Emergency Resuscitation Procedure · 2015-09-21 · Since 2011, GIZ has been collaborating with the National Civil Defence College, Nagpur for implementing the “Civil Defence and

Training Module 6

Emergency Resuscitation Procedure

Training Module 1

Earthquake Survival

Training Module 6


Training Module 1

Earthquake Survival

Training Module 6


Since 2011, GIZ has been collaborating with the National Civil

Defence College, Nagpur for implementing the “Civil Defence

and Disaster Risk Management” (CD-DRM) project, aimed at

strengthening capacity building initiatives in Civil Defence. The

focus of the programme is on risk reduction for disasters

caused by natural hazards such as floods, cyclones, drought,

or manmade disasters caused by industry. The design and

development of training tools such as an internet based

training and knowledge management system and blended

learning training methodology and the development of training

materials are important activities under this project.

It gives me great pleasure to introduce this training module to

accompany the hands-on training course for trainers and

volunteers. The module will help the development of

knowledge and skills in specific thematic areas to reduce the

risk of disasters.

I take this opportunity to express appreciation for the

commitment of Director National Civil Defence College, the

Director General of Civil Defence, Ministry of Home Affairs,

Government of India, New Delhi, and ifanos Germany and

ifanos India who extended their support and cooperation to

this effort. I wish that such modules are used extensively by all

stake holders across the country.

Guiding word

Dr. Dieter Mutz

Director

GIZ-IGEP

Delhi, October 2012

ISBN: 978-3-944152-05-9

©NCDC & GIZ, 2012

Published by

Environmental Planning and Disaster Risk Management project of

National Civil Defence College

Civil Lines, Nagpur, 440 001, IndiaT: +91 712 2565614, 2562611F: +91 712 2565614I: [email protected]

and

Deutsche Gesellschaft für

Internationale Zusammenarbeit (GIZ) GmbH

Indo-German Environment Partnership

B-5/2 Safdarjung Enclave

New Delhi 110 029, India

T: +91 11 49495353

F: +91 11 49495391

I: www.giz.de

Responsible

National Civil Defence College, Nagpur

Editorial

Mr. G.S. Saini (V.S.M), Director, NCDC, Nagpur

Mr. Florian Bemmerlein-Lux (ifanos concept & planning, Germany)

Dr. Sandhya Chatterji (ifanos concept & planning, India)

Technical support

Mr. Sunil Sawarkar

Mr. Shrikant Kinhikar

Photos and graphs by

Sources of material used, if no other reference provided: http://www.ficci.com/SEDocument/20186/IndiaRiskSurvey2012.pdfhttp://www.bis.org.in/sf/nbc.htmhttp://edudel.nic.in/welcome_folder/national_building_code_dt_210509.pdf

Design and Printing

M/s Rouge Communications, S-185, Greater Kailash Part 2, New Delhi, November, 2012

Disclaimer

Though all care has been taken while researching and compiling the contents provided in this booklet, the National Civil Defence College and the Deutsche Gesellschaftfür international Zusammenarbeit GmbH accept no liability for its correctness.

The reader is advised to confirm specifications and health hazards described in the booklet before taking any steps, suitability of action requires verifications through other sources also.

Information provided here does not constitute an endorsement or recommendation.

Imprint

(iii)(ii)

Since 2011, GIZ has been collaborating with the National Civil

Defence College, Nagpur for implementing the “Civil Defence

and Disaster Risk Management” (CD-DRM) project, aimed at

strengthening capacity building initiatives in Civil Defence. The

focus of the programme is on risk reduction for disasters

caused by natural hazards such as floods, cyclones, drought,

or manmade disasters caused by industry. The design and

development of training tools such as an internet based

training and knowledge management system and blended

learning training methodology and the development of training

materials are important activities under this project.

It gives me great pleasure to introduce this training module to

accompany the hands-on training course for trainers and

volunteers. The module will help the development of

knowledge and skills in specific thematic areas to reduce the

risk of disasters.

I take this opportunity to express appreciation for the

commitment of Director National Civil Defence College, the

Director General of Civil Defence, Ministry of Home Affairs,

Government of India, New Delhi, and ifanos Germany and

ifanos India who extended their support and cooperation to

this effort. I wish that such modules are used extensively by all

stake holders across the country.

Guiding word

Dr. Dieter Mutz

Director

GIZ-IGEP

Delhi, October 2012

ISBN: 978-3-944152-05-9

©NCDC & GIZ, 2012

Published by

Environmental Planning and Disaster Risk Management project of


Civil Lines, Nagpur, 440 001, IndiaT: +91 712 2565614, 2562611F: +91 712 2565614I: [email protected]

and

Deutsche Gesellschaft für

Internationale Zusammenarbeit (GIZ) GmbH

Indo-German Environment Partnership

B-5/2 Safdarjung Enclave

New Delhi 110 029, India

T: +91 11 49495353

F: +91 11 49495391

I: www.giz.de

Responsible

National Civil Defence College, Nagpur

Editorial

Mr. G.S. Saini (V.S.M), Director, NCDC, Nagpur

Mr. Florian Bemmerlein-Lux (ifanos concept & planning, Germany)

Dr. Sandhya Chatterji (ifanos concept & planning, India)

Technical support

Mr. Sunil Sawarkar

Mr. Shrikant Kinhikar

Photos and graphs by

Sources of material used, if no other reference provided: http://www.ficci.com/SEDocument/20186/IndiaRiskSurvey2012.pdfhttp://www.bis.org.in/sf/nbc.htmhttp://edudel.nic.in/welcome_folder/national_building_code_dt_210509.pdf

Design and Printing

M/s Rouge Communications, S-185, Greater Kailash Part 2, New Delhi, November, 2012

Disclaimer

Though all care has been taken while researching and compiling the contents provided in this booklet, the National Civil Defence College and the Deutsche Gesellschaftfür international Zusammenarbeit GmbH accept no liability for its correctness.

The reader is advised to confirm specifications and health hazards described in the booklet before taking any steps, suitability of action requires verifications through other sources also.

Information provided here does not constitute an endorsement or recommendation.

Imprint

(iii)(ii)

Objective of the module:

¢ To know and understand cardiac

arrest, cardiopulmonary resuscitation

¢ To know and understand technique of

CPR

¢ How to overcome on choking

Main target group:

¢ Medical staff

¢ Training persons

¢ Police personnel

¢ Fireman

¢ Volunteers

This module is meant to accompany a hands-on training course and it includes:

1. Types and Technique of CPR; How to give CPR?

2. Technique of avoid chocking and FBAO

3. Technique of AED

The Civil Defence Organisation in India has been a

governmental programme building resilience of individuals and

communities, in order to increase survivability during extreme

event. Recently, the Government of India had amended the Civil

Defence Act, 1968 to include measures relating to disaster

management in the overall operational capabilities of the Civil

Defence Organisation. In view of this, a review of the local and

state level training modules was conducted by NCDC and

upgraded modules prepared.

NCDC believes that “Strong and Resilient Society” within the

nation can only be possible through volunteer activity, that

comes together to serve the Country and its people to overcome

catastrophic impact's from disasters. The NCDC has developed

training modules to include the survival skill oriented programs

so as to sustain higher recovery rate after disaster. The training

modules deal with essential task to be performed during and

after disaster and provide the necessary force level to the district

administration in the form of back up volunteers from the

community.

The module on Cardiopulmonary Resuscitation/Airway

Obstruction Training covers a range of precautionary steps that

are necessary for each individual and the community. It also

guides common people to undertake volunteer action that can

increase their survival during Heart attack, Choking, AED.

Preface

Mr. G.S.Saini (V.S.M.)

Director

NCDC

Nagpur, October 2012

(v)(iv)

Objective of the module:

¢ To know and understand cardiac

arrest, cardiopulmonary resuscitation

¢ To know and understand technique of

CPR

¢ How to overcome on choking

Main target group:

¢ Medical staff

¢ Training persons

¢ Police personnel

¢ Fireman

¢ Volunteers

This module is meant to accompany a hands-on training course and it includes:

1. Types and Technique of CPR; How to give CPR?

2. Technique of avoid chocking and FBAO

3. Technique of AED

The Civil Defence Organisation in India has been a

governmental programme building resilience of individuals and

communities, in order to increase survivability during extreme

event. Recently, the Government of India had amended the Civil

Defence Act, 1968 to include measures relating to disaster

management in the overall operational capabilities of the Civil

Defence Organisation. In view of this, a review of the local and

state level training modules was conducted by NCDC and

upgraded modules prepared.

NCDC believes that “Strong and Resilient Society” within the

nation can only be possible through volunteer activity, that

comes together to serve the Country and its people to overcome

catastrophic impact's from disasters. The NCDC has developed

training modules to include the survival skill oriented programs

so as to sustain higher recovery rate after disaster. The training

modules deal with essential task to be performed during and

after disaster and provide the necessary force level to the district

administration in the form of back up volunteers from the

community.

The module on Cardiopulmonary Resuscitation/Airway

Obstruction Training covers a range of precautionary steps that

are necessary for each individual and the community. It also

guides common people to undertake volunteer action that can

increase their survival during Heart attack, Choking, AED.

Preface

Mr. G.S.Saini (V.S.M.)

Director

NCDC

Nagpur, October 2012

(v)(iv)

(vi)

1 Introduction 2

2 Cardiac Arrest 4

2.1 Signs and symptoms 4

2.2 Treatment 4

2.3 Cardiac chain of survival 5

3 Cardiopulmonary Resuscitation 6

3.1 Call first vs. call fast 6

3.2 Technique of CPR 7

3.3 Fatigue of rescuers 11

4 Automated External Defibrillation (AED) 12

5 Foreign-body Airway Obstruction (Choking) 14

5.1 Symptoms of choking 14

5.2 Care for chocking adults and children 15

5.3 Care for chocking infant 17

5.4 Self-treating chocking 19

6 Summary of Lessons Learnt 20

7 Glossary and Acronyms 22

8 Background Reading Material 24

9 Bibliography 30

Contents

10 About NCDC 31

11 About GIZ 32

12 About the Indo-German Environment Partnership (IGEP) 33programme of GIZ

13 About the Ministry of Home Affairs 34

14 About the Directorate General of Civil Defence 35

15 List of the Modules 36

(vi)

1 Introduction 2

2 Cardiac Arrest 4

2.1 Signs and symptoms 4

2.2 Treatment 4

2.3 Cardiac chain of survival 5

3 Cardiopulmonary Resuscitation 6

3.1 Call first vs. call fast 6

3.2 Technique of CPR 7

3.3 Fatigue of rescuers 11

4 Automated External Defibrillation (AED) 12

5 Foreign-body Airway Obstruction (Choking) 14

5.1 Symptoms of choking 14

5.2 Care for chocking adults and children 15

5.3 Care for chocking infant 17

5.4 Self-treating chocking 19

6 Summary of Lessons Learnt 20

7 Glossary and Acronyms 22

8 Background Reading Material 24

9 Bibliography 30

Contents

10 About NCDC 31

11 About GIZ 32

12 About the Indo-German Environment Partnership (IGEP) 33programme of GIZ

13 About the Ministry of Home Affairs 34

14 About the Directorate General of Civil Defence 35

15 List of the Modules 36

Introduction

Emergency Resuscitation Procedure02

Medical emergencies can be encountered by people anywhere

and anytime. The best possible approach to overcome such

difficult times when specialized emergency care is not available

immediately lies in the skills of first responders in close vicinity,

those who play a most important role.

In present time, an incident of people falling victim to cardiac

arrest has increased tremendously. In addition there has been

an increase in accidents resulting in serious fatal complications.

It is essential that every citizen be trained and prepared to

handle emergency related to Cardiac Arrest & Foreign-Body

Airway Obstruction. The first responder must develop skills to

master the technique of Cardiopulmonary Resuscitation,

Automated External Defibrillation and Heimlich Manoeuvre.

1

Introduction

Emergency Resuscitation Procedure02

Medical emergencies can be encountered by people anywhere

and anytime. The best possible approach to overcome such

difficult times when specialized emergency care is not available

immediately lies in the skills of first responders in close vicinity,

those who play a most important role.

In present time, an incident of people falling victim to cardiac

arrest has increased tremendously. In addition there has been

an increase in accidents resulting in serious fatal complications.

It is essential that every citizen be trained and prepared to

handle emergency related to Cardiac Arrest & Foreign-Body

Airway Obstruction. The first responder must develop skills to

master the technique of Cardiopulmonary Resuscitation,

Automated External Defibrillation and Heimlich Manoeuvre.

1

n aio nt di n cg ao llc fe or r yl hr ea lpE

- to prevent car td sia rec ar

- to ebuy tim t - r ato e hr e es hta trt

efil fo ytilau q- t eo r r toes

Cardiac Arrest

Cardiac arrest, (also known as cardiopulmonary arrest or

circulatory arrest) is the cessation of normal circulation of the

blood due to failure of the heart to contract effectively. Medical

personnel can refer to an unexpected cardiac arrest as a Sudden

Cardiac Arrest (SCA). Causes of sudden cardiac arrest include

such things as:

¢ Heart attack

¢ Certain heart medications

¢ Drug abuse or overdose

¢ Electrocution, drowning, chocking injury

Arrested blood circulation prevents delivery of oxygen to the

body. Lack of oxygen to the brain causes loss of consciousness,

which then results in abnormal or absent breathing. Brain injury

is likely if cardiac arrest goes untreated for more than five

minutes. For the best chance of survival and neurological

recovery, immediate and decisive treatment is imperative.

2.1 Signs and symptoms

However, due to inadequate cerebral perfusion, the patient will

be unconscious and will have stopped breathing. The main

diagnostic criterion to diagnose a cardiac arrest, (as opposed to

respiratory arrest which shares many of the same features), is

lack of circulation, however there are a number of ways of

determining this. Near death experiences are reported by 10-

20% of people who survived cardiac arrest.

2.2 Treatment

Cardiac arrest is a medical emergency that, in certain

situations, is potentially reversible if treated early. The treatment

for cardiac arrest is Cardiopulmonary Resuscitation (CPR) to

provide circulatory support, followed by defibrillation if a

shockable rhythm is present. If a shockable rhythm is not

present after CPR and other interventions, clinical death is

inevitable.

2.3 Cardiac chain of survival

To recognize the urgent need for quick actions to save the lives of cardiac arrest victims, the Citizens created

the concept of the cardiac chain of survival. This chain of survival has four crucial points:

1. Early access: A victim whose heart has stopped needs help immediately! However, it is also important

that you recognize the signs and symptoms of a potential life-threatening injury such as a heart attack or

stroke in a responsive person. Do not wait until a person become unresponsive to start the chain of events

needed to keep him or her alive. Call Emergency Medical Service Number and get help on the way.

2. Early CPR: For a victim without or abnormal signs of breathing, start cardio-pulmonary resuscitation

(CPR) immediately. This helps keep the brain and other vital organs supplied with oxygen until the

automated external defibrillator (AED) arrives. If you have any doubt whether breathing is normal, act as

if it is not normal.

3. Early defibrillation: An AED, now present in many public and work places, can help get the heart beating

normally again after a cardiac arrest. Send someone right away to get the AED.

4. Early advance care: The sooner the victim is treated by emergency care professionals, the better the

chance for survival. You can help make sure the victim reaches this last link in the chain by acting

immediately with the earlier links.

05Cardiac Arrest04

2

Fig. 1: Chain of survival(Source: Koster et al., 2010)


n aio nt di n cg ao llc fe or r yl hr ea lpE

- to prevent car td sia rec ar

- to ebuy tim t - r ato e hr e es hta trt

efil fo ytilau q- t eo r r toes

Cardiac Arrest

Cardiac arrest, (also known as cardiopulmonary arrest or

circulatory arrest) is the cessation of normal circulation of the

blood due to failure of the heart to contract effectively. Medical

personnel can refer to an unexpected cardiac arrest as a Sudden

Cardiac Arrest (SCA). Causes of sudden cardiac arrest include

such things as:

¢ Heart attack

¢ Certain heart medications

¢ Drug abuse or overdose

¢ Electrocution, drowning, chocking injury

Arrested blood circulation prevents delivery of oxygen to the

body. Lack of oxygen to the brain causes loss of consciousness,

which then results in abnormal or absent breathing. Brain injury

is likely if cardiac arrest goes untreated for more than five

minutes. For the best chance of survival and neurological

recovery, immediate and decisive treatment is imperative.

2.1 Signs and symptoms

However, due to inadequate cerebral perfusion, the patient will

be unconscious and will have stopped breathing. The main

diagnostic criterion to diagnose a cardiac arrest, (as opposed to

respiratory arrest which shares many of the same features), is

lack of circulation, however there are a number of ways of

determining this. Near death experiences are reported by 10-

20% of people who survived cardiac arrest.

2.2 Treatment

Cardiac arrest is a medical emergency that, in certain

situations, is potentially reversible if treated early. The treatment

for cardiac arrest is Cardiopulmonary Resuscitation (CPR) to

provide circulatory support, followed by defibrillation if a

shockable rhythm is present. If a shockable rhythm is not

present after CPR and other interventions, clinical death is

inevitable.

2.3 Cardiac chain of survival

To recognize the urgent need for quick actions to save the lives of cardiac arrest victims, the Citizens created

the concept of the cardiac chain of survival. This chain of survival has four crucial points:

1. Early access: A victim whose heart has stopped needs help immediately! However, it is also important

that you recognize the signs and symptoms of a potential life-threatening injury such as a heart attack or

stroke in a responsive person. Do not wait until a person become unresponsive to start the chain of events

needed to keep him or her alive. Call Emergency Medical Service Number and get help on the way.

2. Early CPR: For a victim without or abnormal signs of breathing, start cardio-pulmonary resuscitation

(CPR) immediately. This helps keep the brain and other vital organs supplied with oxygen until the

automated external defibrillator (AED) arrives. If you have any doubt whether breathing is normal, act as

if it is not normal.

3. Early defibrillation: An AED, now present in many public and work places, can help get the heart beating

normally again after a cardiac arrest. Send someone right away to get the AED.

4. Early advance care: The sooner the victim is treated by emergency care professionals, the better the

chance for survival. You can help make sure the victim reaches this last link in the chain by acting

immediately with the earlier links.

05Cardiac Arrest04

2

Fig. 1: Chain of survival(Source: Koster et al., 2010)


Cardiopulm-onary

Resuscitation

CPR combines rescue breathing (to get oxygen into victim's

lungs) with chest compression (to pump the oxygenated

blood to vital organs). Give CPR to any victim who has

no/abnormal breathing. CPR is also used for an

unresponsive chocking victim because the chest

compressions can expel a foreign object from the victim's

airway.

The specific steps for CPR vary somewhat for adults,

children, and infants. It is important to learn and practice

the skills for all age groups. (Source: Koster et al, 2010, p.

1279)]

3.1 Call first vs. call fast

If someone else is present at the scene, have that person

call EMS Number as soon as you recognize a victim is

unresponsive. Shout for anyone who may hear you, and

have them call EMS Number and go for an AED. If you are

alone, follow these guidelines to call first versus call fast. In

some circumstances it is important to start the process of

getting an AED to the victim first before starting CPR.

Call first for

¢ Unresponsive adult victim

¢ Infant or child with known heart problem seen to

collapse suddenly

Call fast (about 2 minutes) for

¢ Unresponsive child or infant (0-8

years)

¢ Adult victim of near-drowning,

poisoning, drug overdose, or

traumatic injury

3.2 Technique of CPR

CPR alternates giving chest

compressions and recue breaths. After

checking the victim's ABCs and

determining there are no/abnormal sign

of breathing, start CPR. For a victim of

any age, these are the general steps of

CPR:

1. Find the correct hand position on

the lower half of the breastbone

midway between the nipples.

[Include picture showing the hand

position ]

2. Compress the chest quickly and

rhythmically at a rate of at least 100

compressions per minute for adult,

child and infant.

3. Alternate chest compressions and

rescue breaths in the correct ratio for

adult, child or infant.

For detailed CPR steps, see “perform the

skill: CPR for Adults and Children” and

“Perform the skill: CPR for infants”. Here

are the primary CPR differences

depending on the victim's age:

Adult Basic Life Support

UNRESPONSIVE?

Shout for help

Open airway

NOT BREATHING NORMALLY?

Call 112*

30 chest compressions

2 rescue breaths 30 compressions

*or national emergency number

0706

3

Emergency Resuscitation Procedure Cardiopulmonary Resuscitation

Cardiopulm-onary

Resuscitation

CPR combines rescue breathing (to get oxygen into victim's

lungs) with chest compression (to pump the oxygenated

blood to vital organs). Give CPR to any victim who has

no/abnormal breathing. CPR is also used for an

unresponsive chocking victim because the chest

compressions can expel a foreign object from the victim's

airway.

The specific steps for CPR vary somewhat for adults,

children, and infants. It is important to learn and practice

the skills for all age groups. (Source: Koster et al, 2010, p.

1279)]

3.1 Call first vs. call fast

If someone else is present at the scene, have that person

call EMS Number as soon as you recognize a victim is

unresponsive. Shout for anyone who may hear you, and

have them call EMS Number and go for an AED. If you are

alone, follow these guidelines to call first versus call fast. In

some circumstances it is important to start the process of

getting an AED to the victim first before starting CPR.

Call first for

¢ Unresponsive adult victim

¢ Infant or child with known heart problem seen to

collapse suddenly

Call fast (about 2 minutes) for

¢ Unresponsive child or infant (0-8

years)

¢ Adult victim of near-drowning,

poisoning, drug overdose, or

traumatic injury

3.2 Technique of CPR

CPR alternates giving chest

compressions and recue breaths. After

checking the victim's ABCs and

determining there are no/abnormal sign

of breathing, start CPR. For a victim of

any age, these are the general steps of

CPR:

1. Find the correct hand position on

the lower half of the breastbone

midway between the nipples.

[Include picture showing the hand

position ]

2. Compress the chest quickly and

rhythmically at a rate of at least 100

compressions per minute for adult,

child and infant.

3. Alternate chest compressions and

rescue breaths in the correct ratio for

adult, child or infant.

For detailed CPR steps, see “perform the

skill: CPR for Adults and Children” and

“Perform the skill: CPR for infants”. Here

are the primary CPR differences

depending on the victim's age:

Adult Basic Life Support

UNRESPONSIVE?

Shout for help

Open airway

NOT BREATHING NORMALLY?

Call 112*

30 chest compressions

2 rescue breaths 30 compressions

*or national emergency number

0706

3

Emergency Resuscitation Procedure Cardiopulmonary Resuscitation

Adults Children Infants

Compression Heels of both hands Heel of one or two hands Two middle fingers

Chest depth 1 ½ to 2 inches1/3 to the depth of the chest

1/2 1/3 to 1/2 the depth of the chest

Compressions to breaths 30 to 2 30 to 2 30 to 2

CPR essentials

Note that the chest compression depth is roughly 1/3 or 1/2 of the depth of the victim's body. This may help

you ensure your chest compressions are deep enough to be effective.

Adult CPR

1. Tilt head2. Give 2 full breaths3. Start compressions using

both hands - 30 times4. Repeat - 2 breaths, 30

compressions5. Continue until the

ambulance arrives, patient recovers or it is impossible to continue.

Child CPR (1-8 years)

1. Tilt head2. Give 2 full breaths3. Start compressions with one

hand - only 30 times4. Repeat - 2 breaths, 30



Infant CPR (0-1 years)DO NOT TILT HEAD!

1. Give 2 breaths (puffs)2. Start compressions using

two fingers only - 30 times3. Repeat - 2 breaths, 30



Fig. 2: CPR essentials

Perform the skill: CPR for adults and children

¢ Open airway and determine the victim is not breathing

¢ Give 2 rescue breaths (1 second each)

¢ Put hand in correct position for chest compressions. For adult, put second hand on top of first and interlock

fingers.

¢ Give 30 chest compressions 1 ½ - 2 inches deep in an adult at rate of 100 per minute. Count aloud for a

steady fast rate: “one, two, and three…” Then give 2 breaths.

¢ Continue cycles of 30 compressions and 2 breaths in adult. If the victim may have been chocking, look

inside mouth when opening the mouth to give breaths, and remove any object by sweeping it out with your

finger.

¢ After 2 minute of CPR, pause and check the victim again for signs of breathing or circulation. If absent,

continue with chest compressions and rescue breaths. Then check again every few minutes.

¢ Continue CPR until:

a. Victim shows signs of circulation or breathing

b. An AED is brought to the scene and ready to use

c. Help arrives and takes over

d. You are too exhausted to continue

¡ If the victim starts breathing and has signs of circulation, put in the recovery position and monitor

his or her condition.

¡ If the victim has signs of breathing or circulation but is not breathing, continue giving rescue

breaths at a rate of 1 every 5 seconds.

¡ If the victim has no signs of circulation, continue with CPR. When an AED arrives, start the AED

sequence.

0908 Emergency Resuscitation Procedure Cardiopulmonary Resuscitation

Adults Children Infants

Compression Heels of both hands Heel of one or two hands Two middle fingers

Chest depth 1 ½ to 2 inches1/3 to the depth of the chest

1/2 1/3 to 1/2 the depth of the chest

Compressions to breaths 30 to 2 30 to 2 30 to 2

CPR essentials

Note that the chest compression depth is roughly 1/3 or 1/2 of the depth of the victim's body. This may help

you ensure your chest compressions are deep enough to be effective.

Adult CPR

1. Tilt head2. Give 2 full breaths3. Start compressions using

both hands - 30 times4. Repeat - 2 breaths, 30



Child CPR (1-8 years)

1. Tilt head2. Give 2 full breaths3. Start compressions with one

hand - only 30 times4. Repeat - 2 breaths, 30



Infant CPR (0-1 years)DO NOT TILT HEAD!

1. Give 2 breaths (puffs)2. Start compressions using

two fingers only - 30 times3. Repeat - 2 breaths, 30



Fig. 2: CPR essentials

Perform the skill: CPR for adults and children

¢ Open airway and determine the victim is not breathing

¢ Give 2 rescue breaths (1 second each)

¢ Put hand in correct position for chest compressions. For adult, put second hand on top of first and interlock

fingers.

¢ Give 30 chest compressions 1 ½ - 2 inches deep in an adult at rate of 100 per minute. Count aloud for a

steady fast rate: “one, two, and three…” Then give 2 breaths.

¢ Continue cycles of 30 compressions and 2 breaths in adult. If the victim may have been chocking, look

inside mouth when opening the mouth to give breaths, and remove any object by sweeping it out with your

finger.

¢ After 2 minute of CPR, pause and check the victim again for signs of breathing or circulation. If absent,

continue with chest compressions and rescue breaths. Then check again every few minutes.


a. Victim shows signs of circulation or breathing

b. An AED is brought to the scene and ready to use

c. Help arrives and takes over

d. You are too exhausted to continue

¡ If the victim starts breathing and has signs of circulation, put in the recovery position and monitor

his or her condition.

¡ If the victim has signs of breathing or circulation but is not breathing, continue giving rescue

breaths at a rate of 1 every 5 seconds.

¡ If the victim has no signs of circulation, continue with CPR. When an AED arrives, start the AED

sequence.

0908 Emergency Resuscitation Procedure Cardiopulmonary Resuscitation

¢ After 2 minutes of CPR, pause and check the victim again for signs of circulation, then continue with chest

compressions and rescue breaths. Check again every few minutes.


a. Infant shows signs of circulation or breathing.

b. Help arrives and takes over.

c. You are too exhausted to continue.

¡ If the infant starts breathing and has signs of circulation, hold the infant and monitor his or her

condition.

¡ If the victim has signs of circulation but is not breathing, continue giving rescue breaths at a rate of

1 every 5 seconds.

3.3 Fatigue of rescuers

If there is more than one rescuer present, another rescuer should take over delivering CPR every 2min to

prevent fatigue. Ensure that interruption of chest compressions is minimal during the changeover of rescuers.

For this purpose, and to count 30 compressions at the required rate, it may be helpful for the rescuer

performing chest compressions to count out loud. Experienced rescuers could do combined two-rescuer CPR

and in that situation they should exchange roles/places every 2min. (Koster et al., 2010, p.1281)Compression only CPR

A non-breathing victim with no signs of circulation needs both rescue breathing and chest compressions to

move oxygenated blood to vital organs. However, if for any reason you cannot or will not give rescue breathing,

still give the victim chest compressions. This gives the victim a better chance for survival than doing nothing.

Perform the skill: CPR for infants

¢ Open the airway and determine the infant is not breathing.

¢ Give 2 rescue breaths (1 second each).

¢ Put your middle fingers just below an imaginary line between nipples for chest compressions.

¢ Give 30 chest compressions 1/3 to 1/2 the depth of the chest at rate of at least 100 per minute. Count

aloud for a steady fast rate: “One, two, and three…” Then give another breath.

¢ Continue cycles of 30 compressions followed by 2 breaths, if the infant may have been chocking, look

inside the mouth when opening it to give rescue breaths.

11Cardiopulmonary Resuscitation10

Warning

Chest compressions: Be careful with your hand position for chest compressions. Do not give compressions over the bottom tip of the breastbone. When compressing, keep your elbows straight and keep your hands in contact with the chest at all times.

Fig. 3: Chest compression


DOWNSTROKE

UPSTROKE

FULCRUM(HIP JOINTS)

¢ After 2 minutes of CPR, pause and check the victim again for signs of circulation, then continue with chest

compressions and rescue breaths. Check again every few minutes.


a. Infant shows signs of circulation or breathing.

b. Help arrives and takes over.

c. You are too exhausted to continue.

¡ If the infant starts breathing and has signs of circulation, hold the infant and monitor his or her

condition.

¡ If the victim has signs of circulation but is not breathing, continue giving rescue breaths at a rate of

1 every 5 seconds.

3.3 Fatigue of rescuers

If there is more than one rescuer present, another rescuer should take over delivering CPR every 2min to

prevent fatigue. Ensure that interruption of chest compressions is minimal during the changeover of rescuers.

For this purpose, and to count 30 compressions at the required rate, it may be helpful for the rescuer

performing chest compressions to count out loud. Experienced rescuers could do combined two-rescuer CPR

and in that situation they should exchange roles/places every 2min. (Koster et al., 2010, p.1281)Compression only CPR

A non-breathing victim with no signs of circulation needs both rescue breathing and chest compressions to

move oxygenated blood to vital organs. However, if for any reason you cannot or will not give rescue breathing,

still give the victim chest compressions. This gives the victim a better chance for survival than doing nothing.

Perform the skill: CPR for infants

¢ Open the airway and determine the infant is not breathing.

¢ Give 2 rescue breaths (1 second each).

¢ Put your middle fingers just below an imaginary line between nipples for chest compressions.

¢ Give 30 chest compressions 1/3 to 1/2 the depth of the chest at rate of at least 100 per minute. Count

aloud for a steady fast rate: “One, two, and three…” Then give another breath.

¢ Continue cycles of 30 compressions followed by 2 breaths, if the infant may have been chocking, look

inside the mouth when opening it to give rescue breaths.

11Cardiopulmonary Resuscitation10

Warning

Chest compressions: Be careful with your hand position for chest compressions. Do not give compressions over the bottom tip of the breastbone. When compressing, keep your elbows straight and keep your hands in contact with the chest at all times.

Fig. 3: Chest compression


DOWNSTROKE

UPSTROKE

FULCRUM(HIP JOINTS)

Automated External

Defibrillation (AED)

Defibrillation is the application of an electric shock to the chest of

a patient who is in cardiac arrest- a non-breathing and pulseless

patient. It has been used for many years by physicians and

paramedics. To get defibrillation to patients early enough, as

many trained people as possible- not just physicians and

paramedics – must be able to perform this life-saving skill.

Automated external defibrillators have made it possible. Now First

Responders, EMT basics, and even members of the public are

able to defibrillate a patient when it is needed.

Automated external defibrillator (AED) can perform the task of

actually interpreting the heart rhythm, just as a physician would.

When necessary, shocks are then delivered by device directly to

the patient. The actual shocks are delivered to the chest through

adhesive pads. These pads are connected to the AED through

cables, which can transmit a shock to the chest that is powerful

enough to correct a lethal heart rhythm. The pads make

defibrillation safer since no one needs to touch the patient at all

during analysis or shocks.

Operating a defibrillator

AED's are safe and accurate. Even so, you must follow operation

guidelines carefully. They will assure safe and proper use of the

defibrillator:

¢ Become familiar with the AED.

¢ Make sure the AED batteries are fully charged

¢ Carefully follow your local protocols

¢ Make sure no one touches the patient while the AED is analysing the heart rhythm or while a shock is

being delivered

¢ Do not apply the AED to a patient with pulse. The shock could cause the heart to stop

¢ AED must not be used on patients less than 12 years of age or those who weigh less than 40 Kg.(90

pounds)

¢ Do not use an AED with patients who have cardiac arrest due to injury or hypothermia (low body

temperature).

Applying adhesive pads

It is through the adhesive pads that the AED monitors heart rhythm and delivers shocks. The pads must be placed in very specific locations as shown in fig 3. Remember, all directions refer to the patient's right and left, not yours.

Fig. 4: Pad placement

13Automated External Defibrilation (AED)12

4


Automated External

Defibrillation (AED)

Defibrillation is the application of an electric shock to the chest of

a patient who is in cardiac arrest- a non-breathing and pulseless

patient. It has been used for many years by physicians and

paramedics. To get defibrillation to patients early enough, as

many trained people as possible- not just physicians and

paramedics – must be able to perform this life-saving skill.

Automated external defibrillators have made it possible. Now First

Responders, EMT basics, and even members of the public are

able to defibrillate a patient when it is needed.

Automated external defibrillator (AED) can perform the task of

actually interpreting the heart rhythm, just as a physician would.

When necessary, shocks are then delivered by device directly to

the patient. The actual shocks are delivered to the chest through

adhesive pads. These pads are connected to the AED through

cables, which can transmit a shock to the chest that is powerful

enough to correct a lethal heart rhythm. The pads make

defibrillation safer since no one needs to touch the patient at all

during analysis or shocks.

Operating a defibrillator

AED's are safe and accurate. Even so, you must follow operation

guidelines carefully. They will assure safe and proper use of the

defibrillator:

¢ Become familiar with the AED.

¢ Make sure the AED batteries are fully charged

¢ Carefully follow your local protocols

¢ Make sure no one touches the patient while the AED is analysing the heart rhythm or while a shock is

being delivered

¢ Do not apply the AED to a patient with pulse. The shock could cause the heart to stop

¢ AED must not be used on patients less than 12 years of age or those who weigh less than 40 Kg.(90

pounds)

¢ Do not use an AED with patients who have cardiac arrest due to injury or hypothermia (low body

temperature).

Applying adhesive pads

It is through the adhesive pads that the AED monitors heart rhythm and delivers shocks. The pads must be placed in very specific locations as shown in fig 3. Remember, all directions refer to the patient's right and left, not yours.

Fig. 4: Pad placement

13Automated External Defibrilation (AED)12

4


Foreign-body Airway Obstruction (Choking)

Foreign-body airway obstruction (FBAO) is an uncommon but

potentially treatable cause of accidental death. As most

choking events are associated with eating, they are commonly

witnessed. Thus, there is often the opportunity for early

intervention while the victim is still responsive. With total

obstruction, the victim becomes unresponsive within minutes.

CPR is given to an unresponsive victim because the chest

thrusts may expel the foreign object (see CPR section).

5.1 Symptoms of choking

¢ Coughing, wheezing, difficulty breathing

¢ Clutching at throat

¢ Pale or bluish colouring around mouth and nail beds

Recognition is the key to successful outcome. It is therefore important to ask the conscious victim:

"Are you choking?” This at least gives the victim who is unable to speak the opportunity to respond

by nodding!

5.2 Care for chocking adults and children

(source: Koster et al, 2010, p.1286) and to recommend a similar procedure as Koster et al, 2010 describes

on pages 1285-1287:

1514

Fig. 5: FBAO treatment

Adult Foreign Body Airway Obstruction Treatment

Assess severity

Severe airway obstruction(ineffective cough)

Mild airway obstruction(ineffective cough)

Start CPR

Unconscious Conscious

5 back blows5 abdominal

thrusts

Continue to checkfor deterioration

to ineffective cough oruntil obstruction relieved

Encourage cough

5

Emergency Resuscitation Procedure Foreign-body Airway Obstruction (Choking)

Foreign-body Airway Obstruction (Choking)

Foreign-body airway obstruction (FBAO) is an uncommon but

potentially treatable cause of accidental death. As most

choking events are associated with eating, they are commonly

witnessed. Thus, there is often the opportunity for early

intervention while the victim is still responsive. With total

obstruction, the victim becomes unresponsive within minutes.

CPR is given to an unresponsive victim because the chest

thrusts may expel the foreign object (see CPR section).

5.1 Symptoms of choking

¢ Coughing, wheezing, difficulty breathing

¢ Clutching at throat

¢ Pale or bluish colouring around mouth and nail beds

Recognition is the key to successful outcome. It is therefore important to ask the conscious victim:

"Are you choking?” This at least gives the victim who is unable to speak the opportunity to respond

by nodding!

5.2 Care for chocking adults and children

(source: Koster et al, 2010, p.1286) and to recommend a similar procedure as Koster et al, 2010 describes

on pages 1285-1287:

1514

Fig. 5: FBAO treatment

Adult Foreign Body Airway Obstruction Treatment

Assess severity

Severe airway obstruction(ineffective cough)

Mild airway obstruction(ineffective cough)

Start CPR

Unconscious Conscious

5 back blows5 abdominal

thrusts

Continue to checkfor deterioration

to ineffective cough oruntil obstruction relieved

Encourage cough

5

Emergency Resuscitation Procedure Foreign-body Airway Obstruction (Choking)

¢ If a victim is coughing forcefully, rescuers should not interfere with this process but encourage the victim to

continue the coughing to clear the object

¢ Rescuers should intervene in victims who show signs of severe airway obstruction, such as a silent cough,

cyanosis, or inability to speak or breathe.

¡ Ask if victim can breathe or speak. If not, get victim's consent and give abdominal thrusts (Heimlich

manoeuvre) in rapid sequence until the obstruction is relieved. If this is not effective, chest thrusts can

also be used. Chest thrusts can also be used in obese victims or victims in late pregnancy. Abdominal

thrusts should not be used in infants under 1 year of age due to risk of causing injury. A detailed

description for the technique of abdominal blows is given in “Perform the skill: Abdominal blows”.

¡ If the victim becomes unconscious, support the victim carefully to the ground; immediately activate the

ambulance service; begin CPR with chest compressions. When the airway is opened during CPR, the

rescuer should look into the mouth for an object causing obstruction, and remove it if it is evident.

Additional Care

¢ For a responsive pregnant or a larger victim, give chest thrusts instead of abdominal thrusts. If a victim

shows signs of severe airway obstruction, abdominal thrusts should be applied

Perform the skill: Abdominal blows

Fig. 7: Abdominal blows

¢ Stand behind the victim and reach around the abdomen.

¢ Make a first with one hand and grasp it with the other (thumb side into abdomen)

¢ Thrust inward and upward into the abdomen with quick jerks. Continue until the victim can expect the

object or becomes unresponsive.

¢ For a responsive pregnant victim or any victim you cannot get your arms around, give chest thrusts.

5.3 Care for chocking infant

¢ If a chocking infant can cry or cough, watch carefully to see if the object comes out.

¢ If the infant cannot cry or cough, follow the steps for back blows and chest thrusts in “Perform the skill:

chocking in an infant”.

1716 Emergency Resuscitation Procedure Foreign-body Airway Obstruction (Choking)

¢ If a victim is coughing forcefully, rescuers should not interfere with this process but encourage the victim to

continue the coughing to clear the object

¢ Rescuers should intervene in victims who show signs of severe airway obstruction, such as a silent cough,

cyanosis, or inability to speak or breathe.

¡ Ask if victim can breathe or speak. If not, get victim's consent and give abdominal thrusts (Heimlich

manoeuvre) in rapid sequence until the obstruction is relieved. If this is not effective, chest thrusts can

also be used. Chest thrusts can also be used in obese victims or victims in late pregnancy. Abdominal

thrusts should not be used in infants under 1 year of age due to risk of causing injury. A detailed

description for the technique of abdominal blows is given in “Perform the skill: Abdominal blows”.

¡ If the victim becomes unconscious, support the victim carefully to the ground; immediately activate the

ambulance service; begin CPR with chest compressions. When the airway is opened during CPR, the

rescuer should look into the mouth for an object causing obstruction, and remove it if it is evident.

Additional Care

¢ For a responsive pregnant or a larger victim, give chest thrusts instead of abdominal thrusts. If a victim

shows signs of severe airway obstruction, abdominal thrusts should be applied

Perform the skill: Abdominal blows

Fig. 7: Abdominal blows

¢ Stand behind the victim and reach around the abdomen.

¢ Make a first with one hand and grasp it with the other (thumb side into abdomen)

¢ Thrust inward and upward into the abdomen with quick jerks. Continue until the victim can expect the

object or becomes unresponsive.

¢ For a responsive pregnant victim or any victim you cannot get your arms around, give chest thrusts.

5.3 Care for chocking infant

¢ If a chocking infant can cry or cough, watch carefully to see if the object comes out.

¢ If the infant cannot cry or cough, follow the steps for back blows and chest thrusts in “Perform the skill:

chocking in an infant”.

1716 Emergency Resuscitation Procedure Foreign-body Airway Obstruction (Choking)

¢ Support the infant's head in one hand, with the torso on your fore-arm and your thigh. Give up to 5 back

blows between the shoulder blades.

¢ Check for object expelled. If not present, continue with next step.

¢ With other hand on back of infant's head, roll the infant face up.

¢ Give up to 5 chest thrusts with middle and ring fingers. Check mouth for expelled object.

¢ Repeat steps 1-4, alternating back blows and chest thrusts and checking the mouth. If alone call the EMS

number

¢ If the infant becomes unresponsive, send someone to call EMS Number, and give CPR. Check for an object

in the mouth before you give a breath, and sweep out any object you see with on finger.

5.4 Self-treating chocking

If you are chocking when alone, give yourself abdominal thrusts to try to expel the object. You may try using

your hands, or lean over and push your abdomen against the back of a chair or other firm object.

19Foreign-body Airway Obstruction (Choking)18

Fig. 8: Back blows and chest thrusts

Perform the skill: Back blows and chest thrusts for a chocking infant


¢ Support the infant's head in one hand, with the torso on your fore-arm and your thigh. Give up to 5 back

blows between the shoulder blades.

¢ Check for object expelled. If not present, continue with next step.

¢ With other hand on back of infant's head, roll the infant face up.

¢ Give up to 5 chest thrusts with middle and ring fingers. Check mouth for expelled object.

¢ Repeat steps 1-4, alternating back blows and chest thrusts and checking the mouth. If alone call the EMS

number

¢ If the infant becomes unresponsive, send someone to call EMS Number, and give CPR. Check for an object

in the mouth before you give a breath, and sweep out any object you see with on finger.

5.4 Self-treating chocking

If you are chocking when alone, give yourself abdominal thrusts to try to expel the object. You may try using

your hands, or lean over and push your abdomen against the back of a chair or other firm object.

19Foreign-body Airway Obstruction (Choking)18

Fig. 8: Back blows and chest thrusts

Perform the skill: Back blows and chest thrusts for a chocking infant


Summary of Lessons

Learnt

¢ Cardiac arrest and choking require fast response by rescuers

¢ In case of a cardiac arrest rescuers need to start the cardiac

chain of survival as soon as possible:

¡ Early access

¡ Early CPR

¡ Early AED

¡ Early Advanced Care

¢ If you have any doubt whether breathing is normal, act as if

it is not normal.

¢ If you feel not confident to give mouth-to-mouth ventilation

remember that giving compression-only CPR is better than

doing nothing!

¢ If you consider a victim is choking act as follows:

¡ Check if victim can response

¡ Check severity of airway obstruction

¡ Manage accordingly

l Mild obstruction: Encourage coughing

l Severe obstruction:

n Conscious victim: Perform back bows and abdominal bows (for adults and children) or back bows

and chest thrusts (choking infant)

n Unconscious victim: Start CPR

21Summary of Lessons Learnt20

6


Summary of Lessons

Learnt

¢ Cardiac arrest and choking require fast response by rescuers

¢ In case of a cardiac arrest rescuers need to start the cardiac

chain of survival as soon as possible:

¡ Early access

¡ Early CPR

¡ Early AED

¡ Early Advanced Care

¢ If you have any doubt whether breathing is normal, act as if

it is not normal.

¢ If you feel not confident to give mouth-to-mouth ventilation

remember that giving compression-only CPR is better than

doing nothing!

¢ If you consider a victim is choking act as follows:

¡ Check if victim can response

¡ Check severity of airway obstruction

¡ Manage accordingly

l Mild obstruction: Encourage coughing

l Severe obstruction:

n Conscious victim: Perform back bows and abdominal bows (for adults and children) or back bows

and chest thrusts (choking infant)

n Unconscious victim: Start CPR

21Summary of Lessons Learnt20

6


Glossaryand

Acronyms

hospital acute medical care with the goal to either provide treatment to those in need of

urgent medical care, or to arranging for timely removal of the patient to the next point of

definitive care.

FBAO Foreign Body Airway Obstruction: Partial or complete blockage of the breathing tubes to

the lungs due to a foreign body (e.g., food, a bead, toy, etc.).

(http://www.medterms.com/script/main/art.asp?articlekey=8563)

SCA Sudden Cardiac Arrest: Is a condition in which the heart suddenly and unexpectedly stops

beating. When this happens, blood stops flowing to the brain and other vital organs. SCA

usually causes death if it's not treated within minutes.

(http://www.nhlbi.nih.gov/health/health-topics/topics/scda/)

SCD Sudden Cardiac Death: Death caused by unexpected cardiac arrest

23Glossary and Acronyms22

7


AED Automated External Defibrillator is a portable

device that checks the heart rhythm. If

needed, it can send an electric shock to the

heart to try to restore a normal rhythm. AEDs

are used to treat sudden cardiac arrest (SCA).

(http://www.nhlbi.nih.gov/health/health-

topics/topics/aed/)

BLS Basic Life Support: Refers to maintaining

airway patency and supporting breathing and

the circulation without the use of equipment

other than a protective device.

(http://www.resus.org.uk/pages/bls.pdf)

Choking Choking is the physiological response to

sudden airways obstruction.

(http://www.patient.co.uk/doctor/Choking-and-

Foreign-Body-Airway-Obstruction-

%28FBAO%29.htm)

CPR Cardio Pulmonary Resuscitation is an

emergency procedure for a person whose

heart has stopped or is no longer breathing.

CPR can maintain circulation and breathing

until emergency medical help arrives.

(http://www.nlm.nih.gov/medlineplus/cpr.html)

EMS Emergency Medical Services: Provide out-of-

Glossaryand

Acronyms

hospital acute medical care with the goal to either provide treatment to those in need of

urgent medical care, or to arranging for timely removal of the patient to the next point of

definitive care.

FBAO Foreign Body Airway Obstruction: Partial or complete blockage of the breathing tubes to

the lungs due to a foreign body (e.g., food, a bead, toy, etc.).

(http://www.medterms.com/script/main/art.asp?articlekey=8563)

SCA Sudden Cardiac Arrest: Is a condition in which the heart suddenly and unexpectedly stops

beating. When this happens, blood stops flowing to the brain and other vital organs. SCA

usually causes death if it's not treated within minutes.

(http://www.nhlbi.nih.gov/health/health-topics/topics/scda/)

SCD Sudden Cardiac Death: Death caused by unexpected cardiac arrest

23Glossary and Acronyms22

7


AED Automated External Defibrillator is a portable

device that checks the heart rhythm. If

needed, it can send an electric shock to the

heart to try to restore a normal rhythm. AEDs

are used to treat sudden cardiac arrest (SCA).

(http://www.nhlbi.nih.gov/health/health-

topics/topics/aed/)

BLS Basic Life Support: Refers to maintaining

airway patency and supporting breathing and

the circulation without the use of equipment

other than a protective device.

(http://www.resus.org.uk/pages/bls.pdf)

Choking Choking is the physiological response to

sudden airways obstruction.

(http://www.patient.co.uk/doctor/Choking-and-

Foreign-Body-Airway-Obstruction-

%28FBAO%29.htm)

CPR Cardio Pulmonary Resuscitation is an

emergency procedure for a person whose

heart has stopped or is no longer breathing.

CPR can maintain circulation and breathing

until emergency medical help arrives.

(http://www.nlm.nih.gov/medlineplus/cpr.html)

EMS Emergency Medical Services: Provide out-of-

Background Reading Material

Choking and foreign body airway

obstruction (FBAO)

Choking is the physiological response to sudden airways

obstruction. Foreign body airway obstruction (FBAO) causes

asphyxia and is a terrifying condition, occurring very acutely,

with the patient often unable to explain what is happening to

them. If severe, it can result in rapid loss of consciousness and

death if first aid is not undertaken quickly and successfully.

Immediate recognition and response are of the utmost

importance.

Recognition

Because recognition is the key to successful outcome, it is

important to ask the conscious victim "Are you choking?". This

at least gives the victim who is unable to speak the opportunity

to respond by nodding!

Consider the diagnosis of choking particularly if:

¢ Episode occurs whilst eating, and onset was very sudden.

¢ Adult victim - may clutch his or her neck, or points to throat.

¢ Child victim - there may be clues, eg seen eating or playing

with small items just before onset of symptoms.

Assess severity

¢ Mild obstruction:

¡ The patient is able to breathe, cough effectively and

speak.

¡ Children are fully responsive, crying or verbally respond to questions, may have loud cough (and able

to take a breath before coughing).

¢ Severe obstruction is indicated by:

¡ Victim unable to breathe or speak/vocalise.

¡ Wheezy breath sounds.

¡ Attempts at coughing are quiet or silent.

¡ Cyanosis and diminishing conscious level (particularly in children).

¡ Victim unconscious.

Management

Adults

¢ In mild obstruction, encourage the patient to continue coughing, but do nothing else except monitor for

deterioration.

¢ In severe obstruction in a conscious patient:

¡ Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim

well forwards (so that the obstructing object comes out of the mouth rather than going further down the

airway).

¡ Give up to five sharp back blows between the shoulder blades with the heel of your other hand

(checking after each if the obstruction has been relieved).

¡ If unsuccessful, give up to five abdominal thrusts. Stand behind the victim (who is leaning forward) put

both arms around the upper abdomen and clench one fist, grasp it with the other hand and pull sharply

inwards and upwards.

¡ Continue alternating five back blows and five abdominal thrusts until successful or the patient becomes

unconscious.

2524

8

Emergency Resuscitation Procedure Background Reading Material

Background Reading Material

Choking and foreign body airway

obstruction (FBAO)

Choking is the physiological response to sudden airways

obstruction. Foreign body airway obstruction (FBAO) causes

asphyxia and is a terrifying condition, occurring very acutely,

with the patient often unable to explain what is happening to

them. If severe, it can result in rapid loss of consciousness and

death if first aid is not undertaken quickly and successfully.

Immediate recognition and response are of the utmost

importance.

Recognition

Because recognition is the key to successful outcome, it is

important to ask the conscious victim "Are you choking?". This

at least gives the victim who is unable to speak the opportunity

to respond by nodding!

Consider the diagnosis of choking particularly if:

¢ Episode occurs whilst eating, and onset was very sudden.

¢ Adult victim - may clutch his or her neck, or points to throat.

¢ Child victim - there may be clues, eg seen eating or playing

with small items just before onset of symptoms.

Assess severity

¢ Mild obstruction:

¡ The patient is able to breathe, cough effectively and

speak.

¡ Children are fully responsive, crying or verbally respond to questions, may have loud cough (and able

to take a breath before coughing).

¢ Severe obstruction is indicated by:

¡ Victim unable to breathe or speak/vocalise.

¡ Wheezy breath sounds.

¡ Attempts at coughing are quiet or silent.

¡ Cyanosis and diminishing conscious level (particularly in children).

¡ Victim unconscious.

Management

Adults

¢ In mild obstruction, encourage the patient to continue coughing, but do nothing else except monitor for

deterioration.

¢ In severe obstruction in a conscious patient:

¡ Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim

well forwards (so that the obstructing object comes out of the mouth rather than going further down the

airway).

¡ Give up to five sharp back blows between the shoulder blades with the heel of your other hand

(checking after each if the obstruction has been relieved).

¡ If unsuccessful, give up to five abdominal thrusts. Stand behind the victim (who is leaning forward) put

both arms around the upper abdomen and clench one fist, grasp it with the other hand and pull sharply

inwards and upwards.

¡ Continue alternating five back blows and five abdominal thrusts until successful or the patient becomes

unconscious.

2524

8

Emergency Resuscitation Procedure Background Reading Material

In an unconscious patient:

¡ Lower the patient to the floor.

¡ Call an ambulance immediately.

¡ Begin CPR (even if a pulse is present in the unconscious choking victim).

¢ If coughing effectively, just encourage the child to cough, and monitor continuously.

¢ If coughing is, or is becoming, ineffective, shout for help and assess the child's conscious level.

¢ If the child is conscious, give up to five back blows, followed by five chest thrusts to infants or five

abdominal thrusts to children (repeat the sequence until the obstruction is relieved or the patient becomes

unconscious).

¡ For infants (<1 year old): back blows and chest thrusts:

l In a seated position, support the infant in a head-downwards, prone position to let gravity aid

removal of the foreign body.

l Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two

fingers from the same hand at the same point on the other side of the jaw. Do not compress the soft

tissues under the jaw, as this will aggravate the airway obstruction.

l Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the

shoulder blades).

l After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the

manoeuvre up to five times.

l After five unsuccessful back blows, use chest thrusts: turn the infant into a head-downwards supine

position by placing your free arm along the infant's back and encircling the occiput with your hand.

Support the infant down your arm, which is placed down (or across) your thigh. Identify the

Children

landmark for chest compression. This is the lower sternum, about a finger's breadth above the

xiphisternum. Deliver five chest thrusts. These are similar to chest compressions for CPR, but

sharper in nature and delivered at a slower rate.

¡ For children (1 year old to puberty): back blows and abdominal thrusts:

l Blows to the back are more effective if the child is positioned head down. A small child can be

placed across the lap as with an infant. If this is not possible, support the child in a forward-leaning

position.

l Deliver up to five sharp back blows with the heel of one hand in the middle of the back between the

shoulder blades.

l After five unsuccessful back blows, abdominal thrusts may be used in children over 1 year old:

n Stand or kneel behind the child, placing arms around torso. Placed clenched fist between the

umbilicus and xiphisternum (ensuring no pressure is applied to either landmark).

n Grasp this hand with your other hand and pull sharply inwards and upwards, repeating up to 5

times.

¢ If the child becomes unconscious, place him or her on a flat, firm surface, shouting for help if none has

arrived. Open the mouth and look for any obvious object. If one is seen, make an attempt to remove it with

a single finger sweep (don't do blind finger sweeps).

¢ If unsuccessful, begin CPR as for paediatric basic life support, beginning with five rescue breaths, checking

for rise and fall of the chest each time (reposition the head each time if a breath does not make the chest

rise, before making the next attempt).

Epidemiology

Choking is a risk whenever food is consumed. A US study suggests an incidence of death due to FBAO of 0.66

per 100,000 population. An Australian study looking at incidence of foreign body asphyxia admission rate in

Incidence

2726 Emergency Resuscitation Procedure Background Reading Material

In an unconscious patient:

¡ Lower the patient to the floor.

¡ Call an ambulance immediately.

¡ Begin CPR (even if a pulse is present in the unconscious choking victim).

¢ If coughing effectively, just encourage the child to cough, and monitor continuously.

¢ If coughing is, or is becoming, ineffective, shout for help and assess the child's conscious level.

¢ If the child is conscious, give up to five back blows, followed by five chest thrusts to infants or five

abdominal thrusts to children (repeat the sequence until the obstruction is relieved or the patient becomes

unconscious).

¡ For infants (<1 year old): back blows and chest thrusts:

l In a seated position, support the infant in a head-downwards, prone position to let gravity aid

removal of the foreign body.

l Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two

fingers from the same hand at the same point on the other side of the jaw. Do not compress the soft

tissues under the jaw, as this will aggravate the airway obstruction.

l Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the

shoulder blades).

l After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the

manoeuvre up to five times.

l After five unsuccessful back blows, use chest thrusts: turn the infant into a head-downwards supine

position by placing your free arm along the infant's back and encircling the occiput with your hand.

Support the infant down your arm, which is placed down (or across) your thigh. Identify the

Children

landmark for chest compression. This is the lower sternum, about a finger's breadth above the

xiphisternum. Deliver five chest thrusts. These are similar to chest compressions for CPR, but

sharper in nature and delivered at a slower rate.

¡ For children (1 year old to puberty): back blows and abdominal thrusts:

l Blows to the back are more effective if the child is positioned head down. A small child can be

placed across the lap as with an infant. If this is not possible, support the child in a forward-leaning

position.

l Deliver up to five sharp back blows with the heel of one hand in the middle of the back between the

shoulder blades.

l After five unsuccessful back blows, abdominal thrusts may be used in children over 1 year old:

n Stand or kneel behind the child, placing arms around torso. Placed clenched fist between the

umbilicus and xiphisternum (ensuring no pressure is applied to either landmark).

n Grasp this hand with your other hand and pull sharply inwards and upwards, repeating up to 5

times.

¢ If the child becomes unconscious, place him or her on a flat, firm surface, shouting for help if none has

arrived. Open the mouth and look for any obvious object. If one is seen, make an attempt to remove it with

a single finger sweep (don't do blind finger sweeps).

¢ If unsuccessful, begin CPR as for paediatric basic life support, beginning with five rescue breaths, checking

for rise and fall of the chest each time (reposition the head each time if a breath does not make the chest

rise, before making the next attempt).

Epidemiology

Choking is a risk whenever food is consumed. A US study suggests an incidence of death due to FBAO of 0.66

per 100,000 population. An Australian study looking at incidence of foreign body asphyxia admission rate in

Incidence

2726 Emergency Resuscitation Procedure Background Reading Material

the under-15s shows a rate of 15.1 per 100,000 per annum, peaking in those aged under one and then

gradually declining to low levels by 3 years old.

Risk factors

In one Austrian autopsy series, certain risk factors were identified:

¢ Old age

¢ Poor dentition

¢ Alcohol consumption

¢ Chronic disease

¢ Sedation

¢ Eating risky foods

FBAO was diagnosed correctly in fewer than 10% of cases where help was summoned.

The elderly are a particularly vulnerable group and FBAO is associated with:

¢ A higher risk with soft/slick foods.

¢ Agomphiasis (absence of teeth).

¢ Neurological impairment.

Children, in particular mobile babies and toddlers who orally explore their environments, are at risk from

FBAO. Carers need to maintain vigilance for objects such as coins, balloons, marbles. Risky foods in childhood

tend to be round in shape and include sweets, nuts, grapes and improperly chewed other food.

Rapid evaluation is key: swiftly consider other conditions that may cause sudden respiratory distress, cyanosis

or loss of consciousness, such as:

¢ Anaphylaxis

¢ Syncope

Differential diagnosis

¢ Myocardial infarct

¢ Seizure

¢ Inhaled foreign body: after successful treatment for choking, foreign material may still be present in the

upper or lower airways and cause complications such as bronchiectasis or lung abscess later. Anyone with

a persistent cough, difficulty swallowing, or with the sensation of an object being still stuck in the throat

should therefore be referred to A&E. CXR may show an opacity that requires removal at bronchoscopy or

atelectasis. In children, clinical features and radiological findings may have a poor correlation with findings

at bronchoscopy. If a foreign body is suspected, bronchoscopy should be performed at an early stage for

best results.

¢ Iatrogenic: abdominal thrusts can cause serious injuries (eg gastric and splenic rupture) and all victims

receiving abdominal thrusts require examination of the abdomen with a particular view to visceral injuries.

¢ Hypoxic brain injury and death.

Tragedy due to FBAO is unpredictable. In our risk-averse society, we can try to iron out some elements of

increased risk, such as:

¢ Not eating whilst exercising.

¢ Remembering to chew food properly.

¢ Avoiding drunkenness.

¢ Cutting up grapes and not giving peanuts to small children.

We can also increase public awareness of choking and confidence at initiating first aid. The abdominal thrust

manoeuvre used in the prehospital setting on adults has a good rate of success (86.5%). Given the speed with

which individuals lose consciousness and die in a complete airway obstruction and the fact that survival often

requires obstructions to have been cleared prior to the arrival of paramedics, these skills should be widely

taught and practised.

Complications

Prevention

29Background Reading Material28 Emergency Resuscitation Procedure

the under-15s shows a rate of 15.1 per 100,000 per annum, peaking in those aged under one and then

gradually declining to low levels by 3 years old.

Risk factors

In one Austrian autopsy series, certain risk factors were identified:

¢ Old age

¢ Poor dentition

¢ Alcohol consumption

¢ Chronic disease

¢ Sedation

¢ Eating risky foods

FBAO was diagnosed correctly in fewer than 10% of cases where help was summoned.

The elderly are a particularly vulnerable group and FBAO is associated with:

¢ A higher risk with soft/slick foods.

¢ Agomphiasis (absence of teeth).

¢ Neurological impairment.

Children, in particular mobile babies and toddlers who orally explore their environments, are at risk from

FBAO. Carers need to maintain vigilance for objects such as coins, balloons, marbles. Risky foods in childhood

tend to be round in shape and include sweets, nuts, grapes and improperly chewed other food.

Rapid evaluation is key: swiftly consider other conditions that may cause sudden respiratory distress, cyanosis

or loss of consciousness, such as:

¢ Anaphylaxis

¢ Syncope

Differential diagnosis

¢ Myocardial infarct

¢ Seizure

¢ Inhaled foreign body: after successful treatment for choking, foreign material may still be present in the

upper or lower airways and cause complications such as bronchiectasis or lung abscess later. Anyone with

a persistent cough, difficulty swallowing, or with the sensation of an object being still stuck in the throat

should therefore be referred to A&E. CXR may show an opacity that requires removal at bronchoscopy or

atelectasis. In children, clinical features and radiological findings may have a poor correlation with findings

at bronchoscopy. If a foreign body is suspected, bronchoscopy should be performed at an early stage for

best results.

¢ Iatrogenic: abdominal thrusts can cause serious injuries (eg gastric and splenic rupture) and all victims

receiving abdominal thrusts require examination of the abdomen with a particular view to visceral injuries.

¢ Hypoxic brain injury and death.

Tragedy due to FBAO is unpredictable. In our risk-averse society, we can try to iron out some elements of

increased risk, such as:

¢ Not eating whilst exercising.

¢ Remembering to chew food properly.

¢ Avoiding drunkenness.

¢ Cutting up grapes and not giving peanuts to small children.

We can also increase public awareness of choking and confidence at initiating first aid. The abdominal thrust

manoeuvre used in the prehospital setting on adults has a good rate of success (86.5%). Given the speed with

which individuals lose consciousness and die in a complete airway obstruction and the fact that survival often

requires obstructions to have been cleared prior to the arrival of paramedics, these skills should be widely

taught and practised.

Complications

Prevention

29Background Reading Material28 Emergency Resuscitation Procedure

About NCDC

The first Disaster Management Training Institution of the country was founded

on 9th April 1957 at Nagpur as the Central Emergency Relief Training

Institute (CERTI) to support the emergency relief organisation of the

Government of India. This central institute organized advanced and specialist

training for the leaders of disaster relief and response operations to manage the consequences of

any natural or man-made disaster.

In 1962, the training curriculum of the college got a Civil Defence twist and in 1968, after the

enactment of CD legislation, the college was rechristened as National Civil Defence College.


Govt. of India, Ministry of Home Affairs,

61/1 Civil Lines, Nagpur, 440 001

Maharashtra, India.

Phone +91 712 2565614, 2562611

Fax +91 712 2565614

Email: [email protected]

http://www.ncdcnagpur.nic.in, http://www.cddrm-ncdc.org

Koster Rudolph W., Michael A. Baubin, Leo L. Bossaert,

Antonio Caballero, Pascal Cassan, Maaret Castrén, Cristina

Granja, Anthony J. Handley, Koenraad G. Monsieurs, Gavin D.

Perkins, Violetta Raffay, Claudio Sandroni (2010):European

Resuscitation Council Guidelines for Resuscitation 2010

Section 2. Adult basic life support and use of automated

external defibrillators,

http://resuscitation-

guidelines.articleinmotion.com/article/S0300-

9572%2810%2900435-1/aim/use-of-an-automated-external-

defibrillator

3130

Bibliography

About NCDCEmergency Resuscitation Procedure

About NCDC

The first Disaster Management Training Institution of the country was founded

on 9th April 1957 at Nagpur as the Central Emergency Relief Training

Institute (CERTI) to support the emergency relief organisation of the

Government of India. This central institute organized advanced and specialist

training for the leaders of disaster relief and response operations to manage the consequences of

any natural or man-made disaster.

In 1962, the training curriculum of the college got a Civil Defence twist and in 1968, after the

enactment of CD legislation, the college was rechristened as National Civil Defence College.


Govt. of India, Ministry of Home Affairs,

61/1 Civil Lines, Nagpur, 440 001

Maharashtra, India.

Phone +91 712 2565614, 2562611

Fax +91 712 2565614

Email: [email protected]

http://www.ncdcnagpur.nic.in, http://www.cddrm-ncdc.org

Koster Rudolph W., Michael A. Baubin, Leo L. Bossaert,

Antonio Caballero, Pascal Cassan, Maaret Castrén, Cristina

Granja, Anthony J. Handley, Koenraad G. Monsieurs, Gavin D.

Perkins, Violetta Raffay, Claudio Sandroni (2010):European

Resuscitation Council Guidelines for Resuscitation 2010

Section 2. Adult basic life support and use of automated

external defibrillators,

http://resuscitation-

guidelines.articleinmotion.com/article/S0300-

9572%2810%2900435-1/aim/use-of-an-automated-external-

defibrillator

3130

Bibliography

About NCDCEmergency Resuscitation Procedure

32

About GIZ

The services delivered by the Deutsche

Gesellschaftfür Internationale

Zusammenarbeit (GIZ) GmbH draw on a wealth of regional and technical expertise and tried and

tested management know-how. As a federal enterprise, we support the German Government in

achieving its objectives in the field of international cooperation for sustainable development. We are

also engaged in international education work around the globe. GIZ currently operates in more than

130 countries worldwide.

Germany has been cooperating with India by providing expertise through GIZ for more than 50

years. To address India's priority of sustainable and inclusive growth, GIZ's joint efforts with the

partners in India currently focus on the following areas:

¢ Energy - Renewable Energy and Energy Efficiency

¢ Sustainable Urban and Industrial Development

¢ Natural Resource Management

¢ Private Sector Development

¢ Social Protection

¢ Financial Systems Development

¢ HIV/AIDS – Blood Safety

GIZ in India

About the Indo-German Environment

Partnership (IGEP) programme of GIZ

IGEP builds on the experience of the predecessor

Advisory Services in Environment Management (ASEM)

programme but at the same time strengthens its

thematic profile in the urban and industrial sector, up-scales successful pilots and supports the

environmental reform agenda and priority needs of India.

The overall objective of IGEP is that the decision makers at national, state and local level use

innovative solutions for the improvement of urban and industrial environmental management and for

the development of an environment and climate policy that targets inclusive economic growth de-

coupled from resource consumption.

For information visit http://www.igep.in or write at [email protected]

33About the Indo-German Environment Partnership (IGEP) programme of GIZEmergency Resuscitation Procedure

32

About GIZ

The services delivered by the Deutsche

Gesellschaftfür Internationale

Zusammenarbeit (GIZ) GmbH draw on a wealth of regional and technical expertise and tried and

tested management know-how. As a federal enterprise, we support the German Government in

achieving its objectives in the field of international cooperation for sustainable development. We are

also engaged in international education work around the globe. GIZ currently operates in more than

130 countries worldwide.

Germany has been cooperating with India by providing expertise through GIZ for more than 50

years. To address India's priority of sustainable and inclusive growth, GIZ's joint efforts with the

partners in India currently focus on the following areas:

¢ Energy - Renewable Energy and Energy Efficiency

¢ Sustainable Urban and Industrial Development

¢ Natural Resource Management

¢ Private Sector Development

¢ Social Protection

¢ Financial Systems Development

¢ HIV/AIDS – Blood Safety

GIZ in India

About the Indo-German Environment

Partnership (IGEP) programme of GIZ

IGEP builds on the experience of the predecessor

Advisory Services in Environment Management (ASEM)

programme but at the same time strengthens its

thematic profile in the urban and industrial sector, up-scales successful pilots and supports the

environmental reform agenda and priority needs of India.

The overall objective of IGEP is that the decision makers at national, state and local level use

innovative solutions for the improvement of urban and industrial environmental management and for

the development of an environment and climate policy that targets inclusive economic growth de-

coupled from resource consumption.

For information visit http://www.igep.in or write at [email protected]

33About the Indo-German Environment Partnership (IGEP) programme of GIZEmergency Resuscitation Procedure

34

About the Ministry of Home Affairs

The Ministry of Home Affairs is the nodal Department responsible for the

coordination of Disaster management in the Government of India. Since early

2000, the Government has been focusing on developing the capabilities in the

country for preparedness, prevention and mitigation along with developing

capabilities for response. The need to eliminate the underlying vulnerabilities

through systematic integration of disaster risk reduction in development programmes is being

actively pursued at the national and state levels.

Achieving India's development goals and sustainable development are not possible unless it is

ensure that all developments are disaster resilient. The Disaster Management Division in MHA is

responsible for legislation, policy and administrative measures for capacity building, prevention,

mitigation and preparedness to deal with natural and man-made disasters (except drought and

epidemics) and for coordinating response, relief and rehabilitation after disaster strike.

(http://www.mha.nic.in)

About the Directorate General of Civil Defence

Directorate General of Civil Defence was established in M. H. A. in 1962 to

handle all policy and planning matters related to Civil Defence and its running

partners Home Guards and Fire Services.

Civil Defence in the country has been raised on the strength of Civil Defence Act,

1968, C. D. Rules, 1968 and Civil Defence Regulations, 1968. The Civil Defence Legislation is a

Central Act, however, C. D. Regulation, 1968 provides all the powers to implement and execute the C.

D. Scheme to the State Government. Central Govt. is responsible for making the policies, plans and

financing the States for implementing of the different schemes of Civil Defence.

(http;//www.dgcd.nic.in)

35About the Directorate General of Civil DefenceEmergency Resuscitation Procedure

34

About the Ministry of Home Affairs

The Ministry of Home Affairs is the nodal Department responsible for the

coordination of Disaster management in the Government of India. Since early

2000, the Government has been focusing on developing the capabilities in the

country for preparedness, prevention and mitigation along with developing

capabilities for response. The need to eliminate the underlying vulnerabilities

through systematic integration of disaster risk reduction in development programmes is being

actively pursued at the national and state levels.

Achieving India's development goals and sustainable development are not possible unless it is

ensure that all developments are disaster resilient. The Disaster Management Division in MHA is

responsible for legislation, policy and administrative measures for capacity building, prevention,

mitigation and preparedness to deal with natural and man-made disasters (except drought and

epidemics) and for coordinating response, relief and rehabilitation after disaster strike.

(http://www.mha.nic.in)

About the Directorate General of Civil Defence

Directorate General of Civil Defence was established in M. H. A. in 1962 to

handle all policy and planning matters related to Civil Defence and its running

partners Home Guards and Fire Services.

Civil Defence in the country has been raised on the strength of Civil Defence Act,

1968, C. D. Rules, 1968 and Civil Defence Regulations, 1968. The Civil Defence Legislation is a

Central Act, however, C. D. Regulation, 1968 provides all the powers to implement and execute the C.

D. Scheme to the State Government. Central Govt. is responsible for making the policies, plans and

financing the States for implementing of the different schemes of Civil Defence.

(http;//www.dgcd.nic.in)

35About the Directorate General of Civil DefenceEmergency Resuscitation Procedure

Notes:List of the Modules

Earthquake Survival

Transport Accidents Safety

Elementary Fire Safety

Household LPG Safety

Emergency Casualty Handling


Improvised Explosive Devices Safety

Flood & Water Safety

Community Risk Management

Industrial Risk Management

Disease Control

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

36 Emergency Resuscitation Procedure

Notes:List of the Modules

Earthquake Survival

Transport Accidents Safety

Elementary Fire Safety

Household LPG Safety

Emergency Casualty Handling


Improvised Explosive Devices Safety

Flood & Water Safety

Community Risk Management

Industrial Risk Management

Disease Control

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

36 Emergency Resuscitation Procedure

Notes:

Notes:

Documents

Emergency Resuscitation Procedure · 2015-09-21 · Since 2011, GIZ has been collaborating with the National Civil Defence College, Nagpur for implementing the “Civil Defence and