Advanced First Aid

INTRODUCTION “No man can reveal to you ought but that which already lies half asleep in the dawning of your knowledge. The teacher who walks in the shadow of the temple, among his followers, gives not of his wisdom but rather of his faith and his lovingness. ” – Khalil Gibran – The Prophet This course belongs to YOU, and its success depends largely on you. Please enter into discussions ENTHUSIASTICALLY. Please feel free to share your EXPERIENCE with us. Please feel free to say what you think, even if you DISAGREE. You have been given an evaluation form. Please complete this form honestly as your feedback is vital for the improvement of the services G. T. S. C. provides to you. A customer complaint form is available from the instructor. If you have any complaint regarding any facet of the course or facility, please obtain this form and complete it. Completing the customer complaint form will in no way have any effect on your grading and/or passing of the course. AIMS AND OBJECTIVES OF THIS COURSE: To give you a good overview of the principals of advanced first aid, shock, first aid safety, patient assessment, bleeding and wounds, fractures, choking and C. P. R. To help you to reach an acceptable level of providing practical patient treatment. FIRST AID is the initial assistance given for any victim before the arrival of an ambulance, doctor or other qualified person. The purpose of having people trained in First Aid is to provide help and care to the injured or sick, for the shortest possible time, until the care of the patient or victim can be taken over to a better-qualified person. In your working environment the better-qualified person can be the medical clinic staff, the ship’s doctor or nurse, or even the land-based ambulance staff. The fact that you will hand over your patient to another person doesn’t make what you are doing any less important. It is vitally important for any seriously injured or sick person to receive help as soon as possible, and first aiders are trained for this specific reason – to give help and treatment as soon as possible. A first aider, or a person trained in first aid meets the following conditions: He/She is trained by a suitable instructor in specific fields of first aid, according to the guidelines as determined by an international recognized first aid institution. In order to stay current in first aid, the first aider should be examined and tested regularly, preferably every year, since first aid protocols, and more specific CPR protocols, changes almost yearly. The first aider should be re-examined on a regularly basis in order to ensure his/her first aid capability and proficiency. It is also expected from the first aider to ensure that he/she stays up to date in any changes which may occur, obtaining theoretical information through reputable publications or web sites such as the web site of the American Heart Association (www. aha. com). Should the first aider learn about new guidelines, or changes in existing guidelines, he/she should adopt such guidelines and seek the guidance and help of qualified instructors in case of any difficulty. Research has shown that first aiders who are proficient in CPR, loses 60% of their practical skills if they don’t practice CPR within one year of the previous official training they received. This makes it very important to practice CPR at least yearly, if not every six months. PRINCIPLES OF FIRST AID In the world first aid has been as much a part of the culture as drinking tea. Caring volunteers and individuals performed a much-needed service to the sick and injured and laid the foundations for the formal first aid organizations such as St John Ambulance and the Red Cross. The period between the World Wars saw an increased awareness in the community of the benefits of first aid and the combining of other activities, such as surf life saving, with first aid training. It was not until the 1960’s and 1970’s that the general public became involved by attending first aid classes and using this newfound knowledge to their benefit. First aid training has now become virtually indispensable to industry and for an active social life. What is first aid? First aid is the initial care of the injured or sick. It is the care administered by a concerned person as soon as possible after an accident or illness. It is this prompt care and attention that sometimes means the difference between life and death, or between a full or partial recovery. First aid has limitations – not everybody is a doctor – but it is an essential and vital part of the total medical concept. FIRST AID SAVES LIVES! … sk any ambulance officer or doctor who works in the emergency medical field. Immediate action It is important that any action taken by the first aid provider is done as quickly as possible. Quick action is necessary to preserve life and limb. A casualty who is not breathing effectively, or is bleeding copiously, requires immediate intervention, and if quick effective first aid is provided, then the casualty’s chances of recovery are improved immeasurably. It should be remembered though that any action undertaken is to be deliberate and panic by the first aid provider and bystanders will not be eneficial to the casualty. Try to remain calm and think your actions through. How do I get help? To get expert medical assistance, call an ambulance on ‘998’, alternatively you can call the police on 999. If your company has a medical clinic on site, it is better to call the clinic staff and let them decide whether it is necessary to call an outside ambulance. If you are attending a casualty, get a bystander to telephone for help – if you are on your own, then you may have to leave the casualty momentarily to make a call. It’s common sense, the decision is yours! Medic alert Some individuals suffer from certain medical conditions that may cause them to present with serious signs and symptoms at any time. As a form of assistance and notification, these people may wear a form of medical identification, usually a special bracelet, or less commonly, a necklace. These devices are commonly referred to as ‘Medic Alert’ bracelets, but are also known as ‘Vial of Life’ and ‘SOS Talisman’. They are stamped with the person’s identity, the relevant medical condition, and other details which may include allergies, drugs required, or specialized medical contact. Medical conditions that may be notified vary from specific heart diseases, to diabetes, epilepsy, asthma etc. AIMS OF FIRST AID The aims of first aid are basically the preservation of life, the prevention of worsening of he patients’ condition and the promotion of recovery of the patient. The preservation of life is the most important function of the first aider, and this specific function can easily be accomplished and demonstrated in the choking victim or the patient going into sudden cardiac arrest. In both these cases, the immediate, correct and efficient treatment given by the irst aider can really save the life. In these cases, if the patient has to wait for advanced life support as rendered by higher trained medical staff, the waiting time can very well mean the end of the patient – THERE IS NO TIME TO WAIT – help must be given immediately, and the first aider is the best and most readily available person to do this. The second aim of first aid, the prevention of the worsening of condition, is part of the scope of the first aider. For example, if somebody falls and break his upper leg (fracture of the femur), the patient can loose up to 1500ml body fluids because of the facture. If the patient is allowed to move around with an unsplinted or unstable fracture, the amount of body fluids lost can double. Losing more body fluids will result in greater shock and the worsening of the patient’s condition, even to such a point that the patient may die. The third aim – to promote recovery will be fulfilled if the first aider renders effective, indicated treatment. As in the example mentioned in the above paragraph, the early stabilizing of the fracture reduces fluid loss, combats shock and relieves swelling and pain. These combined factors will surely lead to a faster recovery of the patient, not only in helping recovery. SCABCS SCABCS is the prime consideration for everyone involved in the care and treatment of casualties. Experienced first aid providers, ambulance crews, nurses and medical specialists, are all-aware of the importance of Safety, Communication, Airway, Breathing, Circulation and Stop profuse bleeding Safety • to yourself: don’t put yourself in danger! • to others: don’t allow bystanders to be exposed to danger! • to the casualty: remove the danger from the casualty, or the casualty from the danger! If it is not safe to touch or treat the patient, then don’t! Part of safety includes protecting yourself against infectious diseases. Infectious diseases are those diseases that cause infections to the human body, and in some cases are transmitted by contact or by cross-infection. Infection may be due to bacteria, viruses, parasites or fungi. The usual methods of communication are; direct contact (contact with an infected person), indirect contact (through faeces, air conditioning, or similar), or through a host (insects, worms). Many deadly infectious diseases have been eradicated in the world, but several, such as poliomyelitis (a virus), are again on the increase. Many are preventable by immunization. Some, such as the Human Immuno-deficiency Virus (HIV), have no cure or medical prevention. Examples of infectious diseases are: PARASITIC INFECTIONS: Malaria, tapeworm, hookworm, itch mites, pubic and body lice. FUNGAL INFECTIONS: Ringworm, tinea (Athlete’s Foot), thrush. BACTERIAL INFECTIONS: Throat infections, whooping cough, diphtheria, rheumatic fever, tuberculosis strains, cholera, staphylococcus infection, and some forms of meningitis. VIRAL INFECTIONS: Measles, mumps, rubella, hepatitis, influenza, chicken pox, HIV, SARS, common cold, bronchitis. The human body has natural defences against infection, and remains immune to certain types. Immunity is usually achieved by previous exposure to a particular infection, with resultant chemical antibodies being produced. The blood contains leukocytes (white blood cells), which assist in the production of antibodies. The leukocytes and antibodies combat any infection, which invades the body. Unfortunately, the body’s natural defences work slowly and cannot cope adequately with particularly virulent nfections. It is at this stage that the body requires help in the form of medically prescribed antibiotics or similar drugs. Advice on general precautions that can be offered by the first aid provider are: (avoid direct contact with infection (avoid transmitting infection (care of the susceptible, i. e. , the ill, the elderly, the very young (care in nutrition and preparation of food (maintenance of personal hygiene (maintenance of sanitary standards There is no definitive first aid treatment for infectious diseases. However, the first aid provider should be familiar with the signs and symptoms of the common diseases, and provide advice to the infected person to seek appropriate medical attention. Communication • use the shake and shout method! • is the casualty alert? • is the casualty drowsy or confused? • is the casualty unconscious, but reacting? • is the casualty unconscious with no reaction? Level of consciousness refers to the level of brain function detectable. Prior to continuing the examination of the patient, we need to determine the level of consciousness. The level of consciousness can be divided into hundreds of small steps, each step referring to a different level of brain function. In basic first aid, we are primarily concerned with the following levels of consciousness: |Alert and responsive |Responds to verbal or physical stimuli, knows who, where and what. | |Disorientated and confused |May respond to verbal and physical stimuli but does not know who, where or what | |Stuporous but arousable |Responds to verbal and/or physical stimuli omentarily | |Unconscious |Responds only to physical stimuli, will respond to painful stimuli | |Comatose |Breathing and heartbeat present, does not respond to verbal stimuli, may respond to painful | | |stimuli | |Clinically dead |Breathing and/or heart function may be present, no detectable brain function present | |Biological dead |No body or brain functions present | | | | Airway • is the airway open and clear? • is there noisy breathing? • are there potential obstructions such as blood? Breathing • look to see if the chest and/or abdomen moves! • look for signs of breathing – general appearance of the patient If the casualty is conscious, then treat the injuries or illness according to the signs and symptoms. If the casualty is unconscious, and breathing spontaneously, place him or her in the recovery or lateral position, then treat any injuries. If the casualty is unconscious, and not breathing, then commence resuscitation as required, according to the CPR protocol Stop profuse bleeding If any excessive (profuse) bleeding is present, this must be controlled as soon as possible. In general, profuse bleeding will be bleeding from an artery – seldom this bleeding will be from veins. Wounds, bleeding and control of bleeding will be discussed in detail later on during this course. CPR & CHOKING Basic Life Support (BLS) is the part of emergency care that prevents respiratory or cardiac arrest through prompt recognition and intervention, or supports the ventilation and circulation of a victim of cardiac arrest by means of Cardio-Pulmonary Resuscitation (CPR). [1] BLS can therefore be seen as the provision of external cardiac/chest compressions, accompanied by artificial ventilation.. The major objective of performing CPR is to supply oxygen to the vital organs until such time that advanced care can be given, or until the victim’s own body functions are restored. The patient, whose circulation or breathing has been interrupted for less than 4 minutes, has an excellent chance to recover fully if BLS is performed within 4 minutes, and ACLS follows within the first 8 minutes. The longer it takes before BLS and ACLS are rendered, the smaller the chance for survival (Table 1). The Sequence of Adult BLS Unresponsiveness Before you touch any patient, you should ensure that you have Latex (or similar) gloves on both hands, to protect you against any disease the patient may have. To determine if a patient is unresponsive, you should talk to the patient, and gently shake the shoulders of the patient. Care should be taken if the patient has had, or could have sustained trauma, since the shaking of a trauma patient’s shoulders could cause paralysis in a patient with a cervical spine injury. Trauma patients should not be shaken, and in this case “touch and talk” is safer that “shout and shake”[30] Remember that the unresponsive patient you may encounter, could be unresponsive due to an anxiety attack, hypoglycaemic coma or even because the patient took his prescribed sleeping tablet. In this case the patient may not respond to talking, shouting or shaking, same as the deaf patient will not respond to talking. In most cases, it is more advisable to give a pain stimulus to an unconscious patient if he/she didn’t reach to “touch and talk” or “shake and shout”. Pain should be given only to determine the level of unconsciousness and must be given to the patient in such a way that it cannot be described as assault or leave any damage to the patient. A safe way of giving pain is to press down on the fossa (depression) behind the collar bone, at the root of the neck. Airway If the patient is unresponsive, you should determine if the patient is breathing. In order to determine patient respiration, you must ensure that the airway is open, and the only way to be sure that the airway is open, is to open it manually. Before opening the airway, the patient should be positioned supine. If you suspect the patient has received any trauma (injury, falling down, etc. ), the patient must be treated as though he has spinal injuries. You cannot simply turn the patient. You should roll the patient as a unit, keeping the spinal column intact and aligned [31]. Once the patient is supine, you should position yourself at the victims’ side. In a supine unconscious patient, the most common cause for airway obstruction is the tongue, falling back against the back of the throat. 16] Since the tongue is attached to the lower jaw, moving the lower jaw away from the back of the throat will move the tongue away from the back of the throat and open the airway. Use the HEAD TILT-CHIN LIFT method of opening the airway by following these steps: 1. place one hand on the forehead of the patient and apply firm backward pressure to tilt the head back. 2. place the fingers of the other hand under the bony part of the lower jaw. 3. lift the chin forward and support the jaw, helping to tilt the head backwards. 4. the mouth should not be closed when lifting the chin. [32] Breathing The first objective after opening the airway is to determine if the patient is breathing or not. To determine if the patient is breathing, you should LOOK, LISTEN & FEEL: 1. Look at the patient’s chest and observe if there are any raising and falling movements of the chest present. (If the patient is a male, you will have a better chance to observe upper abdomen movement since men use the diaphragm primarily breathing, while woman tend to use the intercostal muscles primarily for breathing. ) 2. With your ears close to the mouth of the patient, you should listen and feel and for any air moving into or out of the patient’s mount or nose. If no air is exhaled, and no chest movement can be detected, the patient is in respiratory arrest. The evaluation procedure should take between 3 and 5 seconds. [33] If the patient is breathing after the airway is opened, the patient should be placed in the recovery position. A trauma patient should not be moved without special precautions. Your actions will be determined by the nature of the breathing, the history of the patient and your own level of training and expertise. Ventilation Ventilations must be given if the patient is not breathing. Whichever device you use, you should initially give two slow ventilations, each ventilation lasting 1 second. The 1-second time period for ventilation is necessary in order to deliver slow inspiratory breaths. By giving the ventilations with a slow inspiratory flow rate and avoid the trapping of air in the lungs between ventilations, the possibility of exceeding the oesophageal opening pressure will be less. It should result in less gastric distension, regurgitation and aspiration. [37] Care must be taken not to ventilate with excessive volume, since the excessive air can go only to the stomach. Ventilate only until the chest rises. Exhalation is a passive phenomenon and occurs primarily during chest compressions if CPR is being performed. [37] Although mouth-to-mouth ventilation is effective, it should be avoided because of the dangers of cross-infection. It can however be given to somebody which you know have no infectious disease, like your own small child. In all other patients, a barrier-device must be used to ventilate. Two types of barrier devices are available and acceptable: masks and face shields. Masks have a one-way-valve to prevent the air escaping from the patient to come in contact with the ventilator. Face shields have no valve, the only protection it gives is against direct contact, which makes face shields almost impractical. [8] A facemask is used in the following way: 1. Place the mask around the patient’s mouth and nose using the bridge of the nose as a guide for the correct position. 2. Grab the lower jaw and thrust it upwards against the mask, which you are pressing downwards with your thumbs and index fingers of both hands. 3. Ventilate through the one-way valve and observe that the chest is rising. 4. Remove the mask and allow the air to escape from the patient’s lungs. If the mask is equipped with a one-way valve, there is no need to remove the mask after each ventilation. [19] Repeat the four steps. A more effective method of ventilation is using a bag-valve-mask (BVM), since a BVM delivers at least 21% oxygen whereas expired air ventilation delivers maximum 16% oxygen. A BVM should be used as follows: 1. Choose the proper size mask for the patient. The wide base of the mask should fit snugly between the chin prominence and the lower lip, and extend to cover the bridge of the nose at its apex. 2. Ensure that the cuff of the mask is inflated in order to create a seal between the mask and the patient. 3. The and holding the mask should have the thumb placed on top of the flat surface of the transparent plastic, one or two fingers on the wide transparent base of the mask, and two or three fingers should grab the mandible of the patient. 4. Press down on the transparent part of the mask, while pulling the mandible towards the mask; at the same time the hand holding the mask should not only pull the mandible towards the mask, but should also perform a chin-lift in order to keep the airway open. 5. Using the other hand, depress the bag portion of the BVM in order to ventilate the patient. 6. While pressing the bag portion, listen carefully for air escaping between the mask and the patient, and feel for any resistance while pressing the bag (bagging). 7. Don’t remove the bag in order to allow expired air to escape. 8. It is more effective and easier if one person is using both hands to hold the mask in place while another person is bagging. Chest compressions The chest compression technique consists of serial, rhythmic applications of pressure over the lower half of the sternum[4] These compressions provide circulation as a result of a generalised increase in intra-thoracic pressure or direct compression of the heart. [5,6] The patient must be in a horizontal, supine position during chest compressions. Even with properly performed compressions, blood flow to the brain is reduced. Proper hand position is on the lower half of the sternum. It does not matter which method you use to establish the lower half of the sternum, however, the long axis of the heel of the hand is located on the lower half of the long axis of the sternum. The fingers can be interlocked or free, but should be kept off the chest. It is, however, good practice to interlock the fingers to ensure that no pressure is exerted on the ribs. People with arthritic hands and/or wrists can use the hand which was used to locate the lower half of the sternum, to grasp the wrist of the hand which is on the chest. [1] Effective chest compressions are achieved by following the guidelines: 1. Your elbows should be locked into position, your arms straightened and your shoulders directly above the patient’s sternum 2. To achieve the most pressure with the least effort, lean forward until your shoulders are directly over your outstretched hands (lean forward until the body reaches natural imbalance – a point at which there would be a sensation of falling forward if the hands and arms were not providing support). The weight of your shoulders, chest and back creates the necessary pressure that makes compressions easier on the arms and shoulders. Natural body weight falling forward provides the force to depress the sternum. 3. The sternum should be depressed approximately 1? to 2 inches (3. 8 to 5. 1cm) for the normal-sized adult. The depth of compressions may change according to the size of the chest of the patient; a large, barrel-shaped chest may need deeper compressions. The only way to know that your compressions are deep enough is to have somebody feel for palpable carotid pulse. If your compressions create palpable carotid pulse, the compression depth is sufficient. 4. Release pressure on the chest between compressions to allow blood to flow into the chest and heart. The chest must be allowed to return to its normal position. 5. The duration of the compression should be equal to the duration of pressure release: in other words, the time you spend to press down on the chest should be the same as the time you spend to “come up” from the chest. 6. There should be no pause between compressions in a cycle, don’t pause on top. 7. Do not lift the hands from the chest, you will loose correct hand position. 8. Bouncing compressions, jerky movements, improper hand position and leaning on the chest can decrease the effectiveness of the compressions and can cause injuries. 9. The chest compression rate should be minimum 80 to 100 per minute. [40] Cardiac output resulting from chest compressions is likely to be only 17% – 25% of normal cardiac output. [7] Sequence for Adult One-person CPR 1. Determine unresponsiveness. a. Tap or gently shake the shoulders and shout. b. Consider giving painful stimuli. c. Call for help locally, inform the help of the situation you have. 2. Open the airway a. Position the patient. b. Open the airway by head tilt-chin lift manoeuvre or jaw-thrust. 3. Assess breathing a. Look for signs of breathing for up to 10 seconds. b. If the patient is unresponsive but obviously breathing and if there is no trauma, place the patient in the recovery position and maintain an open airway. c. Ventilate twice using BVM or pocket mask barrier device. d. If unable to ventilate twice, reposition the head and attempt to ventilate again. e. If ventilation is still unsuccessful, perform the foreign body airway obstruction sequence. f. If ventilation is successful, continue to next step. 4. Chest compressions: ? Position yourself properly ? Determine correct hand position Perform 30 compressions at a rate of 100 compressions per minute. ? Open the airway and give two slow ventilations. (1 seconds per ventilation) ? Re-determine proper hand position and begin 30 more compressions at a rate of 100 per minute. ? Continue 30 compressions and 2 breaths until the patient is resuscitated that is breathing returns or the EMS/Ambulance arrives Two-person adult CPR When another person is available to assist you with CPR, the second person can perform the chest compressions when the first person becomes fatigued. This change should be done with as little interruption as possible. The ratio of compressions to breaths remains 30 compressions to 2 breaths. Foreign body airway obstruction Because early recognition of airway obstruction is vital to a successful outcome, it is important to distinguish between airway obstruction, stroke, heart attack et cetera. Obstruction can be partial or full. If partial, the patient may be able to have sufficient air exchange, and will remain conscious, coughing forcefully and wheezing between coughs. In this case, the patient should be encouraged to continue forceful coughing until the obstruction is cleared and you should not interfere with the patients’ attempts to expel the obstruction. If the obstruction isn’t cleared rapidly, advanced help should be called without delay. A partial obstruction with inadequate air exchange to remain conscious should be treated like a patient with full airway obstruction. With complete airway obstruction the patient will be unable to breath, cough and speak, and may clutch the neck with his hand. Ask the patient if he is choking, even though he cannot speak, he may nod his head to indicate that he is. In this case, death will follow quickly if action is not taken immediately. The Abdominal Thrust The Abdominal Thrust is recommended for expelling a foreign body from the airway. [13] By applying forceful, upwards and inwards pressure on the abdomen inferior to the diaphragm, the intestine, liver, stomach and spleen is forced upwards, transferring the force to the diaphragm. The diaphragm is displaced upwards, transferring the force directly to the lungs. The pressure generated is then exerted on the obstruction. The aim is to create enough pressure on the obstruction (foreign body), to force the foreign body upwards in the airway, and thus clearing the airway. One should remember that it is very possible to damage internal organs like the abdominal or thoracic viscera, the spleen and the liver while doing the Abdominal Thrust. [14] To minimise this possibility, your hands should never be placed on the xiphoid of the sternum or on the lower margins of the rib cage. They should be below this area but above the navel and in the midline. [42] Abdominal Thrust with patient sitting/standing. [13,14,15] 1. Stand behind patient, wrap your arms around the patient’s waist. 2. Make a fist with one hand. 3. Place the thumb side of the fist against the patient’s abdomen, in the midline and slightly above the navel. 4. Stay well away form the xiphoid process. 5. Grab the fist with the other hand and press the fist into the patient’s abdomen with a quick upward thrust. 6. Repeat the thrusts and continue until the foreign object is expelled or until the patient becomes unconscious. 7. Each thrust should be an independent movement. Abdominal Thrust with patient lying down. [43] 1. Place the patient is supine position. 2. Kneel aside the patient’s thighs and place the heel of one hand against the patient’s abdomen, in the midline and slightly above the navel. 3. Keep well away from the patient’s xiphoid process. 4. Place the second hand directly on top of the first hand. 5. Press on the abdomen with a quick, upward thrust. 6. Use your body weight and shoulder muscles to perform the manoeuvre. Chest thrusts with patient sitting or standing This technique is only used in the late stage of pregnancy and on markedly obese patients. 1. Stand behind patient with your arms directly under the patient’s armpits, and encircle the chest. 2. Place the heel side of your fist on the centre of the patient’s sternum, avoiding the xiphoid process and the margins of the rib cage. 3. Grab your fist with your other hand and perform backward thrusts until the foreign body is expelled or until the victim becomes unconscious. Chest thrusts with patient lying down. This should be done only in the last stage of pregnancy and when the Heimlich manoeuvre cannot be applied to the conscious/unconscious obese patient. 1. Place the patient on his back and kneel close to the victim’s side. 2. The hand position is exactly the same as for CPR. 3. Deliver each thrust firmly and distinctly. Management sequence for obstructed airway: 1. Do abdominal thrusts (or chest thrusts for late stages of pregnancy and obese patients), and repeat doing thrusts on the conscious victim until the obstruction is expelled or until the patient becomes unconscious. 2. Open the airway, look in the mouth for any visible obstruction, and attempt to ventilate. If ventilation attempt is unsuccessful; 3. Re-open the airway and attempt to ventilate again. If ventilation is still ineffective; 4. Perform 30 chest compressions 5. Open airway, look inside mouth for visible obstruction and do finger sweep. 6. Attempt ventilation. If ventilation is unsuccessful; 7. Re-open airway and attempt to ventilate again. If unsuccessful; 8. Perform 30 chest compressions 9. Repeat steps 5 to 8 until successful or until death certification. 10. If successful, treat according to patient’s condition. ———————– Head tilt-chin lift. Note that the fingers lifting the chin are not exerting pressure on the soft tissues under the chin. Wrong head tilt-chin lift. Fingers exerting pressure on the soft tissues under the chin can press the tongue towards the palate – causing airway obstruction. Observe for breathing. Recovery position Position of the facemask. Ventilating with a BVM. Note at least two fingers pressing down on the plastic part of the mask to ensure a tight seal between the mask and the face of the patient. Note that at least two fingers should grasp the bony part of the chin and pull it against the BVM facemask. Place the middle finger on the Xiphoid process against the sub-sternal notch and the index finger on the sternum. [pic] Place the heel of the other hand next to the index finger, making sure that the heel is on the lower half of the sternum. Figure. Place the first hand on top of the other hand and interlock the fingers to ensure that there is no pressure on the ribs. Figure. Correct compression position. Note that the elbows are locked, the heel of the lower hand is on the sternum, and the shoulders are directly above the hand and the sternum. Abdominal Thrust in conscious patient (sitting or standing). Abdominal thrusts on an unconscious patient. Chest thrusts on the conscious pregnant or markedly obese patient. Chest thrusts on the unconscious pregnant or markedly obese patient.

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