintaining head tilt and chin lift, take your mouth away from the casualty and allow the chest to fall fully as the air comes out.

Chest compression

If there are no signs of a circulation, or you are at all unsure, you will need to start chest compression once 2 effective rescue breaths have been given. Chest compression is performed with the casualty lying flat on his back on a firm surface. By rhythmically depressing the breastbone towards the backbone, blood is made to flow out of the heart and around the body.

Kneeling by the side of the casualty find the lower half of the breastbone by running the index and middle fingers of one hand up the lower margin of the ribcage and finding the notch where the ribs join. With your middle finger in this notch place your index finger on the breastbone above.

Slide the heel of your other hand down the breastbone until it reaches your index finger. It will then be in the middle of the lower half of the breastbone. Place the heel of your first hand on top of the other and interlock the fingers. With your elbows straight, bring your shoulders up until they are directly over the casualty's chest.

Note that the fingers are clear of the chest

Depress and release the breastbone 4-5 centimetres (1½ - 2 inches). The recommended rate is approximately 100 chest compressions per minute. You might find it helpful to count aloud "One, two, three ... fifteen."

Chest compression must always be combined with rescue breathing so after every 15 compressions give 2 effective rescue breaths.

Continue to alternate 2 breaths with 15 compressions.

Recovery position

The unconscious casualty who is breathing should be placed in the recovery position. This allows the tongue to fall forward keeping the airway clear. It also reduces the risk of stomach contents entering the air passages.

Kneel beside the casualty and if he is wearing spectacles remove them. Make sure his legs are straight. Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm uppermost.

Bring the arm furthest from you across the chest. Hold the back of the casualty's hand against his nearer cheek.

With your other hand grasp the thigh furthest from you and pull up the knee, keeping the foot flat on the ground. Keeping the hand pressed to the cheek, pull on the thigh to roll the casualty onto his side, towards you.

Adjust the upper leg so that the hip and knee are both bent at right angles to prevent him rolling onto his face. Tilt the head back to ensure that the airway stays open, adjusting the hand under the cheek if necessary. Recheck for signs of breathing at regular intervals.

Resuscitation of children

In the following description please note: a baby is a child of less than one year; a child is aged between 1 year and adulthood; a younger child is aged between 1 and about 8 years; an older child is aged over the age of about 8 years.

Children are at risk from accidents in the home, in water, and on the road, when airway and breathing problems can occur. Fortunately heart attacks are rare in children.

Heart attack

Every year about 170,000 people in the United Kingdom die from a heart attack. Many of them could be saved if they or someone nearby recognised the early warning signs and called for professional help quickly.

A heart attack most commonly occurs when a clot suddenly reduces the blood supply to the heart muscle, for example in one of the "coronary" arteries, which feed blood to the heart. The effect depends on the extent to which the heart muscle is affected - many heart attack victims recover completely.

The main risk during a heart attack is that the heart will stop beating (cardiac arrest).

Recognition of a heart attack

The "warning signs" of a heart attack are described below, but an attack can also happen without any prior warning at all. Most people having a heart attack experience chest pain which does not go away. The type of pain may vary; it may sometimes feel like severe indigestion. Occasionally, however, a heart attack can occur with the victim experiencing only minor feelings of discomfort.

Action

Make the person comfortable and help him find a relaxed position which will reduce the work of the heart; a half sitting position with head and shoulders supported and knees bent is often preferred. Do not give him anything to eat or drink. Fetch a bowl if the casualty thinks he is going to be sick.

Dial 999 for an ambulance and telephone the victim's own doctors. DON'T WASTE TIME!

"Warning signs" of a heart attack

• Persistent crushing pain in centre of chest
      - often wraps around body like a tight band
      - may spread to arms, throat, jaw, back, or abdomen
      - does not go away with rest
  
• Being short of breath
• Feeling sick
• Feeling weak or dizzy
• Sweating may develop
• Skin may become "ashen" pale with blueness of the lips
• Pulse is usually fast and may become weak and irregular

Choking

Choking occurs when a "foreign body", for example a piece of food, lodges in the back of the throat blocking the entrance to the windpipe. A choking casualty may have difficulty breathing and may turn blue. If conscious, he may try to indicate that he is choking by grasping his neck with his hands or pointing to his throat.

Choking in adults

Reassure the casualty. If he is breathing, encourage him to cough but do nothing else.

If he shows signs of becoming weak, or stops coughing:
Stand to the side and slightly behind him. Support his chest with one hand and lean him well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the windpipe. Give up to 5 sharp blows to the back between the shoulder blades.

If this fails try abdominal thrusts. These force air out of the lungs by the sudden inward and upward movement of the abdomen against the diaphragm:

Stand behind the casualty and put both arms around the upper part of the abdomen just below the rib cage. Clench your fist and grasp it with your other hand. Pull sharply inwards and upwards; the obstruction may then pop out of the mouth. Give up to 5 thrusts, then 5 more back blows if necessary. Keep alternating 5 back blows with 5 abdominal thrusts until the obstruction is removed.

If the casualty becomes unconscious:
Loss of consciousness may result in relaxation of the muscles in the throat and allow air to pass down into the lungs. If at any time a choking victim loses consciousness:

Tilt the casualty's head and remove any visible obstruction from the mouth.

Open his airway further by lifting his chin.

Check for breathing by looking, listening and feeling.

Attempt to give 2 rescue breaths.

If rescue breaths can be achieved within 5 attempts:

    - Check for signs of a circulation
    - Start chest compression and/or rescue breathing as appropriate

If rescue breaths cannot be achieved within 5 attempts:

    - Start chest compression immediately to relieve the obstruction.
       Do not check for signs of a circulation
    - After 15 compressions, check the mouth for any obstruction,
       then attempt further rescue breaths
    - Continue to give cycles of 15 compressions
       followed by attempts at rescue breaths.

If at any time rescue breaths can be achieved:

    - Check for signs of a circulation
    - Start chest compression and/or rescue breathing as appropriate.

Choking in a baby

Only attempt to clear an obstruction if the baby is unable to breathe for himself. Never try to remove an obstruction by blindly putting your fingers in his mouth.

Bleeding

Severe bleeding can result in poor circulation and may lead to the casualty's death. It therefore needs to be controlled.

Using disposable gloves if available, remove clothing to expose the wound. Press down on top of the wound using your hand, together with a dressing or pad if one is available.

If the injured part can be raised above the level of the heart, this will slow down the blood flow to the wound.

If you cannot apply direct pressure over the wound, grasp or squeeze the edges of the wound together. Do not remove anything sticking out of the wound - it may cause extensive bleeding.

Lay the casualty down if possible and raise the legs to improve blood flow to the vital organs.

Protect the casualty from the cold - cover with a blanket or coat. Do not give the casualty anything to eat or drink in case an anaesthetic is needed later.

Summary of resuscitation procedures

Summary of resuscitation procedure for adults

1. Remember - seconds count

2. Look for danger - approach with care

3. Assess responsiveness - shake and shout

4. Shout for help - ask someone to assist you

5. Open the airway by head tilt and chin lift (if you suspect a neck injury, try chin lift only)

6. Check for breathing - look, listen and feel for up to 10 seconds

Responsive and breathing:

• Leave him in the position you found him (unless this is dangerous)

• Get help if necessary

• Keep checking his condition

Unconscious but breathing normally:

• Turn him into the recovery position

• Dial 999 for an ambulance

• Check for continued breathing

Unconscious and not breathing:

Send someone to dial 999 or, if you are alone, go yourself.

• Give 2 effective rescue breaths

• Check for signs of a circulation - look, listen and feel for normal breathing, coughing or movement - for no more than 10 seconds:

Continue resuscitation until:

    - circulation and breathing are restored or

    - a doctor or qualified professional assumes responsibility for the casualty or

    - another rescuer takes over from you or

    - you are completely exhausted and unable to continue.

Summary of resuscitation procedure for an older child
(over 8 years to adult)

Follow the same procedure as for an adult (see above) but remember that you should give up to 5 initial rescue breaths. If you are alone, you should perform resuscitation for about a minute before leaving the casualty and going to dial 999 for an ambulance yourself.

Summary of resuscitation procedure for a younger child
(1 - 8 years)

Follow the same procedure as for an older child (see above) but remember that you will only need one hand to perform chest compression. Continue in cycles of 1 breath to 5 compressions.

Summary of resuscitation procedure for a baby
(under 1 year)

• Send someone to dial 999 or, if you are alone, perform resuscitation for one minute before making the call yourself
• Give up to 5 rescue breaths, blowing into the baby's mouth and nose together, and making sure at least 2 are effective
• Check for signs of a circulation - look, listen and feel for normal breathing, coughing or movement - for no more than 10 seconds:
  • If there are no signs of a circulation, give 5 chest compressions, using 2 fingers, and continue cycles of 1 breath to 5 compressions
  • If you are sure there is a circulation, continue rescue breathing and recheck for signs of circulation once a minute. If breathing restarts, place baby on his side and continue to check his condition.

Introduction to Automated External Defibrillators (AEDs) for the Citizen

Most of this document is concerned with the first aid procedures that will sustain life in a casualty with cardiopulmonary arrest until the arrival of the emergency services. The modest flow of blood achieved by cardiopulmonary resuscitation (CPR) may make the difference between life and death because it supplies enough oxygen to vital organs to keep the casualty alive until normal breathing and circulation can be restored.

Ventricular fibrillation is responsible for the great majority of sudden cardiac deaths. It is a condition in which the heart "quivers" rather than beats properly and, once it has developed, time is the most crucial factor that determines the chances of successful resuscitation. The only effective treatment for ventricular fibrillation is defibrillation - a term used to describe the application of a high energy electric shock to the chest of the casualty to restart the heart. This procedure is widely portrayed in films and medically orientated television dramas. It must be performed within a very few minutes of the start of ventricular fibrillation if it is going to succeed.

CPR by itself is unlikely to restart a heart that has stopped. At best it is considered a "holding measure" until more advanced treatment is possible. CPR will buy time until a defibrillator can be brought to the casualty, but unless it is started within the first few minutes after cardiac arrest very few victims survive even when defibrillation is carried out later.

Until recently, the use of defibrillators required considerable training and skill, but the introduction of the automated external defibrillator (AED) has meant that defibrillation can now be carried out by trained first aid personnel and other lay responders. All that is required is the ability to recognise that cardiac arrest may have occurred and to attach two adhesive electrode pads to the chest wall. Audible voice prompts and visual instructions then guide the operator through the rest of the defibrillation procedure.

AEDs are increasingly being provided in venues where large numbers of the public congregate like airports, railway stations, sports grounds and shopping complexes. The intention is that they should be operated by lay personnel, often security staff or other trained workers at the site. The UK Government has recently launched a major initiative to provide defibrillators at different public locations throughout England, and these will be installed during the years 2000 and 2001.

The average citizen may soon not only be able to provide CPR to keep alive a victim of sudden cardiopulmonary arrest, but may also be able to carry out definitive life saving treatment by using an AED.

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