First Aid: Resuscitation
To maintain life, we need our hearts to pump oxygenated blood to our vital organs. To achieve this we need to be breathing and our hearts need to be pumping. Should either of these functions stop, our brain and other vital organs will start to deteriorate (brain cells usually die within 3-4 minutes due to lack of oxygen) which will eventually lead to death.
‘Ventricular fibrillation’ is the most common result of cardiac arrest, caused by heart attack. When this happens, the best chance of survival for the patient is to have their heart ‘restarted’ with a defibrillator. These are carried on all ambulances, and can also be found in some public places (shopping centres, etc.). These days’ defibrillators are very sophisticated, and will talk you through the process, but you should be trained in the use of them before attempting to use one. However, even if you are trained to use one, you must call an ambulance first, as this will give the casualty the best chance of survival.
Even so, we need to keep the heart and brain oxygenated as best we can while help is on the way; this is when we start Cardio Pulmonary Resuscitation (CPR).
Reviving someone who is unconscious and/or not breathing or not breathing normally is called resuscitation.
If the victim is not breathing or is not breathing normally, any source of suffocation should be removed and resuscitation is to be started.
Chest compressions with or without rescue breathings are performed by an individual during cardio pulmonary resuscitation (CPR) in an attempt to restore spontaneous circulation.
For untrained or minimally trained first aid providers treating an adult victim, compression-only CPR is recommended. These chest compressions ensure a small but crucial supply of blood to the heart and brain.
For formally trained first aid providers (and professionals) treating an adult victim, compression with breaths is recommended. If the trained first aid provider is unable or unwilling, or in any other circumstance, compression-only CPR may be substituted for compression with breaths. For babies and children under one year, compressions with breaths are always recommended.
In case of a cardiac arrest (heart stops functioning) you might notice the following signs:
- sudden collapse,
- loss of consciousness,
- no breathing,
- no pulse (however this is not always easy for laypeople to confirm).
How to observe responsiveness and consciousness
Unconsciousness occurs when a person is suddenly unable to respond to stimuli like sound or pain, and appears to be asleep. A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.
People who become unconscious do not respond to loud sounds or shaking. They may even stop breathing or their pulse may become faint. This calls for immediate emergency attention. The sooner the person receives emergency first aid, the better it is.
The AVPU scale (an acronym from “alert, voice, pain, unresponsiveness”) is a system by which a first aider can measure and record a patient’s responsiveness, indicating the level of consciousness. It is based on the casualty’s eye opening, verbal and movement (motor) responses.
The AVPU scale has only four possible outcomes:
A – Alert.
The person is fully awake (although not necessarily oriented). The person will spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function.
V – Responding to voice.
The person makes some kind of response when you talk to him. It could be opening his eyes, responding to your questions or initiating a move. These responses could be as little as a grunt, moan, or slight movement of a limb when prompted by the voice of the rescuer.
P – Responding to pain.
The patient makes a response of any kind on the application of pain stimulus, such as a central pain stimulus like a rub on his breastbone or a peripheral stimulus such as squeezing his fingers. Patients with some level of consciousness (a fully conscious patient would not require any pain stimulus) may respond by using their voice, moving their eyes, or moving part of their body (including abnormal posturing).
U – Unresponsiveness also noted as ‘Unconsciousness’.
This outcome is recorded if the patient does not give any eye, voice or motor response to voice or pain.
To check a person’s responsiveness/consciousness state check the following:
1. A person who looks around, speaks, responds clearly to questions, feels touch and moves or walks around, is considered alert (A).
2. The person opens his eyes and responds to simple questions: “What is your name?” “Where do you live?” “How old are you?” The person responds to simple commands: “Squeeze my hand.” “Move your arm/leg/foot/hand.” If the person responds, he is responsive to voice (V).
3. If there is still no response, pinch the person and see if he opens his eyes or moves. If the person responds to pain, he is responsive to pain (P). If the person does not react to any of these stimuli, he is in an unconscious state (U).
Note that a person might only partially respond to the stimuli you provide (sound,touch, pain) and might be in an in-between (groggy) state.
How to observe the breathing
The airway may be narrowed or blocked making breathing noisy or impossible. Reasons for blockage may be:
- Loss of muscular control in the throat may allow the tongue to sag back and block the air passage.
- When the reflexes are impaired, saliva may lie in the back of the throat, blocking the airway.
- Any foreign body in the throat may block the air passage e.g. vomit, blood, dentures etc.
It is essential to establish a clear airway immediately. Unless you can clearly see that the person is breathing normally, an unconscious person must be turned onto his back to unblock the breathing passage and to check for breathing. Unblocking the breathing passage takes priority over concerns about a potential spinal injury.
To observe the breathing do following:
1. If the person is unconscious and is not on his back, turn him on to his back.
2. Kneel beside the casualty.
3. Lift the chin forwards with the index and middle fingers of one hand while pressing the forehead backwards with the palm of the other hand. This manoeuvre will lift the tongue forward and clear the airways
4. Observe breathing by listening, feeling and looking
5. After opening the victim’s airway, check to see if the victim is breathing. To do this, place your cheek in front of the victim’s mouth (about 3-5 cm away) while looking down his chest (towards his feet). If desired, you can also gently place a hand on the center of the victim’s chest. This allows you to observe whether the victim is breathing in the following ways:
a. look for chest/abdominal movement,
b. listen to breathing sounds,
c. feel the air coming out of the nose or mouth.
6. If the casualty’s chest still fails to rise, first assume that the airway is not fully open. Once the airway is cleared the casualty may begin breathing spontaneously. Else, clear the airway by removing any visible item that is blocking the airway:
a. Hook your first two fingers covered with clean cloth/gloves.
b. Sweep round inside the mouth/ throat.
c. Check again the breathing.
How to observe pulse
Feeling the pulse is not always easy. Feeling the pulse during an emergency at the wrist is often unreliable. The pulse can be felt by placing the finger tips gently on the voice box and sliding them down into the hollow between the voice box and the adjoining muscle.
Do not loose time trying to locate and feel the pulse. The current resuscitation guidelines for laypeople direct that resuscitation (CPR) is to be started when the person is not breathing or not breathing normally and does not require to check the pulse.
If the casualty is not breathing normally:
The first thing to do in this situation is call 999 for an ambulance. If someone is with you, get them to do this so you don’t have to leave the casualty. If you are alone, and do not have a mobile with you, you may need to leave the casualty to do this. However, it is vital that an ambulance is called, as the casualty will stand a much better chance of survival with help on the way. Once the ambulance is called, start CPR:
· Place the heel of one hand in the centre of the casualty’s chest. Place the other hand on top and interlink your fingers.
· Take a position next to the casualty’s chest, kneeling at whichever side feels more comfortable for you.
· Press down firmly on the casualty’s breastbone current guidelines suggest pushing down to a depth of 6cm) then release the pressure, but try not to lose contact with the casualty. This is known as a chest compression. When applying pressure, avoid doing so on the ribs, upper abdomen or the end of the casualty’s breastbone.
· Each compression should take the same amount of time.
· Carry out 30 chest compressions at a speed of 100-120 compressions per minute.
· After 30 chest compressions, you must administer two rescue breaths
In an ideal situation, the casualty will be on a flat hard surface to be able to administer CPR. However, this isn’t always the case, and you may find that you need to perform CPR on a casualty who is, for example, in bed. If this situation arises, try to get the casualty onto the floor without hurting yourself or the casualty. If it is not possible, remove any pillows or cushions so the casualty is lying flat and attempt CPR. This is still better than doing nothing.
Combining chest compressions with rescue breaths:
· After chest compressions, make sure the casualty’s airway is clear by tilting their head back.
· Pinch the casualty’s nose closed; this will make sure the breath you give them does not escape.
· Take a breath and place your mouth over the casualty’s, forming a seal.
· Steadily blow into the casualty’s mouth, making sure their head is tilted back and the airway is open. Keep your eyes down on the casualty’s chest to make sure it rises (this should take about a second). This is known as a rescue breath.
· Remove your mouth from the casualty’s and leave enough room for you to take a fresh breath of air. Keep the casualty’s airway open and watch for the chest deflating, as the air is expelled.
· Place your mouth over the casualty’s forming the seal again and give another rescue breath. You need to do this twice.
· Replace your hands on the casualty’s chest immediately and perform another 30 chest compressions, followed by 2 more rescue breaths.
Should your rescue breaths not be effective, follow the steps below:
· Give a further 30 chest compressions.
· Remove any visible obstructions in the casualty’s mouth.
· Make certain their airway is clear by tilting their head back and lifting the chin. If the airway is not clear, the breath you give will not fill their lungs.
Do not give the casualty more than two rescue breaths before continuing with chest compressions. If you have someone with you, take it in turns to administer chest compressions. Every 1-2 minutes, change over so one person administers chest compressions while the other gives the rescue breaths.
Ensure there is as little delay in swapping as possible, so the casualty is constantly receiving CPR. Continue CPR until: The emergency services arrive to take over. You become too fatigued to continue.
Resuscitation for babies and children:
Understandably, some people are reluctant to perform CPR on a child or baby for fear of causing further harm to them. However, a child in this state is likely to suffer far worse consequences if CPR is not administered. Please keep that in mind should the situation ever arise.
CPR on a child is very similar to CPR on an adult. There are only a few minor modifications to the process, which are detailed below
· Give the child 5 rescue breaths before starting CPR, then switch back to 30 chest compressions to 2 rescue breaths.
· If you are alone, perform CPR for about a minute before going for help.
Chest compressions on a child should be about one-third of the depth of the chest. For a baby under 1 year old, only use two fingers to administer CPR. For a child over 1 year use either one or two hands to compress the chest, again one third of the depth of the chest.