Perform First Aid to Restore Breathing and/or Pulse

Conditions: You see an adult casualty who is unconscious and does not appear to be breathing. You are not in a combat situation or chemical environment. You will need a nasopharyngeal airway (NPA).

Standards: Take appropriate action, in the correct sequence, to restore breathing and, if necessary, the pulse. Continue until the casualty’s breathing/pulse returns, a qualified person relieves you, a physician stops you, or you are too tired to continue.

Performance Steps:

1. Roll the casualty onto his/her back, if necessary, and place him/her on a hard, flat surface.

WARNING: The casualty should be carefully rolled as a whole, so the body does not twist.

a. Kneel beside the casualty.

b. Raise the near arm and straighten it out above the head.

c. Adjust the legs so they are together and straight or nearly straight.

d. Place one hand on the back of the casualty’s head and neck.

e. Grasp the casualty under the arm with the free hand.

f. Pull steadily and evenly toward yourself, keeping the head and neck in line with the torso.

g. Roll the casualty as a single unit.

h. Place the casualty’s arms at his/her sides.

2. Open the airway.

Note: If foreign material or vomit is in the mouth, it should be removed as quickly as possible (see step 7).

a. Head-tilt/chin-lift method.

CAUTION: Do NOT use this method if a spinal or neck injury is suspected.

(1) Kneel at the level of the casualty's shoulders.

(2) Place one hand on the casualty's forehead and apply firm, backward pressure with the palm to tilt the head back.

(3) Place the fingertips of the other hand under the bony part of the lower jaw and lift, bringing the chin forward.

Note: Do NOT use the thumb to lift. Do NOT completely close the casualty’s mouth.

CAUTION: Do NOT press deeply into the soft tissue under the chin with the fingers.

b. Jaw-thrust method.

CAUTION: Use this method if a spinal or neck injury is suspected.

(1) Kneel above the casualty's head (looking toward the casualty's feet).

(2) Rest your elbows on the ground or floor.

(3) Place one hand on each side of the casualty’s lower jaw at the angle of the jaw, below the ears.

(4) Stabilize the casualty’s head with your forearms.

(5) Use the index fingers to push the angles of the casualty’s lower jaw forward.

Note: If the casualty's lips are still closed after the jaw has been moved forward, use your thumbs to retract the lower lip and allow air to enter the casualty's mouth.

CAUTION: Do not tilt or rotate the casualty’s head.

• Check for breathing.

• • While maintaining the open airway position, place an ear over the casualty’s mouth and nose, looking toward the chest and stomach.
  • Look for the chest to rise and fall.
  • Listen for air escaping during exhalation.
  • Feel for the flow of air on the side of your face.
  • Count the number of respirations for 15 seconds.
  • Take appropriate action.
    • If the casualty is unconscious; if respiratory rate is less than 2 in 15 seconds; and/or if the casualty is making snoring or gurgling sounds, insert an NPA.

CAUTION: Do NOT use the NPA if there is clear fluid (cerebrospinal fluid-CSF) coming from the ears or nose. This may indicate a skull fracture.

• • • • Keep the casualty in a face-up position.
      • Lubricate the tube with water.
      • Push the tip of the casualty’s nose upward gently.
      • Position the tube so that the bevel (pointed end) of the airway faces toward the septum (the partition inside the nose that separates the nostrils).

Note: Most NPAs are designed to be placed in the right nostril.

• • • • Insert the airway into the nostril and advance it until the flange rests against the nostril.

CAUTION: Never force the a rway into the casualty’s nostril. If resistance is met, pull the tube out and attempt to insert it in the other nostril. If neither nostril will accommodate the airway, place the casualty in the recovery position.

• • • • Place the casualty in the recovery position by rolling him/her as a single unit onto his/her side, placing the hand of his/her upper arm under his/her chin, and flexing his/her upper leg.
      • Watch the casualty closely for life-threatening conditions and check for other injuries, if necessary. Seek medical aid.

• • • If the casualty is not breathing, continue with step 4 if the tactical situation permits.

Note: If the casualty resumes breathing at any time during this procedure, the airway should be kept open and the casualty should be monitored. If the casualty continues to breathe, he/she should be transported to medical aid. Otherwise, the procedure should be continued.

4. Give breaths to ensure an open airway.

Note: When mouth-to-mouth resuscitation breathing cannot be performed because the casualty has jaw injuries or spasms, the mouth-to-nose method may be more effective.

Note: Perform the mouth-to-nose method by blowing into the nose while holding the lips closed. Let air escape by removing your mouth and, in some cases, separating the casualty's lips.

• Insert a face shield, if available, into the casualty's mouth, with the short airway portion over the top of the tongue, and flatten the plastic sheet around the mouth.
• Maintain the airway and gently pinch the nose closed, using the hand on the casualty's forehead.
• Take a deep breath and place your mouth, in an airtight seal, around the casualty's mouth.
• Give two full breaths (1 1/2 to 2 seconds each), taking a breath between them, while watching for the chest to rise and fall and listening and/or feeling for air to escape during exhalation.

Note: If chest rises, go to step 8.

Note: If chest does not rise after the first breath, continue with step 5.

5. Reposition the casualty's head slightly farther backward and repeat the breaths.

Note: If chest rises, go to step 8.

Note: If chest does not rise, continue with step 6.

6. Perform abdominal or chest thrusts.

Note: Abdominal thrusts should be used unless the casualty is in the advanced stages of pregnancy, is very obese, or has a significant abdominal wound.

• Abdominal thrusts.

• • Kneel astride the casualty's thighs.
  • Place the heel of one hand against the casualty's abdomen, slightly above the navel but well below the tip of the breastbone, with the fingers pointing toward the casualty's head.
  • Place the other hand on top of the first.
  • Press into the abdomen with a quick forward and upward thrust.

Note: Each thrust should be a separate, distinct movement.

• • Give several thrusts (up to five).

• Chest thrusts.

• • Kneel close to the side of the casualty's body.
  • Locate the lower edge of the casualty's ribs and run the fingers up along the rib cage to the notch where the ribs meet the breastbone.
  • Place the middle finger on the notch with the index finger just above it on the lower end of the breastbone.
  • Place the heel of the other hand on the lower half of the breastbone, next to the two fingers.
  • Remove the fingers from the notch and place that hand on top of the other hand, extending or interlacing the fingers.
  • Straighten and lock the elbows with the shoulders directly above the hands.
  • Without bending the elbows, rocking, or allowing the shoulders to sag, apply enough pressure to depress the breastbone 1 1/2 to 2 inches.

Note: Each thrust should be given slowly, distinctly, and with the intent of relieving the obstruction.

• • Give several thrusts (up to five).

7. Perform a finger sweep and repeat breaths.

• Open the mouth by grasping the tongue and lower jaw to lift the jaw open or crossing the fingers and thumb to push the teeth apart.
• Insert the index finger of the other hand down along the cheek to the base of the tongue.
• Use a hooking motion from the side of the mouth toward the center to dislodge the object.

WARNING: Take care NOT to force the object deeper into the airway.

• Reopen the airway and repeat the breaths. Note: If chest rises, go to step 8.

Note: If chest does not rise, repeat steps 6 and 7 until the airway is clear.

8. Check for a pulse for 5 to 10 seconds.

Note: Use the first two fingers in the groove in the casualty's throat beside the Adam's apple. Do NOT use the thumb.

• If a pulse is found but the casualty is not breathing, continue mouth-to-mouth resuscitation.

• • Give breaths at the rate of about 12 breaths per minute.
  • Recheck for pulse and breathing for 3 to 5 seconds after every 12 breaths. If the pulse stops, go to step 9.
  • Continue until the casualty’s breathing returns, a qualified person relieves you, a physician stops you, or you are too tired to continue. If the breathing returns, go to step 10.

• If no pulse is found, you must perform cardiopulmonary resuscitation (CPR). Continue with step 9.

9. Perform cardiopulmonary resuscitation.

• Position your hands for external chest compressions.

• • With the middle and index fingers of the hand nearest the casualty’s feet, locate the lower margin of the casualty’s rib cage on the side near the rescuer.
  • Move the fingers up the rib cage to the notch where the ribs meet the breastbone in the center of the lower part of the chest.
  • With the middle finger on the notch, place the index finger next to it on the lower end of the breastbone.
  • Place the heel of the other hand on the lower half of the breastbone, next to the index finger of the first hand.
  • Remove the first hand from the notch and place it on top of the hand on the breastbone so that both hands are parallel to each other.

Note: You may either extend or interlace your fingers, but keep the fingers off the casualty’s chest.

• Position your body.

• • Lock your elbows with the arms straight.
  • Position your shoulders directly over your hands.

• Give 15 compressions.

• • Press straight down to depress the breastbone 1 1/2 to 2 inches.
  • Come straight up and completely release pressure on the breastbone to allow the chest to return to its normal position. The time allowed for release should equal the time required for compression.
  • Give 15 compressions in 9 to 11 seconds (at a rate of 100 per minute).

Note: Do NOT remove the heel of your hand from the casualty’s chest or reposition your hand between compressions.

• Give two full breaths.

• • Open the casualty’s airway.
  • Give two full breaths (1 1/2 to 2 seconds each).

• Repeat steps 9c through 9d four times.

• Reassess the casualty.

• • Check for the return of the pulse for 3 to 5 seconds.

• • • If the pulse is present, continue with step 9f(2).
    • If the pulse is absent, continue with step 9g.

• • Check breathing for 3 to 5 seconds.

• • • If the casualty is breathing, continue with step 10.
    • If the casualty is not breathing, continue mouth-to-mouth resuscitation (step 8a).

• Resume CPR with compressions (step 9c).

• Recheck for pulse every 3 to 5 minutes.

• Continue CPR until the casualty’s pulse returns, you are relieved by a qualified person, stopped by a physician, or you are too tired to continue.

10. Once the casualty is breathing and has a pulse, place in the recovery position until help arrives. Watch the casualty closely for life-threatening conditions, maintain an open airway, and check for other injuries, if necessary.