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unit six resuscitation
learning outcomes
How you might be assessed
Perform cardiopulmonary resuscitation (CPR) techniques
Underpinning knowledge
List stages in the chain of survival.
Perform one- and two-person patient assessment.
Demonstrate a knowledge of when to start CPR, and
the flow chart procedures for CPR.
Define the rate for CPR.
Perform mouth-to-mouth, mouth-to-nose and mouthto-mask rescue breathing techniques as part of CPR.
Define the differences between infant and adult
resuscitation methods.
Perform one- and two-person CPR techniques.
Demonstrate and describe procedures for managing
patients after CPR.
List who should be sent to hospital.
A number of oral or written questions relating to
resuscitation techniques, sequences, timing, and
procedures will be asked. Examples may include: How
long would you continue with CPR? Two full breaths would
be conducted after what stage of patient assessment?
What are the three methods of maintaining a clear airway?
Practical demonstration
You will be asked to perform CPR by yourself and with
a second operator. This may be conducted on a live
patient or a manikin and be simulated on an adult,
infant or child using different rescue breathing
techniques (mouth-to-nose, mouth-to-mouth, mouthto-mask, mouth-to-mask with oxygen).
Scenario
During the scenario you may be presented with one or
more simulated patients who may be either
unconscious, not breathing and have no signs of life. It
may also involve other team members in a two-person
or three-person operation. A qualified defibrillation or
ARC operator may also be involved using a defibrillator
or oxygen equipment on the patient. You will need to
resuscitate the patient using the skills obtained within
this unit. Complications may also be experienced and
operators should carry out the resuscitation using safe
work practices and procedures.
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chain of survival
The assessment and management of a collapsed person is
based on the idea of the ‘chain of survival’. This is early
access, early cardiopulmonary resuscitation (CPR), early
defibrillation and early advanced life support. This means
that you must act quickly to assess a patient and begin
resuscitation for a patient to survive.
Resuscitation is the preservation or restoration of life
by establishing and maintaining a person’s airway,
breathing and circulation.
All body tissues, especially the brain, must be supplied with adequate oxygen. All persons who are unconscious require treatment, using the principles of
resuscitation.
Surf Life Saving Australia’s primary patient for resuscitation is the drowned or asphyxiated patient, therefore
the need to deliver oxygen to that patient is vital for successful resuscitation.
D
Check for danger/hazards/risks/safety
Make comfortable
Yes
Response
R
No
(call for help)
Unconscious patient
A
Open and clear airway
Check for breathing and signs of life
Breathing normally
Breathing absent
B
2 initial rescue breaths
(4 seconds)
Breathing present
Lateral position
Observe: airway breathing
Manage: bleeding; shock; injuries
DRABCD flowchart
D
Administer oxygen
and defibrillation
if equipment and
appropriately trained
personnel are present
Compressions
Commence cardiopulmonary resuscitation
(CPR)
30:2
Continue CPR until
signs of life return
C
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Early access
Early CPR
Early defibrillation
63
Early advanced
life support
Chain of survival
response
Assess the consciousness of a patient by gently
squeezing the patient’s shoulders, taking care not to
move the neck. Hold their hands and ask them to
squeeze your hands or open their eyes.
resuscitation
In this unit you will learn to perform patient assessment
and cardiopulmonary resuscitation (CPR) as a member of
a two-person team. You will be the person referred to as
the ‘airway operator’. Another lifesaver will be the ECC
(external chest compression) operator and resuscitate the
patient with you.
DRABCD
The principles of DRABCD apply to all cases of resuscitation. They guide you in your assessment and management
of a patient.
danger
Assess for danger to yourself, bystanders and the
patient and remove the danger or those threatened if
necessary.
Check for response
If there is no response to touch and to the spoken
word or a simple command, the person must be regarded
as unconscious, and assessment and care of the airway,
breathing and signs of life become a priority.
The conscious patient should be carefully assessed,
made comfortable and managed according to the signs
and symptoms described in Unit 4: Basic First Aid.
assessment of the unconscious patient
The airway operator, who will look after the patient’s
airway, and the ECC operator, who will perform chest
compressions, must work as a team.
The airway operator supports the head firmly and
maintains head tilt and jaw lift at all times, whilst the
ECC operator manages the roll of the patient.
The ECC operator will:
Assess for danger
Make sure that there is no danger to yourself or
bystanders or further danger to the patient. This involves
checking the area around the site of the incident. Usually,
the most experienced lifesaver present must assume
responsibility for managing the situation and allocating
tasks until an ambulance or medical assistance arrives.
Place the patient’s left arm outwards at right angles to
their body.
Lift the patient’s right leg to approximately 90 degrees
(this will help as a lever when the patient is turned).
Place the patient’s right arm across their chest and
then, with hands on the shoulder and hip, roll the body
towards the ECC operator. (You may use the shoulder
and a hand under the knee roll in larger patients.)
The airway is then assessed.
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two-person
assessment
CPR
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64
airway operator’s other hand is applied to the patient’s chin,
using a jaw support ‘pistol grip’ method while lifting the
jaw upwards and slightly outwards. The airway operator
can then firmly but gently tilt the patient’s head backwards.
Gently turn the patient onto their side using the hip and
shoulder roll
airway
The key to successful resuscitation is a clear airway.
Tilt the head backwards and lift the jaw.
Turn the patient’s face slightly downwards if you
do not think there is a neck injury.
Check the airway is clear by looking directly into
the mouth. Make sure all foreign material is removed
(e.g. vomit, loose dentures etc.).
backward head tilt
The airway operator will open the airway to ensure the
easy passage of air to and from the lungs. The patient’s
head should be tilted backwards, whilst lifting the jaw.
The jaw may be held either at the chin (jaw support) or at
the back of the jaw (jaw thrust).
REMEMBER THIS
Objective is jaw lift and is achieved by:
(1) jaw support (pistol grip), or
(2) jaw thrust.
Pistol grip
The airway operator’s middle finger is bent, and placed
into the groove under the middle of the patient’s chin.
The resuscitator’s thumb is placed along the front of
the patient’s lower jaw, between the lower lip and the
point of the chin.
The airway operator’s index finger lies along the bony
part of the patient’s jawbone.
The airway operator’s middle, ring and small fingers
are curled in towards the palm of the hand.
The fingers are kept clear of the soft tissues of the
patient’s throat and neck by keeping the airway
operator’s elbow lifted.
The resuscitator then lifts the jaw upwards and
slightly outward, and this assists in preventing the tongue
from obstructing the airway..
jaw thrust
Jaw lift
Jaw
support
Jaw
thrust
jaw support ‘pistol grip’
Jaw support is an essential part of maintaining a clear
airway. The tongue is attached to the lower jaw. If the jaw
is allowed to fall back, the attached tongue will block the
passage of air through the airway at the pharynx. With the
patient on their back, the airway operator kneels beside
their head and places one hand over the top of the forehead
with the thumb lying along the patient’s hair line. The
Jaw thrust is a very efficient method of lifting the patient’s
jaw, but it is a little more time-consuming to teach and
learn than jaw support. Lifesavers are encouraged to
understand and use this method because of its efficiency,
and because it is used in mouth-to-mask resuscitation.
In the jaw thrust method, the airway operator’s
middle, ring and little fingers are applied to the back part
of the patient’s jaw on either side behind the angle of the
jaw — lifting the jawbone upwards and outwards,
opening the airway.
The index finger is applied to the line of the jaw, in
front of the angle of the jaw and the thumbs are applied
to either side of the mouth or, when using a mask, to seal
the mask against the face.
In learning this hold, there is no substitute for frequent practice sessions — on other people rather than on
manikins. While manikins are essential in practice, jaw
holds are best taught on the human jaw, as there are great
size variations both in jaws and in lifesavers’ hands.
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Jaw thrust
65
breathing
Check for breathing using ‘look, listen and feel’.
look
clearing the airway
The airway operator helps clear foreign material from the
mouth by keeping the head tilted back with the face
turned slightly downwards. This position allows drainage
of fluids and mucus from the mouth.
The ECC operator looks in the patient’s mouth to see
whether the upper airway is blocked by the tongue or by
foreign material in the mouth while the airway operator
manages the airway.
Using the fingers the ECC operator clears away any
solids such as vomitus (preferably whilst wearing gloves,
although no time can be wasted waiting for them).
False teeth (dentures) are not removed unless they are
loose and interfering with the patient’s airway.
Clearing mouth of fluid and mucus
Airway operator looking, listening and feeling.
listen
The airway operator listens for sounds of air entering and
leaving the lungs, with their ear about 5 cm from the
patient’s nose and mouth.
feel
With their cheek over the patient’s mouth and nose, the
airway operator feels on their cheek for any movement of
air from the patient’s mouth or nose. The ECC operator
continues to observe the chest and check for signs of life.
Airway operator looking listening and feeling
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The exact positions of airway operators’ fingers and
thumbs will vary depending on the shape and size of the
patient’s jaw and the individual airway operator’s hands.
The diagram above should be regarded as a guide only.
The airway operator may be positioned behind the
head of the patient or alongside the patient.
Head tilt and jaw lift should be used whether the
patient is lying on their back or their side. The patient’s
airway must be kept open at all times.
resuscitation
The airway operator looks down towards the chest and
upper abdomen and the ECC operator looks from above,
assessing for movement of the chest and upper abdomen.
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Absence or presence of breathing
The decision on whether the patient is breathing normally
is made jointly, which emphasises the need for operators
to communicate continuously on the state and needs of
the patient. In practice, the decision on breathing is usually easy, but a brisk breeze and the noise of the sea can
add to lifesavers’ difficulties. Ignore the occasional gasp,
this would not be considered normal breathing and the
patient would require the start of rescue breathing.
External chest compression (ECC) has been proven to
be capable of providing circulation of blood after cardiac
arrest. In this procedure, the heart is rhythmically compressed between the breastbone (sternum) and the backbone (spine).
Collarbone
Breast bone
Heart
Signs of life
Whilst the airway operator is delivering the two breaths,
the ECC operator checks for signs of life. Rescuers should
start CPR if the patient, has no signs of life ie:
unconscious;
unresponsive;
not moving;
not breathing normally.
Xiphoid
If no breathing or signs of life are detected, begin CPR.
Ribs
compressions
The ECC operator, using a hip and shoulder roll, rolls the
patient onto their back, the airway operator holds the head
firmly and maintains head tilt and jaw lift at all times.
The airway operator takes up a comfortable position,
preferably with a facemask held firmly to the face using
jaw thrust. If there is no mask available the airway operator gets ready to begin mouth-to-mouth resuscitation or
mouth-to-nose resuscitation, whichever is preferred, or is
most effective.
Anatomy of external cardiac compression
hand positions for the ECC
operator
The ECC operator should kneel comfortably close to and
alongside the chest of the patient, so that they can apply
vertical rhythmic, squeezing compression. This position
will vary slightly for rescuers of differing sizes and shapes.
The rescuer may be on either side of the patient, and procedures should be practised from both sides.
For the purpose of this description, we will assume the
ECC operator kneels on the patient’s left side. The patient’s
left arm should be placed at right angles to the body.
sternum
Hip and shoulder roll
xiphisternum
The airway operator then gives two breaths in
approximately 4 seconds.
If breathing returns, place the patient in the lateral
position (see section on the lateral position in this unit)
and monitor the airway and breathing. If the patient is
breathing normally then circulation will be present.
A person whose heart has stopped may be kept alive
by rescuers who provide artificial ventilation of the lungs
(rescue breathing) and an artificial circulation of the
blood (ECC). This procedure is known as cardiopulmonary resuscitation, which is shortened to CPR.
Location of sternum and xiphisternum
The ECC operator’s hands must be correctly placed,
especially in relation to the lower end of the patient’s
sternum.
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There are different methods which may be taught to
identify the lower half of the sternum (e.g. index
finger method). Alternatively direct visualisation
may be used to locate the compression point. For
ease of teaching, the lower half of the sternum
equates with the ‘centre of the chest’.
Rib walk — index finger method
The ECC operator should feel along the patient’s lower
ribs to where they join in the midline.
Feeling lower rib line.
correct compression technique
Having obtained the correct compression point, the ECC
operator places the heel of the preferred hand with the
arm slightly bent (see below) on this point, fingers raised
and relaxed, so that all pressure is applied to the patient’s
sternum and none to the ribs.
The other hand is placed securely on top of the first.
To prevent the top hand slipping (and avoid inaccurate
compression), the fingers of the upper hand should be
locked around the wrist of the lower hand.
If the ECC operator’s hands are not locked (especially
with wet hands), there is an increased risk that the force
of compression will not be applied vertically through the
correct point or the hands may slip on the chest.
The operator applies vertical pressure from the
shoulder through the heel of the compressing (upper)
hand, keeping the elbow of the compressing arm as
straight as possible, and using the weight of their body as
the compressing force. This takes less physical effort than
trying to use the arm muscles, and will thus be less tiring.
Compressions should be rhythmical, with equal time
given to compression and relaxation. Extensive practice
with a manikin is essential.
In an adult, the sternum is compressed by one-third
the depth of the chest for each compression (at least
4–5 cm) during CPR.
unit six
Below where the ribs join in the midline is a small bone
called the xiphoid, or xiphisternum. This bone is easily felt
in some people, but very difficult to feel in others.
Just above the xiphisternum at the point where it
meets the sternum is a small notch. Once found, the ECC
operator should mark this point with the middle finger of
the preferred hand with the index finger next to it. The
heel of the other hand is then placed so it just touches this
index finger. At all times this hand, which is the compressing hand, must stay above the xiphisternum, and on
the lower half of the sternum.
If the correct point is not found, then compression may
be too low and not only will the heart be incompletely or
insufficiently compressed, but the stomach may also be
compressed, possibly causing vomiting or regurgitation. It
is also possible to damage organs in the upper abdomen.
Correct position for lower hand above the xiphoid
67
resuscitation
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Vertical chest compression
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On an adult patient the ECC operator uses a compression rate of approximately 100 compressions per
minute. The airway operator will administer two
inflations after every thirty compressions. The ECC
operator will need to pause compressions for the
inflations, which begins as the 30th compression is
being released and before the first compression of the
next cycle.
obey all instructions, and continue CPR until return of
signs of life.
Prolonged interruption to compression
should be avoided
Compressions should be counted out loud by either operator or by a bystander, and at the point of maximum
compression.
The airway operator and the ECC operator (if possible) should count the number of cycles and coordinate
rotation of the ECC operator at least every five cycles
(every two minutes). Rotation should occur more frequently should the ECC operator feel tired. Any timing of
rotation should aim to minimise the interuption of
compressions.
If oxygen equipment is available and appropriately
trained personnel present, oxygen assisted resuscitation
may be introduced.
Both operators should continually assess for signs of
life.
Preparation for defibrillation
defibrillation
placing a patient in the
lateral position
If a defibrillation unit and trained operator are available, defibrillation should be administered as soon as
possible. Continue CPR until the patient is prepared and
the unit is ready. The trained operator of the defibrillation unit will be in charge of the procedure. You should
Adult/older child
Age range
Compress with
Depth of compression
If breathing is present the patient is turned into the
lateral position in order to provide airway drainage
and the airway, breathing and other signs of life are
monitored.
All unconscious breathing persons should be nursed on
their side with careful attention given to the airway. The
patient may be placed on either side, but if on the beach
they should be placed facing towards the sea.
Child
Infant
9 and above
1 to 8 years
Newborn to 12 months
2 hands
1 or 2 hands
2 fingers
1/3 depth of chest
1/3 depth of chest
1/3 depth of chest
(4–5 cm)
Method
Compressions:
Breaths
Rate
Approx
Cycles per min
Cardiopulmonary resuscitation
1 person and 2 person
30:2
100 comp/min
21/2
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69
To place a patient into the lateral position:
The airway operator will manage the airway by holding
the patient’s head in backward head tilt.
The ECC operator turns the patient on their side in the
same way previously described with the airway
operator turning the patient’s head so that no rotation
of the cervical spine occurs.
The ECC operator places the upper leg, with the knee
bent, at approximately 90 degrees to the body and
ensures that the knee and lower half of the leg are
resting on the sand to keep the body stable.
The ECC operator also places the arm clear of the body
at about 90 degrees.
Oxygen therapy is given at a rate of 8 litres per
minute until the patient is handed to the ambulance staff.
A rate of 14 or 15 litres per minute can also be used if
there is enough oxygen available.
one-person
assessment
and CPR
This position may be a compromise between the ideal
position for rescue breathing and ECC.
There will be occasions in which one lifesaver will
have no choice but to start resuscitation alone or will
choose this method over a two person operation. In this
situation, the lifesaver will need to administer both rescue
breathing and external chest compressions, and so it is
most important that they place themselves in a comfortable position close to the patient before they begin.
Carry out the elements of DRABCD as follows:
danger
Assess for danger and move the patient if necessary.
response
Assess consciousness by gently squeezing the patient’s
shoulders without moving the neck, and asking simple
questions.
If the patient is unconscious:
turn the patient on their side (lateral position).
airway
Monitoring airway and breathing in the lateral position
Turn the face slightly downward if there is no neck
injury. (If a spinal injury is suspected roll the whole
body slightly forward into a drainage position.)
Tilt the head backwards.
Lift the jaw.
Clear the airway.
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Delivering defibrillation
resuscitation
Administering oxygen therapy in the lateral position
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breathing
Check for breathing.
look
Look at the chest and upper abdomen for movement.
listen
Listen for the sounds of air entering and leaving the
lungs, with your ear about 5 cm from the patient’s
nose and mouth.
feel
Feel for any movement of air from the patient’s mouth
or nose on your cheek.
Determining correct hand position
If there is no breathing or signs of life, roll the patient
onto their back and then give two breaths in 4 seconds. If
you are by yourself you will need to let go of the head to
roll the patient. As soon as the roll is complete, regain control of the head.
compressions
The operator should check for signs of life and start CPR
if the patient is:
unconscious;
unresponsive;
not moving;
not breathing normally.
Applying vertical compressions
Feeling lower rib line to locate xiphoid
Using a ratio of 30 compressions to 2 breaths, deliver
compressions at a rate of 100 per minute. Continually
monitor patient for breathing and signs of life.
defibrillation
If a defibrillation unit and trained operator are available, defibrillation should be administered as soon as
possible. Continue CPR until the patient is prepared and
the unit is ready. The trained operator of the defibrillation unit will be in charge of the procedure. You should
obey all instructions, and continue CPR until signs of
life return.
Delivering mouth-to-mouth ventilations (rescue breathing)
If breathing and signs of life are present, the patient is
turned into the lateral position in order to provide airway
drainage and the airway, breathing and other signs of life
are monitored.
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71
for how long should CPR
be continued?
CPR should be continued until the signs of life return or
until the patient is taken into the care of a doctor or
senior ambulance personnel member, or the rescuer
cannot physically continue. Remember: don’t give up —
many people have made a perfect recovery after resuscitation attempts that have lasted over an hour. Continue
CPR:
until the patient recovers (breathing and signs of life
restored);
until someone takes over or until the patient is taken
into care of a doctor or ambulance personnel;
until the rescuer cannot physically continue;
until the patient is pronounced dead;
temporarily if the person is to be defibrillated.
If signs of life and breathing have returned, you should
roll the patient into the lateral position and give oxygen
therapy (if it is available), call for help if this has not
already been done, and monitor the airway and
breathing.
If oxygen therapy is available, give it at a rate of 8
litres per minute, until the patient is handed over to the
ambulance. The rate of 14 or 15 litres per minute can be
used, and will give a higher percentage of oxygen in
inhaled air. It should be used for those patients needing
higher oxygen concentrations, but it obviously reduces the
time oxygen can be given from a smaller source of oxygen,
such as the ‘C’ cylinder in a portable oxygen source.
methods of
performing
rescue breathing
For the purposes of drill, uniformity and simplicity, this
manual describes rescue breathing from the patient’s right
side, as most (but not all) right-handed rescuers feel more
comfortable on the patient’s right side.
In actual resuscitation, lifesavers may perform resuscitation from either side, and it is important to practise so
that you are proficient at giving rescue breaths from
either side.
The three methods of rescue breathing are:
1. Mouth-to-mask
2. Mouth-to-mouth
3. Mouth-to-nose
NOTE Mouth to mask is the preferred method for all
rescue breathing to prevent infection and for resuscitator
‘comfort’ — most patients (especially drowning patients)
will vomit during CPR. All lifesavers should carry pocket
masks with them at all times during a patrol — then use
them when necessary. Pocket masks must be readily available to each patrol and mobile unit.
Each method is effective, provided that the patient’s
airway is clear, an effective seal is obtained and the airway
operator uses the correct force and rate of inflation.
mouth-to-mask
rescue breathing
Administering oxygen therapy to patient in lateral position
This is the recommended form of rescue breathing, and is
a simple variation on the jaw thrust method of holding
the airway open. The general rules are exactly the same as
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successful
resuscitation
resuscitation
Defibrillation operator prior to administering shock
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described below for mouth-to-mouth rescue breathing
and it should be used as often as possible.
Backward head tilt is essential, except when a neck
injury is suspected. The patient’s jaw is lifted by the jaw
thrust method and the rescuer’s thumbs, with or without
index fingers, are used to secure a firm seal between the
mask and the patient’s face.
Kneel beside the patient’s head, and tilt the head
back. Open the airway with jaw support or thrust.
Take a deep breath, open your mouth as widely as
possible and place it over the patient’s slightly open
mouth, sealing the nose with your cheek.
Blow until you see the patient’s chest rise, then lift
your mouth from the patient’s mouth, allowing the air
to leave the lungs whilst turning your head and
placing your ear about 5 cm from the mouth to listen
for, and to feel, the air leaving, while you watch the
chest return to its original position.
Watch the upper abdomen, and maintain head tilt, to
ensure that the stomach is not becoming swollen with
air (distension).
NOTE The most common errors in rescue breathing are
loss of head tilt, jaw lift and over-inflation.
sealing the airway
Sealing the patient’s nose is necessary during mouth-tomouth rescue breathing, and this is best done by the rescuer’s cheek. Occasionally, air will continue to escape
from the patient’s nose. In such cases, it is necessary to
change to the jaw support method (using jaw thrust) and
seal the nostrils with your thumb and forefinger.
Jaw thrust
CPR should never be delayed while waiting for a
mask or oxygen to arrive at the scene. However, masks
should be carried with you when on patrol.
Mouth-to-mask rescue breathing can be more effective using oxygen. If oxygen equipment arrives, the
trained operator may attach the tube to the special
oxygen tubing connection on the mask, or place the
oxygen tubing through the main opening of the mask,
where it is held in place by the airway operator’s fingers,
or by the airway operator’s mouth as they breathe into
the mask. Practice of this technique is essential.
If oxygen-aided rescue breathing with the airbag is to
be carried out, the airway operator will need to work with
both the ECC operator and the Air Bag Oxygen
Resuscitator operator, and hold the mask firmly on the
mouth and nose so that oxygen-aided resuscitation can be
administered. The Air Bag Oxygen Resuscitator operator
will tell the airway operator when they are going to attach
the airbag to the mask. The airway operator must make
sure that they maintain the airway and hold the mask on
firmly so that the resuscitation continues to be effective.
mouth-to-mouth
rescue breathing
Although it is possible for rescue breaths to be performed
in different positions, it is customary for the patient to be
positioned on their back.
Mouth to mouth rescue breathing
NOTE If the nostrils are sealed in this way, there is a tendency to lose head tilt, so added care is needed to make
sure that this does not happen.
mouth-to-nose
rescue breathing
Mouth-to-nose rescue breathing is used:
If the airway operator prefers this method.
In deep water rescue breathing.
In CPR of infants, when the rescuer’s mouth may cover
the infant’s mouth and nose.
If the patient’s jaws are tightly clenched.
In cases where severe facial injuries make it the
preferable method.
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The technique for mouth-to-nose rescue breathing is
similar to that used for mouth-to-mouth, except in
mouth-to-nose rescue breathing:
Air is blown into the nose.
The mouth must be sealed during inflation. In both
methods, the air exits through both the mouth and the
nose.
Sealing the mouth is achieved by pushing the lips
together with the thumb, as shown in the photograph.
It may also be conducted using jaw thrust.
The rules for inflating and watching the patient’s chest
are the same as in mouth-to-mouth rescue breathing.
Pushing the lips together for mouth-to-nose rescue
breathing
73
It has been stressed that
resuscitation must be
started as early as possible.
In some rescues, depending
on the equipment available
and the abilities of the
rescuers present, it may be
possible to deliver some
breaths before reaching the
beach. If this can be done,
it will improve the
non-breathing patient’s
chances of survival. However,
all the deep water techniques
outlined in this manual
require flotation devices, great
expertise and considerable
levels of physical fitness.
complications
during rescue
breathing
blocked airway
If the patient’s chest does not rise with inflation, check
that:
the head is tilted back and the jaw is lifted correctly;
there is no foreign material in the airway;
the seal is firm;
enough air is being blown in.
Opening mouth after inflation
rescue breathing in
deep water
This technique is described in Unit 10: Rescue
Techniques.
If inflation is not occurring after you have made these
checks, it is likely that there is foreign material in the
back of the throat (pharynx) or airway. The chest compression component of CPR can potentially expel the foreign material upwards into the mouth. Check in the
mouth prior to giving each set of rescue breaths to visualise and remove any new material found.
vomiting and regurgitation
Vomiting is an active process in which muscular action
makes the stomach eject its contents upwards. It is
nearly always accompanied by a loud noise. A rescuer
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will usually know when a patient is vomiting or is
about to vomit.
Regurgitation is the silent flow of stomach contents
into the mouth and nose. It is this silence that makes
regurgitation so dangerous as it may be very difficult
to detect.
Regurgitation can occur in any unconscious person but
is more likely when there is pressure on the abdomen
particularly when distended by air in the stomach,
when moving the person, or when performing rescue
breathing on a patient who has a partially blocked
airway. It is extremely common during resuscitation,
especially in cases of drowning where large amounts
of water may be swallowed.
A person who regurgitates or vomits while lying face
up is very likely to inhale some of the stomach
contents into the lungs, which may lead to serious
lung damage and infection. Brain damage and even
death may occur from lack of oxygen if the airway
becomes blocked this way.
Therefore all unconscious breathing patients should
be laid on their side with their head tilted backward
and the mouth pointing slightly downwards, so that
any stomach contents brought up will drain on to the
ground and not be aspirated back into the lungs.
Vomiting and regurgitation, together with the loss
of head tilt and no jaw lift, are the most common
and most important problems likely to occur during
rescue breathing. The need to check and prevent this
occurring must be stressed during instruction and
assessment, and in any situation in which simulated
emergencies are rehearsed.
After rolling the patient onto their side due to
regurgitation or vomiting, the airway needs to be cleared
of foreign material, then the airway operator is to assess
the breathing as previously described. If no breathing is
present the patient is to be rolled onto their back and
two breaths in 4 seconds are to be delivered. Commence
CPR in the absence of signs of life.
distension of the stomach
In cases of drowning, the patient’s stomach is often
swollen at the time of rescue. This swelling of the
stomach sometimes occurs because victims have eaten or
drunk just beforehand, but most often because, in the
process of drowning, they may swallow great quantities
of water and air.
Stomach swelling may be made worse if:
rescue breathing is performed with the airway partly
blocked by the tongue or foreign material;
the airway operator blows too hard, or blows too
much air.
A distended stomach can be recognised by noting a
persistent and possibly increasing swelling in the upper
part of the patient’s abdomen.
NOTE A distended stomach leads to increased upward
pressure on the lungs, making rescue breathing more difficult. It also greatly increases the risk of regurgitation.
No attempt should be made by lifesavers to reduce the
swelling of a patient’s abdomen; treatment of this condition should be left to paramedics or hospital staff. Check
that all of the rules for correct rescue breathing are being
followed and that the airway is not blocked.
Further stomach distension can be prevented by:
following the rules for maintaining a clear airway;
watching for the rise and fall of the chest;
blowing only until you see the chest rise;
not blowing too quickly.
CPR on infants
and children
An infant is a person newborn to 12 months; and a child
is defined as being aged between 12 months and 8 years,
taking into account variation of body size. For patients of
this age, the rules for resuscitation are a little different,
although most basic principles are the same.
An infant’s airway is different and is more easily
blocked because:
the head is relatively large;
the neck is relatively short;
the tongue is large;
the windpipe is soft and easily compressed;
the adenoids may be large.
Many infants breathe through their nose, so it is
important to clear the nose, if possible.
Backward head tilt should not be used with infants
as it stretches the tissues and it may block the airway.
1. The head should be kept in the neutral position, with
the lower jaw lifted at the point of the chin. If the
neutral position does not provide a clear airway, it may
be necessary to tilt the head back very slightly.
2. When performing rescue breathing, the airway
operator places his or her mouth over the infant’s nose
and mouth (or onto the mask if it fits) and, with a
slightly open mouth, puffs in just enough air to cause
the chest to rise.
3. The volume of air required is very small and practice
should be carried out on infant manikins.
In older children, the rules are the same as those for
resuscitating adults, except for the volume of air to be
blown into the patient. Great care must be taken in
judging the volume of air to be blown into the lungs of a
small person, as blowing too much increases the risk of
regurgitation.
In all age groups, the airway operator should blow
until the patient’s chest is seen to rise, and then stop.
Regurgitation may be caused by over-inflation.
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major points of difference
between resuscitating infants
and children compared to adults
In infants, compression is done with two fingers — to
approximately one-third depth of chest.
In children, compression is done with one or two
hands — to approximately one-third depth of chest.
Procedure for infants
and children
The compression point for children and infants is the
lower part of the sternum, just as it is in adults.
management of
the patient after
CPR
When normal breathing starts again, roll the patient
into the lateral position, and keep the airway open.
Remember that recovery may only be temporary and
that you must continue to watch the patient closely.
Breathing may stop after early success with
resuscitation — if this happens, CPR must be
started again.
You should continue to check for signs of life.
Protect the patient from extremes of heat and cold
and, depending on the circumstances, use blankets or
protection from the hot sun. In either case, make sure
that what you do does not interfere with your
observation of the patient’s airway and breathing.
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Handle the patient gently at all times.
After regaining consciousness the patient should be
made comfortable and reassured.
If defibrillator pads have been applied to the patient
by a qualified operator, they should be left in position.
All patients who have received resuscitation must be
referred to hospital.
who should be
sent to hospital?
Send to hospital, as soon a possible, any person who:
has lost consciousness, even for a brief period;
required either initial rescue breathing or CPR;
may have a second condition, such as a heart attack
or a neck injury;
has a persistent cough or an abnormal colour.
The decision on less serious cases is more difficult, but
the following guidelines should be followed.
If, after 10 to 15 minutes of observation and appropriate warming, the patient has the following:
no cough;
a normal rate of breathing;
normal skin colour;
no shivering;
full consciousness and alertness;
then it is reasonable to allow the patient to return home,
although it would be unwise to let the patient drive a
vehicle. Remember to record the patient’s details.
If any of the previous conditions do not apply or if the
lifesaver has any doubt about the patient’s state of health,
the patient should be advised to seek medical advice as
soon as is practicable.
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