ESBRIEF INTRODUCTION

This chapter will deal with medical injuries and illnesses commonly encountered in the outdoors and how
one can help others in these situations. Discussions will also include aquatic and environment hazards that
potentially might be the cause of the illness and injuries. First aid administration is a life-saving skill that
requires training. It has to be noted that the discussion in this chapter should not take the place of first aid
training, but rather serve as a basic information and guide, so one may know to react and respond given
certain medical and emergency situations.
First aid is the provision of immediate care to a victim with an injury of illness, usually affected by a lay
person, and performed within a limited skill range. First aid is normally performed until the injury or
illness is satisfactorily dealt with (such as in the case of small cuts, minor bruises, and blisters) or until the
next level of care, such as an ambulance or doctor, arrives.

It involves calling for help and providing lifesaving techniques, as well as more basic self- care
and home remedies.

Guiding Principles

The key guiding principles and purpose of first aid, is often

given in the mnemonic "3 Ps". These three points govern all
the actions undertaken by a first aider.

1. Prevent further injury

2. Preserve life
3. Promote recovery
Scope and Limitation
Limitations First aid does not imply medical
treatment and is by no means a
The nature of first aid means that most people will only have replacement for it.
a limited knowledge, and first aiders are advised to seek
professional help (for instance from the ambulance service or a doctor) when
they reach the limits of their knowledge.

The Do’s of First aid:

1. Do be polite
2. Do remain calm- and calming
3. Do obtain consent when performing the first aid
4. Do take precautions against infection such as HIV. Take precautions in exposing
yourself to bodily secretions such as blood, saliva and other discharges.

Objectives of First Aid

First aid aims to accomplish the following goals.
 Preserved life.
 Prevent further harm and complications.
 Seek immediate medical help.
 Provide reassurance.

LEGAL CONSIDERATIONS AND LIABILITY

According to the Article 12 no. 4 of Act No. 3815 of the Philippine Revised Penal Code Book One

“any person who, while performing a lawful act with due care, causes an injury by mere accident
without fault or intention of causing it” is exempt

According to the Article 275 no. 1 and 2 of Act NO. 3815 of the Philippine Revised Penal Code Book
two: “Abandonment of person in danger and abandonment of one’s own victim”.

Anyone who shall fail to render assistant to any person whom he shall in an inhabitant place
wounded or in danger of dying, when he can render such assistance without detriment to himself,
unless such omission shall constitute to a more serious offense.

Anyone who shall fall to help or render assistance to another whom he has accident wounded or
injured.
Consent ( Permission )
Before giving First Aid to a casualty it is necessary to ask for their permission to do so. If the
casualty is able to respond they will respond either yes or no. If the casualty is unable to respond,
that is they are unconscious, it is taken for granted they would have provided permission if they
were conscious / able too. If attending a child, permission should be sought from the parent or
guardian. If the parent or guardian is not present, then immediate action should be taken for the
casualty in a life-threatening situation.
There is an assumption that everyone who needs help wants it. That is not always true. In order
to care for someone in need, you must have permission. In the medical field, permission is called
consent.
Touching someone without his or her consent can be assault or even battery. It is especially true
if a victim has expressly forbidden you from touching him or her.
Two forms of medical consent:
1. Expressed or verbal consent - is communicated to you either verbally or in written
form. The victim tells you it is ok to provide assistance. The victim must be able to
clearly communicate his or her wishes for expressed consent to count.
2. Implied consent-happens when you are unable to communicate with the victim. Most
commonly, this is because the victim is unconscious. When a victim cannot express his or
her wishes, there is an assumption that they would ask for help if they could. When a
child in a life threatening situation and a parent or legal guardian is not available for
consent.
Consent is also implied for victims who speak a language you don't understand. When a victim
can't verbally communicate, body language and other nonverbal cues are used instead. In other
words, if the victim doesn't let you help, that means "no."

Duty to act ( Duty of care and responsibility )

No one is required to render first aid under normal circumstances. Even a physician could ignore
a stranger suffering a heart attack if he chose to do so.
Exceptions include situations where a person's employment designates the rendering of first aid
as a part of described job duties. Examples include lifeguards, law enforcement officers, park
rangers and safety officers in industry.
A duty to provide first aid also exists where an individual has presumed responsibility for
another person's safety, as in the case of a parent-child or driver-passenger relationship.
While in most cases there is no legal responsibility to provide first aid care to another person,
there is a very clear responsibility to continue care once you start. You cannot start first aid and
then stop unless the victim no longer needs your attention, other first aiders take over the
responsibility from you or you are physically unable to continue care.

Abandonment
It means leaving a victim after starting to give help without ensuring someone else will continue
the care at the same level or higher. Once you have started providing care, you must not leave a
victim who still needs first aid until another competent and trained person takes responsibility for
the victim.

Negligence
Means not following accepted standards of care and causing injury to the victim.

Negligence requires three elements to be proven:

1. Having a duty to act
 You had a duty to care for the victim
 Often, if you begin first aid, then a duty of care exists
2. Breaching that duty by giving a substandard care
 You didn’t perform first aid properly or went beyond your level of training.
 The standard of care is what a reasonable person with the same training would do in
similar circumstances.
3. Causation or causing injury and damage
 The damages caused were your fault
 Causation requires proof that your act of omission, cause the damage.
Breach of duty
Generally, a first aider breaches or breaks his or her duty to a victim by failing to provide the
type of care that would be provided by a person having the same or similar training.

One’s duty can be breached by:

1. Acts of omission -is the failure to do what a reasonably prudent person with the same
training would do in the same or similar circumstances. (example: Forgetting to put a
dressing )
2. Acts of commission – is doing something that a reasonably prudent person would not do
under the same or similar circumstances. ( example: cutting a snakebite site )

Injury and Damages inflicted

Injury and damages must have resulted from breach of duty.
Injury and damages include:
1. Physical damage
2. Physical pain and suffering
3. Mental anguish
4. Medical expenses
5. Sometimes loss of earnings and earning capacity

Good Samaritan Law

Good Samaritan Law are laws that reduce the liability to those who choose to aid others who are
injured or ill, though it does not protect you from being sued, it just significantly reduces your
liability. They are intended to reduce bystanders' hesitation to assist, for fear of being prosecuted
for unintentional injury or wrongful death. In other countries Good Samaritan laws describe a
legal requirement for citizens to assist people in distress, unless doing so would put themselves
in harm's way. Citizens are often required to, at minimum, call the local emergency number.
Typically, the Good Samaritan legislation does not cover an individual who exceeds their
training level or scope of practice; nor would you be protected against gross negligence.

Good samaritan immunity generally applies only when the rescuer is:
1. Acting during an emergency
2. Acting in good faith, which means he or she has good intentions
3. Acting without compensation
4. Not guilty of any malicious misconduct or gross negligence toward the victim.

Assisting with Medication

Assisting with medications can be a vital component during a medical emergency. Assisting with
medications includes helping the victim locate the medication, taking the cap off of a bottle of
pills, and reading the label to ensure that the victim is going to take the right medication.
Assisting, however, does not imply actually administering the medication -- this is an advanced
level skill, which, if done, may open you up to liability from going beyond your level of training.
However, by assisting, you may be able to help the victim find their medications more quickly,
resulting in an improved outcome.

Written record
It is good practice to record in writing the details of any First Aid you provide at an incident.
This information may become necessary if the incident is brought to court. In the workplace, it is
a requirement to record all incidents.
Health Hazard and Risks
Common Transmittable Diseases
 Herpes Disease Transmission
 Meningitis Infectious diseases are those that can
 Tuberculosis spread from one person to another
 Hepatitis through the following ways:
 Human Immune Deficiency Virus Direct Contact
(HIV)/Acquired Immune Deficiency Indirect Contact
Syndrome (AIDS) Airborne transmission
Bites
Prevention and Protection
Universal Precaution are a set of strategies developed to prevent
transmission of blood borne pathogens. Body Substance Isolation (BSI) are precautions
taken to isolate or prevent risk of exposure from body secretions and any other types of
body substance such as urine, vomit. Feces, sweat, or sputum. Personal Protective
Equipment (PPE) is specialized clothing equipment and supplies that keep you from direct
contacting infected materials.

EVALUATING EMERGENCIES To obtain consent, do the

following:
It is important for caregivers to evaluate the  Identify yourself
emergency situation so as to administer proper to the victim.
and efficient first aid.
 State your level
of training.
PRINCIPLES OF EMERGENCY ACTION
 Ask the victim
1. Survey the scene
whether you
 Make sure the scene is safe not only for the victim but also for the bystanders
 Ensure the safety of the caregiver may help.
 Cause of injury or illness  Explain what
 Number of victims you observe
2. Do a primary survey  Explain what
 Check the airway, breathing and circulation of the victim you plan to do.
 Check the vital signs of the victim
 Check for injuries of the spinal cord
3. Seek medical attention / call for transport facilities
 Call EMS or local emergency numbers
4. Do a secondary survey
 Do Cephalo – Caudal survey ( Head to Toe )
D – O – T- S ( Deformities – Open wounds – Tenderness ( Sensitivity to touch ) – Swelling
Cephalo-Caudal Survey ( Heat to toe )
1. Head
 Look for D-O-T-S over the entire head
 Look for leakage of blood or fluid from the nose or ears ( indication of brain injury )
2. Eyes
Check and compare the pupils of both eyes and look for the following:
 Dilated pupils indicate bleeding and shock
 Constricted pupils indicate heat stroke or drug overdose
 Unequal pupils indicate stroke or head injury
3. Neck
 Look and feel for D – O – T – S
4. Chest
 Look for D – O – T – S
 Squeeze or compress the sides together for rib pain
5. Abdomen
 Look and feel for D – O – T –S
 Gently press all quadrants for rigidity and tenderness using the pads of your fingers
6. Extremities
 Look and feel the entire length and girth of each extremity for D – O – T– S
 Check each extremity for Circulation, Sensation and Movement.
Method:
Circulation –radial pulse for upper arm. Posterior tibial pulse for the leg.
Sensation – pinch the arm and leg and ask the victim if the pinch can be felt
Movement – ask the patient to wiggle the toes and fingers
 Do a sample history
Sample History
The information in a SAMPLE history can affect the first aid you give.
SAMPLE stands for the following:
S – Signs and symptoms (also known as Chief complaint)
A – Allergies
M – Medications
P – Past and present medical history
L – Last oral intake
E – Events leading prior to illness or injury

MOVING THE VICTIM TO A SAFE PLACE

When is a move a must?
1. Fire or possibility of fire
2. Possibility of explosion
3. Electrical hazards
4. Risk of drowning
5. Extreme temperatures ( too hot or too cold )
6. A dangerous accident scene ( too much traffic or unstable )
7. The need to get another person who is injured

THE SEQUENCE OF BLS:

Assessment, EMS activation, and the ABC’s of CPR

The assessment phases of BLS are crucial. No victim should undergo CPR until the need for
resuscitation has been established by the appropriate assessment.
Each of the ABC’s of CPR – Airway, Breathing, and circulation – begins with an assessment
phase:
 Determine unresponsiveness
 Determine breathlessness
 Determine pulselessness
Assessment also involves a more subtle, constant process of observing and interacting with the
victim. If unresponsiveness is established, The EMS system should be activated.

Activate EMS
Assessment: Determine Unresponsiveness
The rescuer arriving at the side of the victim must quickly assess any injury and determine
whether the person is responsive. The rescuer should tap or gently shake the victim and shout.
“Are you okay? “ If the victim does not respond, the EMS system should be promptly activated.
If the victim has sustained trauma to the head and neck or trauma is suspected, the rescuer should
move the victim only if absolutely necessary. Improper movement may cause paralysis in the
victim with spinal cord Injury.
Activate the EMS system
The EMS system is activated by calling the local emergency telephone number. The person who
calls EMS system should be prepared to give the following information calmly:
1. Location of the emergency ( with names of cross streets or roads, if possible )
2. The telephone number from which the call is made
3. What happened – Heart attack, auto accident, etc.
4. How many people need help
5. Condition of the victim (s)
6. What aid is being given to the victim (s)
7. Any other information requested
To ensure that EMS personnel have no more questions, the caller should hang up only when told
to do so by the operator/dispatcher. The emergency medical dispatcher may ( if also trained )
give the caller instructions on how to initiate CPR. The caller should follow these instructions
until skilled help arrives.

AIRWAY
When the victim is unresponsive, the rescuer must determine if the victim is breathing. This
assessment requires that the victim be positioned properly with the airway opened.
Position the victim
For CPR to be effective, the victim must be supine and on a firm, flat surface. Blood flow to the
brain may be compromised if the head is higher than the feet. Airway management and rescue
breathing are also more easily achieved with the patient supine. It is imperative that the
unconscious victim be positioned as quickly as possible. If the victim is lying face down, the
rescuer must roll the victim as a unit ( “log roll” ) so that the head, shoulders, and torso move
simultaneously without twisting. Particular caution must be exercise if neck and back injury is
suspected.
To position the victim who is lying down, the following sequence may be used:
 Kneel beside the victim at a distance approximately equal to the width of the victim’s
body and at a level of the victim’s shoulders. This permits sufficient space to roll the
victim while the neck is supported.
 Move the victim’s arm closer to you so that it is raised above the victim’s head
  Straighten the victim’s legs if necessary. They should be staright or bent slightly at the
knees.
 Place one hand behind the victim’s head and neck for support
 With the other hand grasp the victim under the arm to brace the shoulder and torso.
 Roll the victim toward you by pulling steadily and evenly at the shoulder while
controlling the head and neck. The head and neck should remain in the same plane as the
torso and the body should be moved as a unit.
The nonbreathing victim should be supine with the arms alongside the body. The victim is now
appropriately positioned for the next step in CPR.
Rescuer position
The rescuer should be at the victim’s side, positioned to easily perform both rescue breathing and
chest compression.
Open the Airway
One of the most important actions for successful resuscitation is immediate opening of the
airway. In the unresponsive victim muscle tone is often impaired, resulting in the obstruction of
the pharynx by the base of the tongue and the soft tissues of the pharynx. The tongue is the most
common cause of airway obstruction in the unconscious victim. Since the tongue is attached to
the lower jaw, moving the lower jaw forward will lift the tongue away from the back of the
throat and open the airway
The rescuer should use the head tilt-chin lift maneuver to open the airway. If foreign material or
vomitus is visible in the mouth it should be removed. Liquids should be wiped out with the index
and the middle fingers covered by a piece of cloth; solid materials should be extracted with a
hooked index finger.

Head tilt-chin maneuver

 Place one hand on the victim’s forehead and apply firm, backward pressure to tilt the
head back.
 Place the fingers of the other hand under the bony part of the chin.
 Lift the chin forward and support the jaw, helping to tilt the head back
Precautions:
 The fingers must not press deeply into the soft tissues under the chin, which might
obstruct the airway.
 The thumb should not be used for lifting the chin.
 The mouth should not be closed.

When mouth- to –nose ventilation is needed, the hand that is already on the chin can be used to
close the mouth to allow for effective mouth-to-nose ventilation. If the victim has loose dentures,
head tilt-chin lift makes a mouth –to-mouth seal easier. Dentures should be removed if they
cannot be kept in place.

BREATHING
BLS healthcare providers must be familiar with the use of the mask ( or other barrier devices )
with a way valve.
Assesment : Determine Breathlessness
To assess the presence or absence of spontaneous breathing:
1. Place your ear over the victim’s mouth and nose while maintaining an open airway
2. While observing the victim’s chest
 Look for the chest to rise and fall
 Listen for air escaping during exhalation
 Feel for the flow of air
If the chest does not rise and fall and no air is exhaled, the victim is breathless. This evaluation
procedure should take only 3-5 seconds.

Recovery Position
If the victim is unresponsive, has no evidence of trauma and is obviously breathing adequately,
the rescuer should place the patient in the “recovery position”
 Roll the victim onto his or her side so that the head, shoulders and torso move
simultaneously without twisting.
 If the victim has sustained trauma or trauma is suspected, the victim should not be
moved.
Perform Rescue Breathing
Mouth-to mouth. Rescue breathing with the mouth –to-mouth technique is a quick, effective
way to provide oxygen to the victim. The rescuer’s exhaledair contains enough oxygen to supply
the victim’s needs. Rescue breathing requires that the rescuer inflate the victims lungs adequately
with each breath.
 Keep the airway open by the head tilt-chin lift maneuver.
 Gently pinch the nose closed with your thumb and index finger ( of the hand on the
forehead ) , thereby preventing air from escaping through the victim’s nose.
 Take a deep breath and seal your lips around the victim’s mouth, creating an airtight seal.
 Then give Two slow breaths ( 1 ½ to 2 seconds per breath )
The rescuer should take a breath after each ventilation and each individual ventilation should be
of sufficient volume to make the chest rise. In most adults, this volume will be 800 to 1200 ml
(0.8 to 1.2 L )
Rescue Breathing should be performed at a rate of 10 to 12 breaths per minute.
Mouth-to-nose. This technique is more effective in some cases than the mouth-to-mouth
technique. This technique is recommended when it is impossible to ventilate through the victim’s
mouth, the mouth cannot be opened ( trismus ) , the mouth is seriously injured, or a tight mouth-
to-mouth seal is difficult to achieve.
 Keep the victim’s head tilted back with one hand on the forehead.
 Use the other hand to lift the victim’s lower jaw ( as in head tilt-chin lift ) and closed the
mouth.
 Take a deep breath, seal your lips around the victim’s nose, and blow.
 Then stop rescue breathing and allow the victim to exhale passively
It may be necessary to open the victim’s mouth intermittently or separate the lips with the thumb
to allow air to be exhaled since nasal obstruction may be present during inhalation.
Mouth-to-stoma. Persons who have undergone a laryngectomy ( surgical removal of the larynx )
have a permanent opening that connects the trachea directly to the front of the neck. When a
certain person requires rescue breathing, direct mouth-to-stoma ventilation should be performed.
 Make an airtight seal around the stoma and blow slowly until the chest rises.
 When rescue breathing is stopped, the victim exhales passively.
Other victims may have temporary tracheostomy tube in the trachea. To ventilate such a person,
the victim’s mouth and nose usually must be sealed by the rescuer’s hand or by a tightly fitting
face mask to prevent leakage of air when the rescuer blows into the tracheostomy tube. If unable
to ventilate through the tube, the tube should be removed and ventilation attempted directly
through the stoma.
Mouth-to-barrier device. Some rescuer may prefer to use barrier device during mouth-to-mouth
ventilation. Two broad categories of devices are available: Masks and face shields. Most masks
have a one-way valve so that exhaled air does not enter the rescuer’s mouth. Many face shields
have no exhalation valve and often air leaks around the shield.
If rescue breathing is necessary is necessary, position the barrier device ( face mask or face
shield ) over the victim’s mouth and nose, ensuring an adequate air seal. The initiate mouth-to-
barrier device breathing using slow inspiratory breaths ( 1 ½ to 2 seconds ).
Mouth-to-mask rescue breathing. This includes a transparent mask with a one-way valve
mouthpiece.
 Place the mask around the patient’s mouth and nose using the bridge of the nose as a
guide for correct position. Positioning of the mask is critical because gaps between the
mask and face will result in air leakage.
 Seal the mask by placing the heel and thumb of each hand along the border of the mask
and compressing firmly to provide a tight seal around the margin of the mask.
 Place your remaining fingers along the boney margin of the jaw and lift the jaw while
performing a head tilt.
 Give breaths in the same sequence and at the same rate as in rescue breathing, observing
chest excursion.
Recommendations for Rescue Breathing
 Give two initial breaths of 1 ½ to 2 seconds each.
 For both one-rescuer and two- rescuer CPR, deliver 10-20 breaths per minute.
 In one-rescuer CPR, pause for ventilation after every 15 chest compressions
 In two-rescuer CPR, pause for ventilation after every 5 chest compressions.

CIRCULATION
Assessment: Determine Pulselessness
Cardiac arrest is recognized by pulselessness in the large arteries of the unconscious victim
  Check the pulse at the carotid artery; this should take no more than 5 to 10 seconds.
 The carotid artery is the most accessible, reliable, and easily learned location for
checking the pulse in adults and children. This artery lies in a groove created by the
trachea and the large strap muscle of the neck.
 While maintaining head tilt with one hand on the forehead, locate the victims larynx with
two or three fingers of the other hand
 Place these fingers into the groove between the trachea and the muscles at the side of the
neck, where the carotid pulse can be felt
The pulse area must be pressed gently to avoid compressing the artery. This technique is more
easily performed on the side nearer the rescuer
If there is a Pulse. Locating and palpating a pulse will take 5 to 10 seconds. If a pulse is present
but there is no breathing, rescue breathing should be initiated at a rate of 10 to 20 times per
minute or once every 5 to 6 seconds. ( After the initial two breaths of 1 ½ to 2 seconds )
If there is No Pulse. If no pulse is palpated, the victim is in cardiac arrest. At this point , if the
EMS system has not already been activated, it should be and chest compressions should be
begun.

CHEST COMPRESSIONS
The chest compression technique consist 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 intrathoracic pressure or direct compression of the heart. Blood circulated to the lungs
by chest compressions will likely receive enough oxygen to maintain life when the compressions
are accompanied by properly performed breathing.
The patient must be in the horizontal, supine position during chest compressions. Even with
properly performed compression, blood flow to the brain is reduced . Whenever the head is
elevated above the heart, blood flow to the brain is further reduced or even eliminated. If the
victim is in bed, a board, preferably the full width of the bed, should be placed under the
patient’s back.
Proper hand position. Proper hand placement is established by identifying the lower half of the
sternum.
 With your hand locate the lower margin of the victim’s rib cage on the side next to the
rescuer.
 Move the fingers up the rib cage to the notch where the ribs meet the sternum in the
center of the lower part of the chest.
 Place the heel of one hand on the lower half of the sternum and place the other hand on
top of the hand on the sternum so that the hands are parallel. The long axis of the heel of
the rescuer’s hand should be placed on the long axis of the sternum. This will keep the
main force of compression on the sternum and decrease the chance of fracture.
 The fingers may be either extended or interlaced but should be kept off the chest.
Proper Compression Technique.
 Your elbows should preferably be locked into position, your arms straightened, and your
shoulders positioned directly over the hands so that the thrust for each chest compression
is straight downward direction, the torso has the tendency to roll. Part of the downward
force is displaced and the chest compression may be less effective.
 To achieve the most pressure with the least effort, lean forward until your shoulders are
directly over your outstretched hands.
 The sternum should be depressed approximately 1 ½ to 2 inches ( 3.8 to 5.1 cm ) for
normal-size adult.
 Release chest compression pressure between each compression to allow blood to flow
into the chest and heart.
 Do not lift the hands from the chest or change position, or correct position may be lost.
Bouncing compressions, jerky movements, improper hand position and leaning on the chest can
decrease effectiveness of resuscitation and are more likely to cause injuries.
The chest compression rate should be a minimum of 80 to 100 per minute if possible and
duration of chest compression should be 50% of the compression – release cycle.
Recommendations for Chest compression
The chest compression rate should be a minimum of 80 and up to 100 per minute if possible.

FOREIGN-BODY AIRWAY OBSTRUCTION MANAGEMENT

Causes and Precautions
Upper airway obstruction can cause unconsciousness and cardiopulmonary arrest, but far more
often unconsciousness and cardiopulmonary arrest cause upper airway obstruction.
An unconscious patient can develop airway obstruction when the tongue falls back into the
pharynx, obstructing the upper airway. Bleeding from head and facial injuries may also obstruct
the upper airway, particularly if the patient is unconscious.
Foreign-body airway obstruction of the airway usually occurs during eating. In adults, meat is
the most common cause of obstruction, although variety of other foods and foreign-bodies have
been the cause of choking in children and some adults.
Common factors associated with choking on food include large, poorly chewed pieces of food,
elevated alcohol levels and dentures.
People may help prevent foreign-body airway obstruction by:
1. Cutting food into small pieces and chewing slowly and thoroughly, especially if wearing
dentures.
2. Avoid laughing and talking during chewing and swallowing.
3. Avoid excessive intake of alcohol.
4. Restricting children from walking, running, or playing when they have food in their
mouths.
5. Keep foreign objects (e.g. marbles, beads, thumbtacks ) away from infants and children.
6. Withholding peanuts, peanut butter, popcorn, hotdogs and other foods that must be
thoroughly chewed from children unable to do so.
Recognition of Foreign-Body Airway Obstruction
Because early recognition of airway obstruction is the key to successful outcome, it is important
to distinguish this emergency from fainting, stroke, heart attack, epilepsy, drug overdose or other
conditions that can cause sudden respiratory failure but are treated differently.
Foreign bodies may cause either partial or complete airways obstruction.
Partial airway obstruction. The victim may be capable of either “good air exchange” or “poor
air exchange.”
With good ( adequate ) air exchange, the victim remains conscious and can cough forcefully,
although frequently wheezing between coughs. As long as good air exchange continues, the
victim should be encouraged to continue spontaneous coughing and breathing efforts. At this
point do not interfere with the victim’s attempts to expel the foreign body, but stay with the
victim and monitor these attempts. If partial airways obstruction persists, activate the EMS
system.
Poor ( inadequate ) Air exchange may occur initially, or good air exchange may progress to poor
air exchange, as indicated by a weak, ineffective cough, high- pitched noise while inhaling,
increases respiratory difficulty, and possibly cyanosis. A partial obstruction with poor air
exchange should be treated as if it were a complete airway obstruction.
Complete airway obstruction. The victim is unable to speak, breathe or couch and may clutch
the neck with the thumb and fingers ( the public should be encouraged to use this sign, the
universal distress signal, when choking ).
Ask the victim if he or she is choking. Movement of air will be absent if complete airway
obstruction is present. Oxygen saturation in the blood will decrease rapidly because the
obstructed airway prevents entry of air to the lungs, resulting in unconsciousness. Death will
follow rapidly if prompt action is not taken.

MANAGEMENT OF THE OBSTRUCTED AIRWAY

The Heimlich maneuver ( subdiaphragmatic abdominal thrusts ) is recommended for relieving
foreign-body airway obstruction. By elevating the diaphragm, the Heimlich maneuver can force
air from the lungs to create an artificial cough intended to expel a foreign body obstructing the
airway.
Heimlich Maneuver with victim standing or sitting
The rescuer should stand behind the victim, wrap his or her arms around the victim’s waist and
proceed as follows:
1. Make a fist with one hand.
2. Place the thumb side of the fist against the victim’s abdomen, in the midline slightly
above the navel and well below the tip of the xiphoid process.
3. Grasp the fist with the other hand and press the fist into the victim’s abdomen with a
quick upward thrust.
4. Repeat the thrust and continue until the object is expelled from the airway or the patient
becomes unconscious.
5. Each new thrust should be separate and distinct movement.
Heimlich Maneuver with victim lying down
1. Place the victim in supine position, face up
 2. Kneel astride the victim’s thigh and place the heel of one hand against the victim’s
abdomen, in the midline slightly above the navel and well below the tip of the xiphoid.
3. Place the second hand directly on top of the first.
4. Press into the abdomen with a quick upward thrust.
If you are in the correct position, you will have a natural midabdominal position and are thus
unlikely to direct the thrust right or left. A rescuer too short to reach around the waist of an
unconscious victim can use this technique. The rescuer can use his or her body weight to perform
the maneuver
The self –administered Heimlich Maneuver
To treat one’s own complete foreign-body airway obstruction:
1. Make a fist with one hand.
2. Place the thumb side on the abdomen above the navel and below the xiphoid process.
3. Grasp the fist with the other hand.
4. Press inward and upward toward the diaphragm with a quick motion.
If unsuccessful, press the upper abdomen quickly over any firm surface, such as back of a chair,
side of the table, or porch railing. Several thrusts may be needed to clear the airway.
Chest Thrust with the victim Standing or sitting
This technique is to be used only in the late stages of pregnancy or in the markedly obese victim.
1. Stand behind the the victim, with your arms directly under the victim’s armpits and
encircle the victim’s chest.
2. Place the thumb side of your fist on the middle of the victim’s breastbone, taking care to
avoid the xiphoid process and the margins of the rib cage.
3. Grab your fist with the other hand and perform backward thrusts until the foreign body is
expelled or the victim becomes unconscious.
Chest Thrusts with the victim Lying down
This maneuver must be used only in the late stages of pregnancy and when Heimlich maneuver
cannot be applied effectively to the unconscious, markedly obese victim.
1. Place the victim on his or her back and kneel close to the victim’s side.
2. The hand position for the application of the chest thrusts is the same as that for chest
compressions. In adult, foe example, the heel of the hand is on the lower half of the
sternum.
3. Deliver each thrust firmly and distinctly, with the intent of relieving the obstruction.

Finger Sweep
This maneuver should be used only in the unconscious victim, never in a seizure victim.
1. With the victim’s face up, open the victim’s mouth by grasping both the tongue and the
lower jaw between the thumb and fingers and lifting the mandible ( tongue-jaw lift ). This
action draws the tongue away from the back of the throat and away from a foreign body
that may be lodged there. This alone may partially relieve the obstruction.
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. Use a hooking action to dislodge the foreign body and maneuver it into the mouth so that
it can be removed.
It is sometimes necessary to use the index finger of to push the foreign body against the opposite
side of the throat to dislodge and remove it. Be careful not to force the object deeper into the
airway. If the foreign body come within reach, grasp and remove it.

Recommended Sequence for Victim Who is or becomes unconscious

1. Open the mouth of the unconscious victim. If you witness a victim losing consciousness
and suspect that a foreign body is present, perform the Finger Sweep.
2. If the victim is found unconscious or no foreign body is suspected during witnessed
unconsciousness, attempt rescue breathing.
3. If unable to ventilate even after attempts to reposition the head, perform the Heimlich
maneuver ( up to 5 times )
4. Open the mouth and perform finger sweep.
5. Attempt to ventilate.
6. If unable to ventilate, reposition the head and try again to ventilate.
7. Repeat the sequence of Heimlich maneuver, finger sweep and attempt to ventilate.
8. Persist in this effort as long as necessary.
9. If the victim resumes effective breathing, place him or her in the recovery position and
monitor closely.
10. Get appropriate medical attention.
General Recommendations
Heimlich maneuver is the recommended technique for relief of foreign-body airway obstruction
in the adult. It may need to be repeated multiple times ( for ease of teaching, multiple may be
interpreted as up to 5 attempts)
It has previously been recommended that the chest thrusts be used in markedly obese person and
in the late stages of pregnancy when there is no room between enlarging uterus and the rib cage
in which to perform abdominal thrust.
As a single method, back blows may not be as effective as the Heimlich maneuver in adults. For
this reason and to simplify training, the Heimlich maneuver is the only method recommended at
this time.
The use of devices to relieve foreign-body airway obstruction is restricted to persons properly
trained in their application. The use of such devices by untrained or inexperience person is
unacceptable. Two types of conventional forceps are acceptable at present for foreign-body
removal, the Kelly clamp and the magill forceps. Both should be used only with direct
visualization of the foreign body.