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Emergency Resuscitation Procedure
Training Module 6
Earthquake Resuscitation
Emergency
Survival
Procedure
Training Module 6
1
Imprint
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, India
T: +91 712 2565614, 2562611
F: +91 712 2565614
I: [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.pdf
http://www.bis.org.in/sf/nbc.htm
http://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.
(ii)
Guiding word
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
Dr. Dieter Mutz
Director
GIZ-IGEP
Delhi, October 2012
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.
(iii)
Preface
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.
Mr. G.S.Saini (V.S.M.)
Director
NCDC
Nagpur, October 2012
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.
(iv)
Objective of the module:
Main target group:
¢ To know and understand cardiac
¢ Medical staff
arrest, cardiopulmonary resuscitation
¢ To know and understand technique of
¢ Training persons
¢ Police personnel
CPR
¢ Fireman
¢ How to overcome on choking
¢ 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
(v)
Contents
1
Introduction
2
2
Cardiac Arrest
4
2.1 Signs and symptoms
4
2.2 Treatment
4
2.3 Cardiac chain of survival
5
Cardiopulmonary Resuscitation
6
3.1 Call first vs. call fast
6
3.2 Technique of CPR
7
3
(vi)
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
10
About NCDC
31
11
About GIZ
32
12
About the Indo-German Environment Partnership (IGEP)
programme of GIZ
33
13
About the Ministry of Home Affairs
34
14
About the Directorate General of Civil Defence
35
15
List of the Modules
36
Medical emergencies can be encountered by people anywhere
and anytime. The best possible approach to overcome such
1
Introduction
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.
02
Emergency Resuscitation Procedure
2
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 1020% 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.
04
Emergency Resuscitation Procedure
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.
og
rec
nition and cal
l fo
r
lp
Ea
he
rl
y
life
- to
of
pr
ev
en
tc
ardia
ty
ali
- to restore qu
c arrest
- to
(Source: Koster et al., 2010)
buy time
- to
restart the he
art
Fig. 1: Chain of survival
Cardiac Arrest
05
CPR combines rescue breathing (to get oxygen into victim's
lungs) with chest compression (to pump the oxygenated
3
Cardiopulmonary
Resuscitation
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
06
Emergency Resuscitation Procedure
Call fast (about 2 minutes) for
¢ Unresponsive child or infant (0-8
Adult Basic Life Support
years)
¢ Adult victim of near-drowning,
UNRESPONSIVE?
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.
2.
3.
Find the correct hand position on
the lower half of the breastbone
midway between the nipples.
[Include picture showing the hand
position ]
Compress the chest quickly and
rhythmically at a rate of at least 100
compressions per minute for adult,
child and infant.
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:
Shout for help
Open airway
NOT BREATHING NORMALLY?
Call 112*
30 chest compressions
2 rescue breaths 30 compressions
*or national emergency number
Cardiopulmonary Resuscitation
07
CPR essentials
Adults
Children
Infants
Compression
Heels of both hands
Heel of one or two hands Two middle fingers
Chest depth
1 ½ to 2 inches
1/3 to 1/2 the depth of the 1/3 to 1/2 the depth of
chest
the chest
Compressions to breaths
30 to 2
30 to 2
30 to 2
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
Child CPR (1-8 years)
1.
2.
3.
1.
2.
3.
4.
5.
Tilt head
Give 2 full breaths
Start compressions using
both hands - 30 times
Repeat - 2 breaths, 30
compressions
Continue until the
ambulance arrives, patient
recovers or it is impossible
to continue.
4.
5.
Tilt head
Give 2 full breaths
Start compressions with one
hand - only 30 times
Repeat - 2 breaths, 30
compressions
Continue until the
ambulance arrives, patient
recovers or it is impossible
to continue.
Fig. 2: CPR essentials
08
Emergency Resuscitation Procedure
Infant CPR (0-1 years)
DO NOT TILT HEAD!
1.
2.
3.
4.
Give 2 breaths (puffs)
Start compressions using
two fingers only - 30 times
Repeat - 2 breaths, 30
compressions
Continue until the
ambulance arrives, patient
recovers or it is impossible
to continue.
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.
Cardiopulmonary Resuscitation
09
UPSTROKE
Warning
DOWNSTROKE
FULCRUM
(HIP JOINTS)
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
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.
10
Emergency Resuscitation Procedure
¢ 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.
¢ Continue CPR until:
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)
Cardiopulmonary Resuscitation
11
Defibrillation is the application of an electric shock to the chest of
a patient who is in cardiac arrest- a non-breathing and pulseless
4
Automated
External
Defibrillation
(AED)
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:
12
Emergency Resuscitation Procedure
¢ 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
Automated External Defibrilation (AED)
13
Foreign-body airway obstruction (FBAO) is an uncommon but
potentially treatable cause of accidental death. As most
5
Foreignbody Airway
Obstruction
(Choking)
14
Emergency Resuscitation Procedure
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
5.2
Care for chocking adults and children
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!
(source: Koster et al, 2010, p.1286) and to recommend a similar procedure as Koster et al, 2010 describes
on pages 1285-1287:
Adult Foreign Body Airway Obstruction Treatment
Assess severity
Mild airway obstruction
(ineffective cough)
Severe airway obstruction
(ineffective cough)
Unconscious
Conscious
Encourage cough
Start CPR
5 back blows
5 abdominal
thrusts
Continue to check
for deterioration
to ineffective cough or
until obstruction relieved
Fig. 5: FBAO treatment
Foreign-body Airway Obstruction (Choking)
15
¢ 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
16
Emergency Resuscitation Procedure
¢ 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”.
Foreign-body Airway Obstruction (Choking)
17
Perform the skill: Back blows and chest thrusts for a chocking infant
Fig. 8: Back blows and chest thrusts
18
Emergency Resuscitation Procedure
¢ 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.
Foreign-body Airway Obstruction (Choking)
19
¢ Cardiac arrest and choking require fast response by rescuers
6
Summary
of Lessons
Learnt
20
Emergency Resuscitation Procedure
¢ 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
n
l
Mild obstruction: Encourage coughing
l
Severe obstruction:
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
Summary of Lessons Learnt
21
AED
Automated External Defibrillator is a portable
device that checks the heart rhythm. If
7
Glossary
and
Acronyms
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/healthtopics/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-andForeign-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
22
Emergency Resuscitation Procedure
Emergency Medical Services: Provide out-of-
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
Glossary and Acronyms
23
Choking and foreign body airway
8
Background
Reading
Material
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.
24
Emergency Resuscitation Procedure
¡ 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.
Background Reading Material
25
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).
Children
¢ 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
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Emergency Resuscitation Procedure
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
Incidence
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
Background Reading Material
27
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.
Differential diagnosis
Rapid evaluation is key: swiftly consider other conditions that may cause sudden respiratory distress, cyanosis
or loss of consciousness, such as:
¢ Anaphylaxis
¢ Syncope
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Emergency Resuscitation Procedure
¢ Myocardial infarct
¢ Seizure
Complications
¢ 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.
Prevention
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.
Background Reading Material
29
Koster Rudolph W., Michael A. Baubin, Leo L. Bossaert,
Antonio Caballero, Pascal Cassan, Maaret Castrén, Cristina
Bibliography
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://resuscitationguidelines.articleinmotion.com/article/S03009572%2810%2900435-1/aim/use-of-an-automated-externaldefibrillator
30
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.
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
About NCDC
31
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.
GIZ in India
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
32
Emergency Resuscitation Procedure
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 decoupled from resource consumption.
For information visit http://www.igep.in or write at [email protected]
About the Indo-German Environment Partnership (IGEP) programme of GIZ
33
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)
34
Emergency Resuscitation Procedure
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)
About the Directorate General of Civil Defence
35
List of the Modules
1.
Earthquake Survival
2.
Transport Accidents Safety
3.
Elementary Fire Safety
4.
Household LPG Safety
5.
Emergency Casualty Handling
6.
Emergency Resuscitation Procedure
7.
Improvised Explosive Devices Safety
8.
Flood & Water Safety
9.
Community Risk Management
10. Industrial Risk Management
11. Disease Control
36
Emergency Resuscitation Procedure
Notes:
Notes: