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A clear airway is essential to sustain life. In certain circumstances a patient may be unable to maintain this for themselves, in which case it is your responsibility. There are two types of obstruction, one renders the patient unconscious and the other causes the patient to choke and cough.

Obstructions can be caused by many things, for example the tongue, swelling of the throat, food or foreign objects.


Choking is very common and can cause death if quick action is not taken. If the brain has been starved of oxygen for as little as three to four minutes it can suffer permanent damage. Choking is more likely to happen when people are talking and eating at the same time.



How do I treat an obstructed airway

Finger sweep

Finger sweep
(Use gloves)

Do not attempt to put your fingers into the mouth of a conscious patient as it will cause greater distress and may push any object further down the throat.

On the unconscious patient incline the head to one side and making sure you can see clearly, sweep the object out.

If chest does not rise check patients mouth and remove any further visible obstructions.

Do not attempt to just feel for an object, if you cannot see it try something else


How do I treat an obstructed airway?

Back slaps

Back slaps

Conscious and unconscious patients can both benefit from this procedure.

A child or infant can be placed over the knee to help the process.

Adult choking sequence

(This sequence is also suitable for use in children over the age of 1 year)

If the victim shows signs of mild airway obstruction, encourage him to continue coughing, but do nothing else.

If the victim shows signs of severe airway obstruction and is conscious:

Give up to five back blows.

Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway.

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

Children choking

Lean the patient over your arm and hold them forwards so that the head is lower than the chest.

Baby choking
Lay the patient over your arm face down and bend them forwards so that the head is lower than the chest.

Healthcare providers should be trained and experienced in taking carotid pulse, although pulse may be present initiate chest compressions on unconscious choking pataint


How do I treat an obstructed airway?

Head and neck tilt

Head and neck tilt

This procedure applies to unconscious patients.

Sometimes by merely raising the chin the tongue is lifted sufficiently off the back of the throat to allow breathing to restart:

 With your fingertips under the point of the patient's chin, lift the chin to open the airway

Tilt the head back by gently placing your hand on the patient's forehead


How do I treat an obstructed airway?

Abdominal thrusts (and back blows)

Abdominal thrusts (and back blows)

Although this procedure can prove very efficient on some patients, you must take special care if performing it on the elderly and it should only be used on children over the age of 1 year in a dire emergency. The abdominal thrust must never be performed on babies: use chest thrusts instead.

The amount of force used must be gauged according to the size of the patient.


If the patient is conscious, stand behind them, Give 5 back sharp blows between the shoulder blades with the heel of your hand, while supporting the chest with your other hand, leaning the patient forward so the obstruction comes out of the mouth then put your arms around them and clasp the hands across the upper part of the abdomen just below the ribs. Lean patient forward clench your fist and place between the umbilicus and bottom end of sternum then in an upward and inward movement force the abdominal contents up under the diaphragm. The residual air within the lungs should then escape expelling the object, repeat up to five times alternating between back blows and abdominal thrusts.

If the patient is unconscious lay them on their back and start CPR.

Healthcare providers should be trained and experienced in taking carotid pulse. Although pulse may be present, initiate chest compressions on unconscious choking patients



If you manage to clear an obstruction still advise your casualty to seek medical attention as the airway maybe damaged.

If patient becomes unconscious from obstructed airway begin CPR if experienced in taking carotid pulse should start chest compressions even if a pulse is present in the unconscious choking patient. If the patient is unconscious, still has a pulse and is BREATHING, then they need to be put in a position that will not allow them to accidentally block their airway. For this we use the recovery position.

  1. Remove patient’s glasses, if present and any keys or hard objects in their pockets
  2. Kneel beside the patient and place both legs straight
  3. Place the patient's arm nearest to you out at right angles to the body, elbow bent with the palm up
  4. Bring the far arm across the chest and hold the back of the hand against the patients check nearest to you
  5. Grasp the far leg just above the knee and pull it up, keeping the foot on the ground
  6. Keeping his hand pressed against patients own cheek, pull on the leg to roll the patient towards you onto their side
  7. With your other hand on the far shoulder pull on the leg to roll the patient towards you onto their side
  8. Adjust the upper leg so that both the hip and the knee are bent at right angles. Tilt the head backwards to make sure that the airway is and remains open
  9. Adjust the hand under the cheek if necessary to keep the head tilted
  10. Monitor the patient's pulse and respirations and be ready to resuscitate if necessary


What should I know about resuscitation?

Basic life support (BLS) is a simple technique to learn, but if carried out efficiently it can be the difference between life and death. Research suggests that BLS will not be successful in bringing a casualty "back to life" but it will maintain cerebral perfusion sufficiently to give advanced life support a fighting chance.

Cardiopulmonary resuscitation (CPR) is a combination of cardiac compressions and ventilations. You can carry out CPR with two operators, as shown below, but you will probably find that it is more efficient to carry out the CPR one operator at a time, changing over when one gets tired.


You need to discover as much history as you can from people at the scene or any obvious clues; if you are first on the scene make sure that you, the patient and any bystanders are safe. Try to stimulate the patient, firstly by speaking loudly to them. Try gently shaking the patient’s shoulders and asking loudly "are you ok?". If you get no response you can apply some painful stimuli, for example rubbing your knuckles on the patient's sternum, or pressing the patient's nail bed with your thumb nail. If you still get no response, lay the patient on their back and move on to airway and cervical spine checks.

Check the cervical spine by feeling for any major abnormalities in either shape or texture and look for any obvious blockages - use a finger sweep if necessary to remove any foreign matter

Open the patient's airway using head tilt/chin lift - this lifts the tongue off the back of the throat thus opening the airway

Then look, listen, and feel for respiratory effort. If the patient is breathing put them into the recovery position and either send for, or go for help yourself. Always reassess the patient's vital signs on your return if you have to leave them yourself.

If spontaneous respiration is absent (respiratory arrest), you need to make a decision about the cause of the arrest. If a colleague or bystander is present they should be sent for help - make sure they ask for AED. If you find yourself alone however, stick to one of the following procedures: Trauma related, non-cardiac, drowning or children or Cardiac related arrest


Cardiac compressions

Cardiac compressions

Cardiac compressions are carried out from the side of the patient.

Place the heel of one hand in the centre of the patient’s chest (this is the lower half of the patient's sternum)

Place the heal of your other hand on top of your first hand

Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs

Do not apply any pressure over the upper abdomen or the bottom end of the sternum

Make sure your shoulders and arms are vertical above the patient’s chest

Each compression releases all pressure on the chest, without losing contact with the sternum

Ratio of 30 compressions to 2 inflations (for an adult)

Ratio of 15 compressions to 2 inflations (for a child) after an initial 5 rescue breaths have been tried

The net effect of your compressions is to squash the heart between the spine and the breastbone causing the blood to be squirted out and off around the body.

You should depress the chest approximately 5 to 6 cm in adults and 4 to 5cm in children and infants but again this will vary from individual to individual. You should attempt a compression rate of 100 per minute in all categories of patient, from adults to infants.

Obviously the smaller your patient the less force you will need to depress the chest, to the point where only two fingers are required for an infant.




Adult ventilations: Ratio of 30 compressions to 2 ventilations.

Healthcare professional’s rescue for children: Ratio of 15 compressions to 2 ventilations; after an initial 5 rescue breaths. 

Lay single rescuers will use 30 to 2 ratio for both for adults and children...

Evidence would suggest that one of the most common mistakes with artificial ventilations is that the rescuer over-inflates the casualty's lungs causing trauma to the alveoli and impairing gaseous exchange. So it is recommended that only a force of inflation sufficient to raise the patient's chest be used. This equates to approximately 400ml of air in the average adult, but obviously the amount must be modified to suit the individual casualty be they large or small, child or adult.

If the chest does not rise it may indicate a blocked airway and you should attempt to remove the blockage using any of the usual methods. It may also be that you are not maintaining an airtight seal around the patient's mouth. This can be difficult in the case of an infant, and in this case both nose and mouth can be covered at the same time.


Rescuers should use safety precautions especially if victim is known to have serious infection. Health care professionals must be trained in use of bag-mask ventilation or using a barrier device during CPR


Trauma-related, non-cardiac, drowning or children

Trauma-related, non-cardiac, drowning or children

If the cause of the respiratory arrest is trauma-related, non-cardiac, drowning, or if your patient happens to be a child, carry out an immediate carotid pulse check for at least 10 seconds.

At the same time look for other signs of life, like twitching eyelids or abdominal or muscle movements. If there is a pulse or you can see other signs of life, ventilate the patient until help arrives.

If all the life signs are absent, enter immediately into 60 seconds of cardiopulmonary resuscitation at a ratio of two inflations to every 30 chest compressions.


After an initial 5 rescue breaths if the child is still not breathing enter immediately into 60 seconds of cardiopulmonary resuscitation at a ratio of two inflation to every fifteen chest compressions.


If there is no response after the CPR call or go for help and then continue until help arrives


Cardiac-related arrest 

Cardiac-related arrest 
(Health care professional)

If the cause of the respiratory arrest is cardiac-related, help must be sought immediately, before any resuscitation is attempted. Obviously if you have a colleague or bystanders to send to call an ambulance (with AED), resuscitation can be started that much quicker.

Once help has been sought, start making sure that everyone is safe and in no danger. 

  1. Gently shake patients shoulder, and ask loudly "are you all right?"
  2. Open airway by placing your hand on patients forehead and gently tilt his head back with your other hand.
  3. Use your finger tips under the point of the patients chin, lift the chin to open airway.
  4. LOOK for chest movement, LISTEN at victims mouth for breath sounds, FEEL for air on your cheek.
  5. (Look, listen and feel for no more than 10 seconds)
  6. (Healthcare professional) Take carotid pulse check and check for other signs of life.
  7. If all vital signs are absent, CPR must be implemented immediately and continued until the patient shows signs of recovery, or you the rescuer are too tired to continue, until help arrives or someone equally qualified can take over, or the patient is certified dead by a medical practitioner.
  8. After 30 compressions open airway again using head tilt and chin lift.
  9. Pinch the soft part of the victims nose closed, using the index finger and thumb of your hand on the forehead.
  10. Maintain chin lift, take a normal breath and place your lips around patients mouth, making sure that you have a good seal.
  11. Blow steadily into his mouth whilst watching for his chest to rise.
  12. Take about one second to make his chest rise in normal breathing.
  13. Maintaining head tilt and chin lift take your mouth away from the patient and watch for his chest to fall as air comes out.
  14. Take another breath and blow into the victims mouth once more - to give total of two effective rescue breaths.
  15. Return your hands without delay to the correct positions on the sternum and give a further 30 compressions.
  16. Continue at a rate of 30 compressions to 2 ventilations.
  17. Do not stop to check the patient unless he shows signs of life or regaining consciousness or starts to breathe normally.
  18. Do not interrupt resuscitation.
  19. Airway Adjuncts
  20. Asses the airway - use an oropharyngeal airway as this will maintain an open airway. Artificial ventilation using a simple device to ventilate the lungs with oxygen enriched air and a pocket mask enables mouth to mask ventilation with supplemental oxygen. A self inflating bag (mask can be used but the operater needs to be trained to use this device successfully) and the insertion of a supraglottic airway (minimizing the risk of gastric inflation) allows continuous chest compression without pausing during ventilation.
  22. Highly trained experienced professionals can use a tracheal tube to secure the airway, but the cessation of chest compressions will compromise coronary and cerebral perfusion. 
  23. AED (Automated External Defibrillator)
  24. This can be used on a patient found unconscious and not breathing properly. Carry out basic life support until AED is available, but as soon as AED arrives, set it up. If there are two rescuers one continues CPR until AED is ready.
  26. Follow the voice prompts which will instruct you to attach the electrode pads, one below right clavicle and second one to the left mid-axillary line, to patient’s bare chest. No one must touch the patient while the AED is analyzing the heart rhythm. If shock is indicated ensure no-one touches the patient and when prompted push the shock button as directed. Continue as directed by the voice prompts, re starting chest compression as prompted and continuing to follow all prompts until ambulance arrives or patient regains consciousness


What is basic life support

AED usage
Attach pads:

If shock advised, give one shock, then resume CPR (30 compressions, 2 rescue breaths) for 2 minutes, the AED will check again.

If no shock advised, then resume CPR (30 compressions, 2 rescue breaths) for 2 minutes, then AED will check again.

Basic life support (BLS) algorithm for children

Check the child in the usual way (open airways etc). If the child is not breathing normally:

Give 5 rescue breaths before starting chest compressions.

Check for breathing. If no breath:

15 chest compressions

2 rescue breaths

15 chest compressions

Compress the chest by at least one third of the child's chest:

Use one or two hands for a child over one year.

Use two fingers only, for a child under one year


How do I assess patients?



History can include both the present and the past.

Present history may include any or all of several aspects listed below, depending on what type of incident you are dealing with:

Mechanism of injury. How did the injury happen? What caused it?

What was the patient doing at the time of the incident?

Were there any witnesses? What is their story of events?

What position did you find the patient in? Have they been moved?

Was anybody else involved?

Past history is mainly about a patient's medical history. This can be obtained in several different ways:

Ask the patient. Never forget that your patient can communicate but be aware that you cannot always believe what they tell you. This can be either deliberate or as a result of the incident causing confusion.

Ask bystanders or relatives .

Look for medic alert bracelets or necklaces.

Look for any medication, inhaler or tablets the patient is carrying.

Look for drug abuse tracks, needle marks, usually on the inside of the lower arm


How do I assess patients?



Signs are those things that you can either see, touch, smell or hear. They include:

  1. Haemorrhage
  2. Swelling
  3. Deformity
  4. Crepitus (sudden escape of air from the bowels)
  5. Incontinence
  6. Wheezy breathing
  7. Skin colour and texture
  8. Breath smell, acetone
  9. Bruising
  10. Sweating
  11. Vomiting
  12. Empty medicine bottles 
  13. Atmospheric smell, gas, solvents



How do I assess patients?



Symptoms are those things that the patient actually experiences and can tell you about.

Obviously these are absent if the patient is unconscious. They might be:

  1. Loss of sensation
  2. Nausea
  3. Feeling hot or cold
  4. Tingling
  5. Weakness
  6. Pain
  7. Dizziness
  8. Memory loss
  9. Loss of normal movement


How do I carry out a patient survey?

 primary survay basic

Before a primary survey can be carried out you must ensure your personal safety - endangering yourself does not help anyone. The primary survey is basically to make sure that life exists and that it can be sustained. There are three main functions to assess for both conscious and unconscious patients:


Is the airway clear? If not, any blockage must be removed using the usual techniques.

Insertion of an oropharyngeal airway or intubation may be indicated. Fit a cervical collar if necessary.


Is breathing spontaneous? Is breathing difficult or laboured?

Assist breathing if necessary and if there is no breathing, start resuscitation


Is there a pulse? If there is no pulse start resuscitation.

Is there any major haemorrhage? Is there any other fluid loss (burns)?

Dress any major trauma and start intravenous fluid replacement in cases of major trauma or serious fluid loss


secondary survey

This is a more detailed examination. A conscious patient can help you out with this procedure, but all aspects must be assessed for both conscious and unconscious patients. As long as the entire body is assessed you can vary the procedure to suit your patient, but in the heat of the moment it can be very useful to follow a set protocol starting at the head and continuing down the body, so you don't miss anything out.


Secondary survey protocol

You will have to remove some items of clothing, but this should be kept to a minimum and the patient's modesty and privacy should be respected at all times. If clothes have to be cut away try to cut along the seams of the garment. If your patient happens to be female special attention must be paid to her privacy and if a female member of staff is present then she should carry out the examination. A professional approach will usually allay any embarrassment for everyone.

This is a very "hands on" procedure so rubber gloves should be worn at all times. Handling should be firm, but not harsh. Palpation of the patient's body should help to ascertain swelling, deformity or fluid loss


secondary survey

what to look for head


Check head for:

  • Cervical spine deformity - fit collar if necessary
  • Jaw bone movement and continuity
  • Swelling or blood loss from the scalp
  • Fractures in facial bones and eye orbits
  • Texture of skin - cold, clammy, hot, sweating, cyanosed (blue tinge), flushed


secondary survey

what to look for eyes


Check eyes for:

  • Equality of pupils
  • Reaction to light - dilate, contract
  • Size of pupils
  • Colour of whites of eyes - blood shot, yellowish


secondary survey

what to look for head orifices

Head orifices

Check orifices for:

  • Blood or other fluid from ears
  • Blood or other fluid from nose
  • Injury to lips or mouth
  • Loose teeth
  • Broken false teeth
  • Vomit
  • Bitten tongue


secondary survey

what to look for Respirations


Check respirations for:

  • Rate - fast, slow
  • Depth - shallow, deep, sighing
  • Rhythm - regular, irregular
  • Sound - noisy, wheezing, quiet, bubbly
  • Odour - acetone, alcohol


secondary survey

what to look for Pulse


  • Check pulse for:
  • Rate - fast, slow
  • Rhythm - regular, irregular
  • Strength - full, shallow, bounding


secondary survey

what to look for Shoulders


Check shoulders for:

Continuity of bones

Deformity or swelling




secondary survey

what to look for Trunk


Check trunk for:

  • Continuity of bones, sternum and ribcage
  • Equality of chest movement
  • Bruising
  • Deformity or swelling
  • Haemorrhage
  • Palpate (feel) abdomen for rigidity or malleability


secondary survey

what to look for Arms


Check arms for:

  • Continuity of bones
  • Deformity or swelling
  • Haemorrhage
  • Abnormal movement at each joint
  • Needle marks on the inside of the lower arms
  • Medic alert bracelets
  • Radial and brachial pulses


secondary survey

what to look for Pelvis


Check pelvis for:


Continuity of pelvic bones

Deformity or swelling




secondary survey

what to look for legs


Check legs for:

  • Continuity of bones
  • Deformity or swelling
  • Bruising
  • Haemorrhage
  • Abnormal movement at all joints
  • Individual toes for continuity and movement
  • Pedal pulse


secondary survey

what to look for Spine


Check spine for:

  • Abnormality and swelling along the areas of the spine that can be palpated (felt) from the natural hollows of the body, eg cervical area, lumbar area.
  • Once satisfied of no major injury turn the patient into the recovery position and inspect the whole length of the spine.


What different levels of conciousness are there?

glasgow coma scale


What different levels of conciousness are there?

paedi GCS


How do I lift and handle patients?








Other factors


Principles of safe manual handling

Principles of safe manual handling

  • Wear appropriate clothing and footwear
  • Never manually lift unless you really need to do so
  • Assess the person to be lifted before starting to lift
  • Always select the appropriate lift and or lifting equipment for the task
  • Identify a lift leader to give directions before starting a lift involving others
  • Explain the lift or manoeuvre to the person to be lifted and any assisting lifter
  • Prepare the handling area
  • Make a good stable base for your feet
  • Keep the person to be lifted as close to your body as possible (wear protective clothing if necessary)
  • Make sure of a good hand grip
  • Test your grip and the weight if necessary before attempting the lift
  • Know your own lifting capability and do not exceed it
  • The lift leader must give clear concise instructions
  • Use rhythm and timing when lifting
  • Raise your head on commencement of the lift
  • Bend your knees not your back when lifting
  • Never lift and twist at the same time


A major incident is defined as being "any incident requiring special arrangements due to the location and the number of casualties involved". This does not necessarily mean a great number of casualties will be involved. Factors like the incident location in relation to receiving hospitals or the availability of ambulance transport may also be important. The types of injury involved may also need special arrangements for their treatment or evacuation from the scene.

Major incident procedure

On arrival at the scene the driver of the first vehicle must maintain constant radio contact with Control. Control will need to know:

Exact location of the incident

Type of incident (plane crash etc)

Approximate number of casualties

Best approach route to the incident

Other services in attendance

This initial report must be constantly updated as more information becomes available. This driver assumes the role of incident officer until a senior officer arrives to take over. It is important that they make a complete reconnaissance of the incident to get accurate information and under no circumstances must they get involved with administering first aid at that point in time.

An "Ambulance Parking Point" must be established for further crews and vehicles and this obviously needs good approach and exit access. Control will then dispatch several officers to the scene to carry out certain designated tasks.

Incident officer
Responsible for the coordination of all ambulance personnel and resources at the scene.

Liaison officer
Dispatched to the designated casualty receiving hospital and is responsible for the coordination of all ambulance personnel and resources and must ensure the quick turnaround of vehicles.

Parking officer
In charge of the "Ambulance Parking Point". Their role is to avoid bottlenecks and abandoned vehicles clogging the system.

Casualty clearing officer
This officer should be either a paramedic or be accompanied by one. Their role is a combination of triage and the priority dispatch of patients from the scene.

Loading officer
Coordinates with the parking officer to ensure a speedy dispatch of patients from the scene in the correct classification of vehicle with the appropriately trained crews on board


Another key thing to be aware of is the increasing amount of hazardous substances being carried by road. Law now demands that every vehicle carrying a hazardous substance must display a warning panel to state certain information about the load - the "United Kingdom Hazard Information System" (UKHIS

Section 1 - Hazcham code
This code refers to Fire Brigade action and is a mixture of numbers (1-4) and letters (PRST WXYZ). The numbers indicate the fire-fighting medium required for the substance (foam, jet, fog or dry agent) and the letters indicate precautions to be observed with regard to breathing apparatus or the disposal of the substance into watercourses and drains. If a letter E appears in the code it means that evacuation of all non-essential personnel and the surrounding area may have to be considered.

Section 2 - United Nations Code Number
Each hazardous substance is allocated a number, which is recognised world-wide. By reporting this number to control the substance can be quickly identified and the appropriate action detailed. Control will have a set of cards (TREM cards) that set out all the emergency information required to deal with an incident involving that particular substance, fire-fighting procedures, emergency first aid etc.

Section 3 - Telephone Number
This section contains an emergency telephone number in order to contact either the manufacturer or the haulier.

Section 4 - Hazard Warning Diamond
This is a pictorial warning of the properties of the substance being carried. This could be any number of properties including: flammable, explosive, corrosive, poisonous etc. A full list can be found in the IHCD Basic Training Manual.

Section 5 - Trademark
This section gives the house mark or symbol of the manufacturer, ICI etc