Basic First Aid Course

AIMS AND OBJECTIVES OF BASIC FIRST AID:

To give you a good overview of the principals of first aid, shock, first aid safety, patient assessment,
bleeding and wounds, fractures, choking and C.P.R.

FIRST AID is the initial assistance given for any victim before the arrival of an ambulance, doctor or
other qualified person. The purpose of having people trained in First Aid is to provide help and care to
the injured or sick, for the shortest possible time, until the care of the patient or victim can be taken over
to a better-qualified person. In your working environment the better- qualified person can be the medical
clinic staff, the ship’s doctor or environment the better-qualified person can be medical clinic staff, the
ship’s doctor or nurse, or even the land-based ambulance staff. The fact that you will hand over your
patient to another person doesn’t make what you are doing any less important. It is vitally important for
any seriously injured or sick person to receive help as soon as possible, and first aiders are trained for
this specific reason- to give help and treatment as soon as possible.

A first aider, or a person trained in first aid meets the following conditions:
He/She is trained by a suitable instructor in specific fields of first aid, according to the guidelines as
determined by an international recognized first aid institution.

In order to stay current in first aid, the first aider should be examined and tested regularly, preferably
every year, since first aid protocols, and more specific CPR protocols, changes
almost yearly. The first aider should be re-examined on a regularly basis in order to ensure his/ her first
aid capability and proficiency.

It is also expected from the first aider to ensure that he/she stays up to date in any changes which may
occur, obtaining theoretical information through reputable publications or web sites such as the web site
of the American Heart Association ([Link]). Should the first aider learn about new guidelines
and seek the guidance and help of qualified instructors in case of any difficulty.

Research have shown that first aiders who are proficient in CPR, loses 60% of their practical skills if
they don’t practice CPR within one year of the previous official training they received. This makes it
very important to practice CPR at least yearly, if not every six months.

The aims of first aid are basically the preservation of life, the prevention of worsening of the patients’
condition and the promotion of recovery of the patient.

The first aim of first aid, preservation of life is the most important function of the first aider, and this
specific function can easily be accomplished and demonstrated in the choking victim or the patient
going into sudden cardiac arrest. In both these cases, the immediate, correct and efficient treatment
given by the first aider can really save the life. In these cases, if the patients have to wait for advanced
life support as rendered by higher trained medical staff, the waiting time can very well mean the end of
the patient-THERE IS NO TIME TO WAIT- help must be given immediately, and the first aider is the
best and most readily available person to do this.

The second aim of first aid, the prevention of the worsening of condition, is also inside the scope of the
first aider. For example, if somebody falls and break his upper leg (fracture of the femur), the patient can
loose up to 1500ml body fluids because of the fracture. If the patient is allowed to move around with an

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un-splinted or unstable fracture, the amount of body fluids lost can double. Losing more body fluids will
result in greater shock and the worsening of the patient’s condition, even to such a point that the patient
may die.

The third aim, the promotion of recovery is always fulfilled whenever the first aider renders effective,
indicated treatment. As in the example mentioned in the above paragraph, the early stabilizing of the
fracture reduces fluid loss, combats shock and relieves swelling and pain. These combined factors will
surely lead to a faster recovery of the patient, not only in helping recovery.

The second and third aim of first aid is also accomplished very efficiently during treatment of a patient
suffering from a stroke. Research have shown that the early calming of the patient
(resulting in less movement and a subsequent lowering of blood pressure) and the early administer of
oxygen can reduce the permanent damage inflicted by a stroke by as much as 50%.

PRINCIPLES OF FIRST AID

In the world first aid has been as much as part of the culture as drinking tea. Caring volunteers and
individuals performed as much needed service to the sick and injured and laid the foundations for the
formal first aid organizations such as St John Ambulance and the Red Cross.

The period between the World Wars saw an increased awareness in the community of the benefits of
first aid and the combining of other activities, such as surf life saving, with first aid training. It was not
until the 1960’s and 1970’s that the general public became involved by attending first aid classes and
using this new found knowledge to their benefit.

First aid training has now become virtually indispensable to industry and
for an active social life.

 What is First Aid?

First aid is the initial care of the injured or sick. It is the care administered by a concerned person as
soon as possible after an accident or illness. It is the prompt care and attention that sometimes means the
difference between life and death, or between a full or partial recovery.

First aid has limitations- not everybody is a doctor- but it is an essential and vital part of the total
medical concept. FIRST AID SAVES LIVES! …. ask any ambulance offer or doctor who works in the
emergency medical field.

Immediate action:

It is important that any action taken by the first aid provider is done as quickly as possible. Quick action
is necessary to preserve the life and truth. A casualty who is not breathing effectively, or is bleeding
copiously, requires immediate intervention, and if quick effective first aid is provided, then the
casualty’s chances of recovery are improved immeasurably. It should be remembered though that any

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action undertaken is to be deliberate and panic by the first aid provider and bystanders will not be
beneficial to the casualty. Try to remain calm and think your actions through.

 How do I get help?

To get expert medical assistance, call the Police ambulance on “999”. If your company has a medical
clinic on site, it is better to call the clinic staff and let them decide whether it is necessary to call an
outside ambulance.

If you are attending a casualty, get a bystander to telephone for help- if you are on your own, then you
may have to leave the casualty momentarily to make a call. It’s common sense, the decision is yours!

Medic alert

Some individuals suffer from certain medical conditions that may cause them to present with serious
signs and symptoms at any time. As a form of assistance and notification, these people may wear a form
of medical identification, usually a special bracelet, or less commonly, a necklace. These devices are
commonly referred to as ‘ Medical Alert’ bracelets, but are also known as ‘Vital of Life’ and ‘SOS
Talisman’. They are stamped with the person’s identity, the relevant medical condition, and other details
which may include allergies, drugs required, or specialized medical contact. Medical conditions that
may be notified vary from specific heart diseases, to diabetes, epilepsy, asthma etc.

SHOCK

The function of the circulation system is to distribute blood to all parts of the body, so the that oxygen
and nutrients it carries can be delivered to the cells. When the system fails, and insufficient oxygen
reaches the cells, the medical condition known as “shock” will develop.
Since the brain and heart need a permanent supply of fresh oxygen, they will first be affected by shock.
Other vital organs, like the liver, spleen, kidneys and pancreas can be without oxygen for a longer time
(15 to 60 minutes) before their function will decrease: The skin, muscles and bone can be without
oxygen for up to 4 hours before permanent damage or death will occur. If shock is not rapidly treated the
vital organs will fail, leading to unconsciousness, coma and death. The condition of shock is increased if
pain is present.
 What causes shock?
 First, shock can develop when the heart fails to pump effectively, resulting in a drop in
circulating blood pressure. The most common cause of this type of shock is a heart
attack.
 Secondly, shock can develop when the volume of fluid circulating around the body is
reduced. External and internal bleeding, or loss, of other body fluids because of
diarrhoea, vomiting, sweating or bums, are the most common reasons. The body responds
by withdrawing the blood supply from the surface and extremities to the core of the body.
The main symptoms and sips of shock is related to this re-distribution of blood

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Recognition
1. A rapid, weak pulse,
2. Pale tissue colour (tissue colour refers to the inside the mouth and under the
eyelids)
3. Reduced peripheral circulation — if the fingernail original colour immediately;
4. Sweating and a cold, clammy skin;
5. Weakness and confusion;
6. Nausea and vomiting;
7. Fast, shallow breathing;
8. Fear and anxiety;
9. Decreased level of consciousness;
10. Heart and brain failure, causing death.

Treatment
1. Call for help
2. Treat any cause of shock (if there is bleeding, stop it, if there is a fracture, stabilize and
immobilize it, if the is no breathing, give ventilation, if the heart stopped, do CPR.)
3. If the casualty is conscious, lay him down on his back,
4. If the casualty is unconscious, turn him on his side — take care of his spinal column.
5. Elevate the legs and arms — if a fracture is present, first immobilize the fracture before
elevating the limb. If the patient has a brain injury, stroke, asthma or a heart attack,
don’t elevate the legs or arms.
6. Give oxygen
7. Loosen tight clothing to allow the patient to breathe easier.
8. Maintain normal body temperature- do not overheat the patient- ideal ambient temperature
is 22-24 degree celsius.
9. Talk constantly with the patient, re-assure him and try to calm him.
10. Check and record breathing, pulse and level of consciousness.
11. DO NOT allow the patient to eat, drink, smoke or move unnecessary
12. DO NOT leave the patient unattended.

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RESPRIRATORY SYSTEM

Oxygen is essential to support life. The process of breathing enables air which contains oxygen to enter
the lungs, where the oxygen are transferred to the blood, and then circulated through the body. The
action of breathing, and the process of gas exchange in the lungs are commonly described as respiration,
and the organs, tissues and structures that enable us to breathe is called the RESPIRATORY SYSTEM.

The respiratory system supply oxygen to the individual cells and removes the waste product, carbon
dioxide. Oxygen is obtained from the air, which is a mixture of oxygen, nitrogen and other gasses.

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Mechanics of breathing
We have three sets of muscles which enable us to breathe. There are two sets of intercostals (between
the ribs) muscles, and the diaphragm, which is below the lungs and above the abdomen.

There are two phases of breathing:

1. Inhalation —when air is drawn into the lungs.
2. Exhalation — the expulsion of air from the lungs.

During inhalation, one set of intercostals muscles and the diaphragm contract to enlarge the chest
cavity. Because the chest cavity becomes bigger, negative pressures are formed inside the chest, and air
from outside the body enters the lungs to equalize the pressure, thus air enters the lungs.
During exhalation, one set of intercostals muscles contract, the other set relaxes, the diaphragm relaxes,
the chest cavity becomes smaller, a higher pressure is created inside the lungs, and the air exits the lungs
to the outside.
Breathing is controlled by the respiration center, situated in the medulla oblongata of the brain. When
the oxygen level in the blood decrease (and the carbon dioxide level increases), the brain sends impulses
through the nerves to the respiration muscles, stimulating them to work faster. This results in an increase
of respiration speed, resulting in more oxygen being present in the lungs and more oxygen present in the
blood. The respiratory muscles works involuntarily, but can be controlled to some extend.

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Respiration rates
The average rate of breathing for an adult is between 12 and 20 times per minute. Children and infants
breathe faster. The breathing rate, or respiration rate may differ vastly, depending on age, level of
fitness, activity level, outside air pressure, temperature and the psychological state of the person.
Respiratory disorders
Asphyxia is the medical term for suffocation, when there is no oxygen being taken up iri the blood.
Reasons for asphyxia include:
 Smothering
 Obstruction of the air passages by means of a
foreign object, strangulation, aspiration, airway
swelling or any other reason which prevents
oxygen from being absorbed into the blood.
 Chest or lung trauma such as external pressure
and pneumothorax injuries.
 Paralysis of the respiratory muscles, due to spinal
or brain injury, electrocution, poison, drugs or a
medical disease such as Gillian Beret.
 Lack of oxygen, where the air doesn’t contain
enough oxygen to sustain life, as can be found in
the presence of certain gasses, chemical fumes,
smoke and high altitude.
 Lung disease or illness, such as emphysemia,
oedema, pneumonia and asthma.

Hypoxia is the medical term for a condition where gas exchange takes place, but the amount of oxygen
absorbed into the blood is not enough to sustain life. In this case the cells of the vital organs (brain arid
heart) starts dying within three to four minutes
• All the causes for asphyxia can be the reasons for hypoxia, the only difference is that in hypoxia, some
gas exchange will still take place.

Signs and symptoms of hypoxia

• Rapid, shallow, distressed breathing
• Decreased level of consciousness,
• Cyanosis and skin! tissue color changes

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• All the signs and symptoms of shock

If hypoxia and asphyxia is not quickly reversed, respiratory and heart functions will stop.
PRIMARY SURVEY:
SCABCS
SCABCS is the prime consideration for everyone involved in the care and treatment of casualties.
Experienced first aid providers, ambulance crews, nurses and medical specialists, are all-aware of the
importance of Safety, Communication, Airway, Breathing, Circulation and Stop profuse bleeding.

SAFETY

 To yourself: don’t put yourself in danger!

 To the casualty: remove the danger from the
casualty, or the casualty from the danger!
 If it is not safe to touch or treat the patient, then
don’t!
Part of safety includes protecting yourself against
infectious diseases.

INFECTIOUS DISEASES:
INFECTIOUS DISEASES are those diseases that cause infections to the human body, and in some cases
are transmitted by contact or by cross-infection. Infection may be due to bacteria, viruses, parasites or
fungi. The usual methods of communication are:
 Direct contact(contact with an infected person)
 Indirect contact(through feces, air conditioning etc)
 Through a Host(insects, worms)
Many deadly infectious diseases have been eradicated in the world, but several, such as poliomyelitis (a
virus), are again on the increase. Many are preventable by immunization. Some, such as the Human
Immunodeficiency Virus (HF’!), have no cure or medical prevention. Examples of infectious diseases
are:

Parasitic Infections: Malaria, tapeworm, hookworm, itch mites, public and

body lice.
Fungal Infections: Ringworm. tinea (Athlete’s Foot).
Bacterial Infections: Throat infections, whooping cough, diphtheria,
rheumatic fever, tuberculosis strains, cholera, staphylococcus infection, and
some forms of meningitis.

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Viral Infections: Measles, mumps, rubella, hepatitis, influenza, chicken pox, HIV/AIDS, common cold,
Ebola fever, Congo fever, bronchitis and SARS. There is no effective treatment for any virus, no
medicine can kill a virus, only the body’s immune system can neutralize a virus.
The human body has natural defenses against infection, and remains immune to certain types: Immunity
is usually achieved by previous exposure to a particular infection, with resultant chemical antibodies
being produced. The blood contains leukocytes (white blood cells), which assist in the production of
antibodies. The leukocytes and antibodies combat any infection, which invades the body. Unfortunately,
the body’s natural defenses work slowly and cannot cope adequately with some infections. It is at this
stage that the body requires help in the form of medically prescribed antibiotics or similar drugs.

General Precautions
1) Avoid direct contact with infection.
2) Avoid transmitting infection.
3) Care of the susceptible, for example: the ill, the elderly, the very young.
4) Care in nutrition and preparation of food.
5) Maintenance of personal hygiene.
6) Maintenance of sanitary standards.

There is no definitive first aid treatment for infectious diseases. However, the first aid provider should
be familiar with the signs and symptoms of the common diseases, and provide advice to the infected
person to seek appropriate medical attention.
You have to protect yourself against infectious diseases which you can get from the patient. In order to
protect yourself, you have to wear the following PPE’s before touching or treating any patient:
1. Medical gloves,
2. Medical face mask,
3. Eye protection
4. A barrier device such as a mask or bag-valve-mask ventilation device (Ambubag) if
you need to do ventilation — mouth-to mouth ventilation is not advised without
proper protection!

COMMUNICATION
 Shake and shout (medical patient) or tap and talk (trauma
patient).
 Is the casualty alert?
 Is the casualty drowsy or confused?
 Is the casualty unconscious, but reacting?

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 Is the casualty unconscious with no reaction?

Level of consciousness refer to the level of brain function detectable. Prior to continuing the
examination of the patient, we need to determine the level of consciousness. The level of consciousness
can be divided into hundreds of small steps, each step referring to a different level of brain function. In
basic first aid, we are primarily concerned with the following levels of consciousness:
Alert and responsive . Responds to verbal or physical stimuli, knows who, where
and what.
Disorientated and confused May respond to verbal and physical stimuli but does not
know who, where or what.
Stuporous but arousable Responds to verbal and/or physical stimuli momentarily.
Unconscious Responds only to physical stimuli, will respond to painful
stimuli.
Comatose Breathing and heartbeat present, does not respond to verbal
stimuli, respond to painful stimuli.
Clinically dead Breathing and/or heart function may be present no detectable
brain function present
Biological dead No body or brain functions present

Unresponsiveness/ Unconsciousness:

Before you touch any patient, you should ensure that you have Latex (or similar) gloves on both hands,
to protect you against any disease the patient may have.
To determine if a patient is unresponsive, you should talk to the patient, and gently shake the shoulders
of the patient. Care should be taken if the patient has had, or could have sustained trauma, since the
shaking of a trauma patient’s shoulders could cause paralysis in a patient with a cervical spine injury.
Trauma patients should not be shaken, and in this case “touch and talk” is safer that “shout and shake”
Remember that the unresponsive patient you may encounter could be unresponsive due to an anxiety
attack, hypoglycaemic coma or even because the patient took his prescribed sleeping tablet. In this case
the patient may not respond to talking, shouting or shaking, same as the deaf patient will not respond to
talking. In order to be sure that the patient is unresponsive, some pain stimuli can be applied, such as
depressing the post-clavicular fossa.

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AIRWAY
If the patient is unresponsive, you should determine if the patient is breathing. In order to determine
patient respiration, you must ensure that the airway is open, and the only way to be sure that the airway
is open, is to open it manually. Before opening the airway, the patient should be positioned supine (lying
flat on his / her back).
If the patient is suspected to have received any trauma (injury, falling down, etc.), the patient must be
treated as if though he has spinal injuries. You cannot simply turn the patient. You should roll the patient
as a unit, keeping the spinal column intact and aligned.

Once the patient is supine, you should position yourself at the victims’ side. In a supine unconscious
patient, the most common cause for airway obstruction is the tongue, falling back against the back of the
throat. Since the tongue is attached to the lower jaw, moving the lower jaw away from the back of the
throat will move the tongue away from the back of the throat and open the airway.
You should use the head tilt-chin lift method of opening the airway by following these steps:
 Place one hand on the forehead of the patient and apply firm backward pressure to tilt the head back
 Place the fingers of the other hand under the bony part of the lower jaw.
 Lift the chin forward and support the jaw, helping to tilt the head backwards.
 The mouth should not be closed when lifting the chin

Figure: Head tilt-chin lift. Note that the finger

Lifting the chin are not exerting pressure
On the soft tissues under the chin.

In trauma patients, you should use the Jaw- thrust manoeuvre to open the airway. Jaw-thrust is achieved by
following these steps:-
 Kneel at the top of the patient’s head, resting your
Elbows on the same surface that the patient is
lying on.
 Reach forward and gently place one hand on each
side of the patient’s lower jaw, at the angles of
the mandible (lower jaw).
 Stabilise the patient’s head with your forearms.
 Using your index fingers, push the angles of the

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mandible forward while tilting the head backward Figure: Jaw thrust. The thumbs can be used to
 You may need to retract the patient’s lower lip open the mouth, but it is not always necessary
with you thumb to keep the mouth open.

This technique is effective in opening the airway, but is fatiguing and technically difficult. If jaw alone
is unsuccessful, the head should be tilted backward very slightly.

BREATHING
The first objective after opening the airway is to determine of the patient is breathing or not. In order to
determine if the patient is breathing, you should:

1. LOOK at the patient’s chest and stomach and observe

if there are any raising and falling movements present.
2. LOOK at the general appearance of the
patient and for signs of oxygen shortage.
If no air is exhaled, and no chest or stomach movement
can be detected, the patient is in respiratory arrest. The
evaluation procedure should take between 3 and 5 seconds.

Figure: Look for breathing

If the patient is breathing after the airway is opened, the patient should be placed in the recovery
position.

Figure: Recovery position

A trauma patient should not be moved without special precautions. Your actions will be determined by
the nature of the breathing, the history of the patient and your own level of training and expertise.

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VENTILATION
Ventilations must be given if the patient is not breathing. Whichever device you use, you should initially
give two slow ventilations, each ventilation lasting two seconds. The 2-second time period for
ventilation is necessary in order to deliver slow inspiratory breaths. Exhalation is a passive phenomenon
and occurs primarily during chest compressions if CPR is being performed. If a pulse is present but
spontaneous respiration is absent, ventilations should be given at a rate of 10 to 12 per minute.

By giving the ventilations with a slow inspiratory flow rate and avoiding trapping of air in the lungs
between ventilations, the possibility of exceeding the oesophageal opening pressure will be less. It
should result in less stomach distension and aspiration (inhaling of stomach contents). Care must be
taken not to ventilate with excessive volume, since the excessive air can only go to the stomach.
Ventilate only until the chest start to rise.

Although mouth-to-mouth ventilation is effective, it must be avoided because of the dangers of cross-
infection. It can however be given to somebody which you know have no infectious disease, like your
own small child. In all other patients, a barrier-device, such as face shields, must be used to ventilate.
Face shields only protect you against direct contact, which makes face shields almost impractical.

CIRCULATION

Pulse check
Determine the absence of pulse by feeling for the carotid artery for up to 10 seconds. Locate the
windpipe while maintaining the head-tilt position. Slide the fingers into the groove between the
windpipe and the muscles at the side of the neck in order to locate the carotid artery. You must feel for
the pulse on your side of the patient, since feeling pulse on the opposite side causes pressure on the
throat and could aggravate swelling or partially obstructed airway. It is important to be sure that there is
no pulse before starting with chest compressions since performing chest compressions on an adult who
has a pulse may result in serious complications.

If a pulse is present, but breathing is

still absent, continue with artificial
Ventilations at a rate of 10-12/ minute.
If no pulse is present, you have
confirmed a definite cardiac arrest. If
help has not been summoned, you should
call now for help

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Figure: Check for carotid pulse.

The chest compression technique consists of serial, rhythmic applications of pressure over the lower half
of the sternum. These compressions provide circulation -as a result of a generalized increase in internal
chest pressure or direct compression of the heart.
The patient must be in a horizontal, supine position during chest compressions. Even with properly
performed compressions, blood flow to the brain is reduced.

The hand position is important. The heel of

the hand must be on the lower half of the
sternum or breastbone. The hand should
touch the imaginary line between the nipples
of a child or male patient.

The hand should not exert pressure directly

on the ribs, or on the xiphoid process. A hand
position which is too low can lead to
liver damage.

Proper hand position is on the lower half of the

sternum. It does not matter which method you
use to establish the lower half of the sternum,
however, the long axis of the heel of the hand is
located on the lower half of the long axis of the
sternum
Figure: Place the head of the hand on the lower
half of the sternum

The fingers can be interlocked or free, but should be kept off the chest. It is, however, good practice to
interlock the fingers to ensure that no pressure is exerted on the ribs.

People with arthritic hands and/or wrists can use the hand which was used to locate the lower half of the
sternum, to grasp the wrist of the hand which is on the chest.

Effective chest compressions are achieved by following the guidelines:

1. Your elbows should be locked into position, your arms straightened and your shoulders directly
above the patient’s sternum.

2. To achieve the most pressure with the least effort, lean forward until your shoulders are directly
over your outstretched hands (lean forward until the body reaches natural imbalance — a point at
which there would be a sensation of falling forward if the hands and arms were not providing
support). The weight of your shoulders, chest and back creates the necessary pressure that makes

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compressions easier on the arms and shoulders. Natural body weight falling forward provides the
force to depress the sternum.

3. The sternum should be depressed approximately 1V to 2 inches (3.8 to 5.1cm) for the normal-
sized adult. The depth of compressions may change according to the size of the chest of the
patient; a large, barrel-shaped chest rriay need deeper compressions — as much as one half of
the depth of the chest. The only way to know that your compressions are deep enough is to have
somebody feel for palpable carotid pulse. If your compressions create palpable carotid pulse, the
compression depth is sufficient.

4. Release pressure on the chest between compressions to allow blood to flow into the chest and
heart. The chest must be allowed to return to its normal position.

5. The duration of the compression should be equal to the duration of pressure release: in other
words, the time you spend to press down on the chest should be same as the time you spend to
“come up” from the chest.

6. There should be no pause between compressions in a cycle, don’t pause on top.

7. Do not lift the hands from the chest, you will loose correct hand position.

8. Bouncing compressions, jerky movements, improper hand

position and leaning on the chest can decrease the
effectiveness of the compressions and can cause injuries.
9. The chest compression rate should be minimum 80 to
100 per minute.

During cardiac arrest, properly performed chest

Compressions can produce systolic arterial blood
pressure peaks of 60 to 80mm Hg, but diastolic
pressure is low.

Figure: Correct compression position.

Note that the elbows are locked ,the heel
Of the lower hand is on the sternum, and the
Shoulders are directly above the hand and the
sternum

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Cardiac output resulting from chest compressions is likely to be only 17% — 25% of normal cardiac
output.

Cough CPR

Self-induced CPR is possible. Its use is limited to clinical situations in which the patient has a cardiac
monitor, the arrest was recognized before loss of consciousness (usually within I( 15 seconds from the
cardiac arrest), and the patient can cough forcefully. The increase intrathoracic pressure will generate
blood flow to the brain to maintain consciousness for prolonged period.

Sequence for Adult One-person CPR

1. Determine unresponsiveness.
a. Tap or gently shake the shoulders and shout
b. Consider giving painful stimuli.
c. Call for help locally, inform the help of the situation you have.

2. Open the airway

a. Position the patient.
b. Open the airway by head tilt-chin lift manoeuvre or jaw-thrust.

3. Assess breathing
a. Look, listen and feel for breathing for up to 10 seconds.
b. If the patient is unresponsive but obviously breathing and if there is no trauma, place the
patient in the recovery position and maintain an open airway.
c. If the adult patient is unresponsive and not breathing, ventilate twice using a barrier device.
d. If unable to ventilate twice, reposition the head and attempt to ventilate again.
e. If ventilation is still unsuccessful, perform the foreign body airway obstruction sequence.
f If ventilation is successful, continue to next step — determine pulse.

4. Determine pulselessness
a. Palpate carotid pulse for up to 10 seconds.
b. If pulse is present and patient is still unresponsive, continue ventilation at 10 to 12 per
minute.
c. If pulse is absent, begin chest compressions:
 Position yourself properly
 Determine correct landmark for hand position
 Perform 15 compressions at a rate of 80 to 100 compressions per minute.
 Open the airway and give two slow ventilations. (2 seconds per ventilation)
 Re-determine proper hand position and begin 15 more compressions at a rate of 80 to 100
per minute.
 Perform at least four complete cycles of 15 compressions and 2 ventilations, but no longer
than about one minute.

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5. Reassess patient.
a. Re-evaluation should be performed after the first minute of CPR, and thereafter every few
minutes. Re-evaluations should last no longer than 5 seconds.
b. After four cycles or about one minute of compressions and ventilations, re-evaluate the
patient.
c. Check for return of carotid pulse (3 to 5 seconds)
d. If pulse still absent, continue with compressions and ventilations.
e. If pulse is present, check breathing;
 If breathing is present, closely monitor breathing and pulse, and treat accordingly
 If breathing is absent, continue ventilations at 10 to 12 per minute
f. Continue treatment accordingly until you have handed the patient over to a higher qualified
professional and then follow instructions.

Two-person Adult CPR

When another person is available to assist you with CPR, the second person can perform the chest
compressions when the first person becomes fatigued. This change should be done with as little
interruption as possible.

When the second person becomes available, the pulse and breathing of the patient should be re-assessed
before CPR is resumed. For example: the first person completes a cycle of 15 compressions and 2
ventilations. The second person can give the two ventilations. CPR is then stopped (if CPR has been
performed for more than one minute) and the pulse is checked.

If pulse is still absent, the second person resumes chest compressions at a rate of 80 to 100 per minute,
and at a ratio of 15 compressions : 2 ventilations and does not precede the chest compressions with
ventilations. No need for a formal “change” exists, only two rules for the change needs to be followed:
1. As little interruption as possible must be made during the change, and;
2. The change should be made after a pulse check.

FOREIGN BODY AIRWAY OBSTRUCTION

Because early recognition of airway obstruction is vital to a successful outcome, it is important to
distinguish between airway obstruction, stroke, heart attack et cetera. Obstruction can be partial or full.
If partial, the patient may be able to have sufficient air exchange, and will remain conscious, coughing
forcefully and wheezing between coughs. In this case, the patient should be encouraged to continue
forceful coughing until the obstruction is cleared and you should not interfere with the patients’ attempts
to expel the obstruction. If the obstruction isn’t cleared rapidly, advanced help should be called without
delay.

A partial obstruction with inadequate air exchange to remain conscious should be treated like

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a patient with full airway obstruction. With complete airway obstruction the patient will be
unable to breath, cough and speak, and may clutch the neck with his hand. Ask the patient if
he is choking, even though he cannot speak, he may nod his head to indicate that he is. In
this case, death will follow quickly if action is not taken immediately.

The Heimlich Manoeuvre

The Heimlich Manoeuvre is recommended for expelling a foreign body from the airway. By applying
forceful, upwards and inwards pressure on the abdomen below the diaphragm, the intestine, liver,
stomach and spleen is forced upwards, transferring the force to the diaphragm. The diaphragm is
displaced u transferring the force directly to the lungs. Because the lungs is now a closed air cavity
(closed by the airway obstruction), a high pressure is created in the lung and this high pressure is exerted
on the obstruction. The aim is to create enough pressure on the obstruction (foreign body), to force the
foreign body upwards in the airway, and thus clearing the airway.

One should remember that it is very possible to damage internal organs like the liver while doing the
Heimlich manoeuvre. To minimize this possibility, your hands should never be placed on the xiphoid of
the sternum or on the lower margins of the rib cage. They should be below this area but above the navel
and in the midline.

Heimlich manoeuvre with patient standing.

Stand behind patient, wrap your arms around the

patient’s waist.

Make a fist with one hand.

Place the thumb side of the fist against the patient’s

abdomen, in the midline and slightly above the navel.

Stay well away form the xiphoid process.

Grab the fist with the other hand and press the fist into
the patient’s abdomen with a quick upward thrust.

Repeat the thrusts and continue until the foreign object

is expelled or until the patient becomes unconscious.

Each thrust should be an independent movement

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Heimlich manoeuvre with patient lying down.

 Place the patient is supine position.

 Kneel aside the patient’s thighs and

place the heel of one hand against the
patient’s abdomen, in the midline and
slightly above the navel.

 Keep well away from the patient’s

xiphoid process.

 Place the second hand directly on top

of the first hand.

 Press on the abdomen with a quick,

upward thrust.

 Use your body weight and shoulder

muscles to perform the manoeuvre. Figure: Abdominal thrusts on unconscious patient.

Chest thrusts with patient sitting or standing.

This technique can be used in the late stage of pregnancy and on markedly obese patients.

 Stand behind patient with your arms directly under the

Patient’s armpits and encircle the chest.

 Place the heel side of your fist on the centre of the

patient’s sternum, avoiding the xiphoid process and the
margins of the rib cage.

 Grab your fist with your other hand and perform

backward thrusts until the foreign body is expelled
or until the victim becomes unconscious.

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Figure: Chest thrusts on the unconscious pregnant or

markedly obese patient.

Chest thrusts with patient lying down.

This should be done only in the last stage of pregnancy and when the Heimlich manoeuvre
cannot be applied to the conscious/unconscious obese patient.

1) Place the patient on his back and

kneel close to the victim’s side.

2) The hand position is exactly the

same as for CPR.

3) Deliver each thrust firmly and

Distinctly.

Figure: Chest thrusts on the unconscious

Pregnant or markedly obese patient

Finger sweep
This manoeuvre should be used only on unconscious patients, never on a patient with
seizures.

1. Grab both the tongue and the lower jaw between your thumb and fingers and lift the lower jaw
(tongue-jaw lift).
2. Insert the index finger of the other hand down along the inside of the cheek and deeply into the throat
to the base of the tongue.
3. Using a hooking action to dislodge the foreign body and manoeuvre it into the mouth so that it can be
removed.
4. Be careful not to push the foreign body deeper into the airway.

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Management sequence for obstructed airway.

 Do abdominal thrusts ( or chest thrusts for late stages of pregnancy and obese patients), and
repeat doing thrusts on the conscious victim until the obstruction is expelled or until the patient
becomes unconscious.

 Open the airway, look in the mouth for any visible obstruction, and attempt to ventilate. If
ventilation attempt is unsuccessful.

 Re-open the airway and attempt to ventilate again, using more force. If ventilation is still
ineffective.

 Perform Heimlich manoeuvre (max 5 times).

 Open airway, look inside mouth for visible obstruction and do finger sweep.

 Attempt ventilation. If ventilation is unsuccessful.

 Re-open airway and attempt to ventilate again, using more force than first ventilation. If
Unsuccessful .

 Perform Heimlich manoeuvre (max 5 times).

 Repeat steps 5 to 8 until successful or until death certification.

 If successful, treat according to patient’s condition.

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BLEEDING AND WOUNDS

Blood consists of red cells (erythrocytes), which convey oxygen throughout the body; white cells
(leukocytes), which fight introduced infection; platelets (thrombocytes), which assist in the clotting
process; and plasma, the fluid portion of blood. There are between six and seven liters of blood in the
average adult body.

Blood is moved around the body und pressure by the cardiovascular system - the heart and blood
vessels. Without an adequate blood volume and pressure, the human body soon collapses. Bleeding, or
hemorrhage, poses a threat by causing both the volume and the pressure bf the blood within the body to
decrease through blood loss.

Types of Bleeding
The types of bleeding and characteristics are:-

 Artery: Bleeding from an artery is characterized by the spurting [Link] is in time with the
heart beat because arteries come directly from the heart and are under greatest pressure.

 Capillary: Bleeding shows by oozing out from the skin. This is because it is under a lot less
pressure.

 Venous: Bleeding from the venous Gushes out and is characterized by being dark red colour,
because the blood has given up oxygen and is on the way back to the heart to be re-pumped to
the lungs. Venous bleeding can be severe, especially from varicose vein.

The body’s initial reaction to bleeding

The body reacts 3 ways to control bleeding:
• Blood clots.
• Ends of vessels contract.
• Blood pressure falls.

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Platelets congregate at the site of the wound.

Fibrin threads start to form a plug, controlling

bleeding

The compact clot seals the wound while

the skin is repaired.

Control of bleeding

 Remove or cut clothing to expose the wound Watch out for sharp objects, such as glass, that
might injure you.
 Apply direct pressure over the wound with your fingers or palm, preferably using a sterile
dressing or gauze. Don’t use cotton wool.

Direct Pressure
Leaving any original pad in place, apply a
sterile dressing. Bandage it in place firmly,
but not a tightly as to impede the circulation.

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If bleeding strikes through the dressing,

Bandage another firmly over the top.

Raise and support an injured limb above

the level of the casualty’s heart. Handle
limbs very gently if the injury involves a
fracture. When a patient is suffering from
a wound and a fracture of a limb, you will
have to stabilize the fracture before you
elevate the limb.

 It may help to lay the casualty down. This will reduce blood flow to the site of injury and
minimize shock.
 If there is a protruding foreign body, build up pads on either side of the object until they are high
enough to bandage over the object without pressing on it.
 Secure and support the injured part as for a broken bone.
 Contact advanced help and if necessary, take the patient to the advanced help (clinic, doctor,
ambulance and hospital).
 Treat the casualty for shock.
 Check the dressing and the circulation beyond the bandage.
Indirect Pressure
Sometimes direct pressure is still not enough to stem the blood flow. (This is usually in the leg where
there has been damage to the main artery in the upper leg-thin). On these occasions you may have to
consider indirect pressure. Indirect pressure may be applied to a pressure point where a main artery runs
close to a bone. Pressure at these points will cut off the blood supply to the limb. It must not be applied
for longer than 10 minutes.

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Brachial

Femoral

Radial and ulnar

Pressure points:
These are specific places in the arms and legs where this pressure
can be applied. These points are just underneath the muscle in the
upper arm and in the groin to cut off supply to the leg. Investigate
on yourself to find the correct place.
Press hard against the bone in the upper arm and your hand should
feel cold, numb and strange. This is because the blood supply has
been cut off.

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EXTERNAL BLEEDING
External bleeding is usually associated with wounds, those injuries that are caused by cutting,
perforating or tearing the skin. Serious wounds involve damage to blood vessels. As arteries carry
oxygenated blood from the heart, damage to a vessel is characterized by bright red blood which spurts’
with each heartbeat. Damage to veins appears as a darker red flow. Capillary damage is associated with
wounds close to the skin and is of a bright red ‘ooze’ from below the surface.

Types of wounds

Incision is the type of wound made by ‘slicing’

with a sharp knife or object.

Treatment of incisions and lacerations:

 Quickly check the wound for foreign bodies.

 Immediately apply pressure to stop any bleeding.
 Apply non-adherent pad or dressing.
 Apply a firm roller bandage.
 Rest and elevate injured limb if injuries permit

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Laceration is a deep wound with associated

loss of tissue- the type of wound barbed
wire or direct force from a blunt object( such
as a fist or boxing glove) would cause.

Penetration wounds are found when a foreign

body enters the body and stay inside the body, or are
removed afterwards. It may be caused to anything
from a corkscrew to a bullet.

Treatment for penetration wounds and penetrating

Objects:

 Inspect the wound- do not remove any

penetrating object
 Stabilize the penetrating object to
prevent movement
 Apply pressure to stop any bleeding.
 Apply non-adherent pad or dressing.
 Apply a firm roller bandage.
 Rest and elevate injured limb if injuries
permit.
 Transport to clinic or hospital urgently

Amputation is the loss of a digit or limb by trauma

Treatment for an amputation

 Apply immediate pressure to stop
any bleeding.

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 Apply a large pad or dressing to

the wound .
 Treat patient for shock.
 Rest and elevate injured limb if possible.
 Collect amputated part-keep moist with wet
gauze, do not wash or clean
 Seal the amputated part in plastic bag or wrap
in similar waterproof material.
 Place in cold water- do not allow the part to
come in direct contact with ice.
 Remember- if the initial dressing doesn’t stop
the bleeding, put another over the top-don’t
remove a dressing once it is in place!
 Ensure the amputated part travels to hospital
with the casualty.

Abrasion is a wound where the

skin layers have been scarped off.

Treatment for an abrasion wound:

 Inspect the wound for foreign bodies.
 Swab with an antiseptic solution like 10%
Povidone Iodine USP.
 Cover with a light, dry dressing if necessary.

Avulsion is a wound where a section of skin and underlying tissue have been partially removed,
Resulting in a “flap”

Treatment for an avulsion wound:

 If “ flap” is open, attempt to put it in it’s

normal place without causing further injuries.

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 Rest of treatment is the same as for any open wound,

the only complicating factor is that the wound is general
large in surface area, which may increase the amount of
blood loss.
 Cover with bandage, apply pressure, elevate etcetera.

INTERNAL BLEEDING
Internal bleeding is classified as either visible, in that the results of the bleeding can be seen, or
concealed, where no direct evidence of bleeding is obvious. Internal Heeding is always to be considered
as a very serious matter, and urgent medical aid is a necessity.

In most instances, obtaining an adequate history of the incident or illness will give the first aid provider
the necessary clue as to whether internal bleeding may be present. Remember that current signs and
symptoms, or the lack of them do not necessarily indicate the casualty’s condition. Certain critical signs
and symptoms may not appear until well after the incident due to the stealth of the bleed.

Characteristics

 Very often there is no visible wound on the outside and no visible bleeding around the site of the
internal bleeding

 Internal bleeding is often due to impact of a blunt object to the body. This impact can cause
organs such as the liver and spleen to burst open, or rupture. Since organs have a very good
blood supply, a ruptured organ can bleed profusely, threatening the life of the patient due to
blood loss. In many cases, a ruptured liver can cause sufficient blood loss that the patient can die
in as little as 20 to 30 minutes.

 If internal bleeding occurs inside the trunk of the body, it is impossible to control, except
through surgery. Internal bleeding in a limb can be controlled by the use of indirect pressure.

 Sometimes you will find no signs of internal bleeding, no swelling, bruising, external wound
and so forth, but the patient is unconscious and in severe shock. If the patient has a history of
trauma, the most common cause will be internal bleeding.

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Visible internal bleeding

Visible internal bleeding is referred to this way because the results are visible:

 Bleeding in the lungs - frothy, bright red blood coughed up by the casualty.
 Bleeding in the stomach - dark coffee grounds”, or red blood in vomit.
 Bowel, or intestinal bleeding - dark, loose, foul smelling stools.
 Anal or vaginal bleeding - usually red blood, mixed with mucous.

Concealed internal bleeding

En these cases, the first aid provider is heavily reliant on history, signs and symptoms.
Judgment and experience play a part, but it may come down to a first aid provider’s “gut
feeling”. If you are unsure, assume the worst and treat for internal bleeding.

Signs and symptoms

 Lowering level of consciousness
 Pale, cool, clammy skin
 Weakness, dizziness or fainting
 Thirst
 Rapid, weak, irregular pulse
 Rapid, shallow breathing shortness of breath
 Swelling or bruising at the injured site
 ‘Guarding’ of the abdomen, with fetal position if lying down
 Pain or discomfort
 Nausea and/or vomiting
 The more symptoms you observe, the more extensive and serious the bleeding.

Care and treatment

 SAFE and ABC
 Activate local emergency procedures
 Position the conscious casualty supine, with legs and arms elevated (care R of
fractures immobilize them first)
 Position the unconscious patient lateral, taking care of his spinal column and
fractures — if any
 Control any bleeding
 Reassurance
 Urgent medical aid
 Give nothing by mouth
 Treat any injuries
 Take note that if the patient swallows blood, he may vomit
 Monitor and record level of consciousness, breathing and pulse rates.

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