Care for shock is standard treatment in all first aid related emergencies. Shock is a condition in which the cardio vascular system fails to provide adequate blood circulation to all parts of the body for perfusion of oxygen. When the body’s organs do not receive an adequate supply of blood, they fail to function properly.

In a minor injury, the body will compensate and this situation will be resolved in a short time. In the case of more severe injuries, the body may not be able to adjust. If the body cannot adjust or compensate for blood or other body fluid loss, shock will occur.

Care for shock is standard treatment in all first aid related emergencies. Shock is a condition in which the cardio vascular system fails to provide adequate blood circulation to all parts of the body for perfusion of oxygen. When the body’s organs do not receive an adequate supply of blood, they fail to function properly.

In a minor injury, the body will compensate and this situation will be resolved in a short time. In the case of more severe injuries, the body may not be able to adjust. If the body cannot adjust or compensate for blood or other body fluid loss, shock will occur.

CAUSES OF SHOCK
Poor pump function	Blood/ Fluid volume loss from blood vessels.	Blood vessels dilate.
Causes: Heart attack, trauma to heart	Causes: Trauma to vessels or tissues; fluid loss from GI tract (vomiting/ diarrhoea) can lower the fluid component of blood	Causes: Infection, drug overdose (narcotic), spinal cord injury.

PROGESSION OF SHOCK

• Initial Phase. Once the patient is injured his/ her body takes a “blow” and the body’s systems cannot function properly. The patient’s vital signs are not normal. This phase is relatively short before the body moves into the next phase.
• Compensated Shock. The body tries to compensate for the injury. The patient looks like he / she is recovering as the body’s function are maintained against all odds (i.e. the vital signs are stable). This is the phase that gives the FA a false sense of security as if the injury is not treated correctly the patient will move into the next phase before one is aware of it.
• Decompensated Shock. The body has done all that is possible to try and compensate for the injury but can no longer maintain the status quo. Once the body has entered into this phase there is little a FA can do.
• Irreversible Shock. This is when shock has progressed to the terminal stage; a transfusion will not even save the patient’s life.

TYPES OF SHOCK

Anaphylactic		Extreme life-threatening allergic reaction due to the exposure to a substance that a patient is hypersensitive to such as medication, bee venom, pollen, foodstuffs, etc.
Hypovolemic		Loss of body fluids due to heavy bleeding, diarrhoea, vomiting or heavy perspiration.
Metabolic		A type of Hypovolemic shock associated with untreated illness. Loss of body fluids and the acid ‑ base balance is altered.
Cardiogenic		The heart failing to pump blood adequately to all vital parts of the body (e.g. Myocardial Infarction).
Respiratory		Failure of the respiratory system to supply the blood, in the lungs with sufficient oxygen (e.g. Lung damage).
Neurogenic		Failure of the nervous system to control the diameter of the blood vessels (e.g. Spinal injury).
Psychogenic		A temporary condition brought on by fear, bad news or sight of blood. Blood vessels suddenly dilate, causing a momentary interruption of the blood flow to the brain.
Septic		This type of shock usually occurs in hospitals where infections are being treated (e.g. Untreated or infected burn wounds).
	SIGNS AND SYMPTOMS OF SHOCK (GENERAL) Skin ‑ pale, cold and clammy. Level of Consciousness ‑ decreases from conscious to unconscious. Respiration ‑ Rapid, shallow, sighing, air hunger. Pulse ‑ initially rapid and strong to rapid and weak. Eyes ‑ dull, pupils dilated. Thirst. Nausea and vomiting. Anxious, restlessness or irritability. Weak, helpless feeling.

 

TREATMENT

W	Warmth - Maintain the casualty's body temperature.
A	Airway - Ensure that the casualty gets enough fresh air and/ or oxygen.
F	Fluids - Nil per mouth.
E	Elevation/ Positioning (This depends on the patient’s injuries or condition). - Raise the legs 20 ‑ 30 cm above the ground. - Recovery position (unconscious patient).  - Semi‑sitting for respiratory or cardiac conditions. - Flat on the back (spinal injury).
R	Reassurance
“The treatment of shock forms the basis of treatment of any patient”

 ANAPHYLACTIC SHOCK

Signs and Symptoms

• Usually rapid presentation.
• History of allergy (look for a “Medic Alert”).
• Red itchy skin.
• Swelling of the eyes, face and throat.
• Symptoms of hay fever (cough, red - watery eyes, sneezing, etc.)
• Dyspnoea.
• Cyanosis (only if laryngospasm is prolonged).
• Drop in blood pressure.
• Drop in level of consciousness.
• Nausea & vomiting.

Treatment

• Determine and remove the cause (if possible).
• Manage the airway.
• Treat as for shock.
• Check the patient to see if he / she have their own medication (e.g. Epi-pen).
• Arrange RAPID transport.

Secondary Assessment

The purpose of a secondary assessment (composed of a head-to-toe, history and vitals) is to continually monitor the victim’s condition and find any non-life-threatening conditions requiring treatment. A secondary assessment should be done for any victim requiring ambulance intervention, or if there is a concern that the victim’s condition may deteriorate.

In some cases, you may want to do an shortened secondary survey - use your best judgment.

Who is this for? 

The Head-to-toe assessment is a technique used by lay rescuers, first responders, and ambulance personnel to identify an injury or illness or determine the extent of an injury or illness.

It is used on victims who meet the following criteria:

•         Victim of trauma injuries (except minor injuries affecting peripheral areas)

•         Unconscious victims

•         Victims with very reduced level of consciousness

If a victim is found unconscious, and no history is available, you should initially assume that the unconsciousness is caused by trauma, and where possible immobilize the spine, until you can establish an alternative cause.

 The secondary assessment should be performed on all the victim meeting the criteria (especially trauma) regardless of gender of rescuer or victim. However, you should be sensitive to gender issues here (as with all aspects of first aid), and if performing a full body check on a member of the opposite sex, it is advisable to ensure there is an observer present, for your own protection. In an emergency however, victim care always takes priority.

Priority of ABCs

The head-to-toe should be completed after the primary survey, so you are already confident in the victim having a patent airway, breathing satisfactorily and with a circulation.

You should always make ABCs a priority when dealing with victims who are appropriate for a secondary survey. In the case of trauma victims, where the victim is conscious and able to talk, keep talking to them throughout. This not only acts to reassure them and inform them

what you're doing, but will assure you that they have a patent airway and are breathing.For unconscious victims, if you are on your own, check the ABCs between checking every body area, or if you are with another competent person, make sure they check ABCs continuously whilst you perform the survey.

 

Remember that if the person is unconscious and if you know or suspect it to be a trauma injury (evidence of blood, fall etc.) than you MUST treat it as a potential spinal injury in the first instance. This is because in trauma, any blow to the head sufficient to cause unconsciousness is also sufficient to cause spinal injury. In this case immobilization of the head, neck and spine takes priority over the secondary survey. If you have a second rescuer or bystander, then have them immobilize while you perform the head-to-toe.

 

What is being looked for?

 

The head-to-toe is a detailed examination where you should look for abnormality. This can take the form of asymmetry; deformity; bruising; point tenderness (wincing or guarding - don't necessarily expect them to tell you); minor bleeding; and medic alert bracelets, anklets, or necklaces.

It is important to remember that some people naturally have unusual body conformation, so be sensitive about this, but don't be afraid to ask the conscious victim or relatives if this is normal for them. It is always worth looking for symmetry - if it is the same both sides, the chances are, it's normal.

The six areas

Divide the body into 6 areas; after you examine each area, you reassess ABCs.

•         Head and neck - The head and neck are important areas to assess, and you should take time and care to look for any potential problems.

•         Head - Using both hands (with gloves on), gently run your hands across the skull, pressing in gently but firmly, starting at the forehead and working around to the back of the head. Feel for indentations, look for blood or fluid and watch the victim for signs of discomfort. If it is a trauma injury, check both ears for signs of blood or fluid.

•         Neck - The neck is an important area. Start at the sides of the neck and gently pressing. Watch carefully for signs of pain. Move around until you reach the spine, moving as far down the neck as possible without moving them, if they are on their back. If there is pain, tenderness or deformity here, then you should stop the survey and immediately immobilize the neck, placing one hand on each side of the head, with the thumb around the ear. This is most comfortable done from 'above' with the victim lying supine on their back, although you should support the victim in the position you find them. If there is room, you can also lie on your front, with your elbows on the floor to support the head. If there are two people, one should immobilize the head, whilst the other continues the survey. If there is only one person, immobilize the head and wait for help.

•         Shoulders, chest and back - This area of the body contains many of the vital organs, so it is important to look for damage which could indicate internal injury

•         Shoulders - You should try and expose the shoulders if possible, looking for obvious deformity, especially around the collar bones. You can try pressing along the line of the collar bone, watching for deformity or pain. You should then place a hand on each shoulder, and gently push down, looking to ensure that one side does not move morethan the other.

•         Chest - The chest is ideally done exposed, although you should be aware of the sensitivity of females to this, and if you are able to keep breasts covered, it is advisable to do so. You should be looking for sections of the chest which are out of line with the rest of it, or which are moving differently to the rest of the chest whilst breathing. You should also look for obvious wounds. You can then gently press on the chest. The best First Aid/Head-to-toe 32 way to do this is to imagine the chest divided in to four quarters running neck to stomach. You should place one hand (balled as a fist works well here, to avoid concerns over excess touching) and press down one on the left and one on the right in each quarter (avoiding breasts if applicable). You are watching for one side moving differently to the other, or for pain being caused.

•         Back - If the victim is lying on their side, or front, you can also feel down their spine. If they are lying on their back, then skip this part of the check, and leave it for the ambulance crew.

•         Arms and hands - Run both your hands down one arm at a time, looking for deformity or pain.

•         Abdomen - The abdomen contains the remainder of the body's critical organs, so it should be checked for potential damage. The abdomen is mostly done by gentle pushing, using the flat of your hands. Again, use symmetry, and push both sides simultaneously. Check if the abdomen feels hard (called 'boarded') or for pain caused by the palpation.

•         Pelvis - The pelvis (hips) is a large bone, with potential for a fair amount of damage. The main diagnostic test to to place a hand on each hip and first gently compress the hips together with both hands (there should be very little movement, and little to no pain). If the patient has moderate to severe pain when the hips are compressed, or the hips move when compressed, do not rock the hips from side to side. If there is no pain or movement, gently push down on the hips in a "rocking" motion to see if there is any movement.

•         Legs and feet - As with arms, use both hands at the same time, running them down the inside and outside of each leg simultaneously (avoiding the groin area on the inside). You should also look for any shortening or rotation of one leg compared to the other. Finally, you take each foot, check that it has normal motility (can be moved normally) and has no obvious injuries

 

As part of your ongoing assessment of the victim, and in preparation for the arrival of any assistance you have called, it is important to keep a check on a victim's vital signs. If possible, these recordings should be written down so that you can keep a record of any changes, and hand this over to the ambulance crew who take the victim from you. Ideally, it should be recorded on a report, which should form part of every first aid kit. Alternatively, you can write it on any piece of paper, or often first aiders end up writing on their protective glove.

 Breathing

 While maintaining an open airway, ensure that the victim is breathing and count the rate of breathing. The easiest way to do this is to count the number of breaths taken in a given time period (15 or 30 seconds are common time frames), and then multiply up to make a minute. The longer the time period, the more accurate it is, however you are likely to want the patient not to converse (as this disrupts their breathing pattern), and it is important not to tell them that you are watching their breathing, as this is likely to make them alter the pattern, so a shorter period is likely to be more useful and reduce worry for the patient.

 In addition to rate, you should note if the breathing is heavy or shallow, and importantly if it is regular. If it is irregular, see if there is a pattern to it (such as breathing slowly, getting faster, then suddenly slower again). Note whether breathing is noisy (wheezing could be a sign of asthma, rattling (also called 'striddor') a sign of fluid in the throat or lungs).

Circulation

 Whereas in the primary survey, we did not check the circulation of the victim to see if the heart was beating (we assumed that if the victim was breathing, their heart was working and if they were not breathing, their heart was also stopped), it is important in monitoring the breathing victim to check their circulation.

 The two main checks are:

• Capillary Refill - The capillaries are the smallest type of blood vessel, and are responsible for getting blood in to all the body tissues. If the blood pressure is not high enough, then not enough blood will be getting to the capillaries. It is especially important to check capillary refill if the victim has suffered an injury to one of their limbs. You check capillary refill by taking the victim's hand, lifting it above the level of the heart, and squeezing reasonably hard for about a second on the nail bed. This should move the blood out, and the nail bed will appear white. If the pink colour returns quickly (and in a healthy victim, it may return before you even move your fingers away to look!), then this is normal. Victims who have poor peripheral circulation, especially the elderly and hypothermia victims, may not demonstrate adequate capillary refill due to general lack of bloodflow, making this test less valuable on these patients. A normal time for the pink colour to return is less than two seconds. If it takes longer than two seconds for colour to return, then this could indicate a problem and you should seek medical advice.

•         Pulse check - As a first aider, you can also check a victim's heart rate by feeling for their pulse. There are three main places you might wish to check for a pulse:

•         Radial pulse - This is the best pulse to look for a first aider, on a conscious victim, as it is non-invasive and relatively easy to find. It is located on the wrist (over the radial bone). To find it, place the victim's hand palm up and take the first two fingers of your hand (NEVER use your thumb, as it contains a pulse of its own) and on the thumb side of the victim's wrist you will feel a rounded piece of bone, move in from here 1-2cm in to a shallow dip at the side of the bone, and press your fingers in (gently), where you should be able to feel a pulse. Taking a pulse here can be a skill that takes practice, so it is worth frequently testing this skill. Should there be no pulse in a victim who is pale and unwell, you are advised to seek medical assistance urgently.

•         Carotid Pulse - This is in the main artery which supplies the head and brain, and is located in the neck. This is best used on unconscious victims, or those victim where you are unable to find a radial pulse. To locate it, place your two fingers in to the indentation to the side of the windpipe, in line with the Adam's Apple (on men), or approximately the location a Adam's Apple would be on women.

•         Pedal Pulse - The pedal pulse can be found in several locations on the foot, and this is used when you suspect a broken leg, in order to ascertain if there is blood flowing to the foot. When measuring a pulse you should measure the pulse rate. This is best achieved by counting the number of beats in 15 seconds, and then multiplying the result by four. You should also check if the pulse is regular or irregular.

Skin

Related to circulation, is the colour of the skin. Changes in circulation will cause the skin to be different colours, and you should note if the victim is flushed, pale, ashen, or blue tinged. It should also be noted if the victim's skin is clammy, sweaty or very dry, and this information should be passed on to the ambulance crew.

Level of Consciousness

You can continue to use the acronym AVPU to assess if the victim's level of consciousness changes while you are with them. To recap, the levels are:

• Alert
• Voice induces response
• Pain induces response
• Unresponsive to stimuli

Pupils

Valuable information can be gained from looking a victim's pupils. For this purpose, first aid kits should have a penlight or small torch in them. Ideally, the pupils of the eye should be equal and reactive to light, usually written down as

PEARL. 

• Pupils
• Equal
• And
• Reactive to Light

To check this, ask the victim to look straight at you with both eyes. Look to see if both pupils are the same size and shape (be sensitive to those who may be blind in one eye, or may even have a glass eye, although they will usually tell you).

To check if they are reactive, take the penlight, and ask the victim to look at your nose. Briefly (5 seconds or so) shield their eye with your hand from the light source where they are (sunlight, room lighting etc.), and then turn on the penlight, positioning it off to the side of their head. Move the penlight in over their eye quickly, and watch to see the size change.

 A normal reaction would be the pupil getting smaller quickly as the light is shone in to it. Repeat on the other eye.

 If both pupils are the same, and both react, note this on your form as PEARL, or else note down what you did, or did not see.

Managing Heart Attack and Angina

Heart attack (myocardial infarction) is when blood supply to the heart or part of the heart is cut off partially or completely, which leads to death of  the heart muscle due to oxygen deprivation. Heart attacks usually occur after periods of rest or being recumbent, and only rarely occur after exercise (despite popular portrayal).

Angina (angina pectoris) is a,'miniature heart attack' caused by a short term blockage. Angina almost always occurs after strenuous exercise or periods of high stress for the victim.

 The key differentiation between a heart attack and angina is that, in line with their typical onset modes, angina should start to relieve very shortly after resting (a few minutes), whereas a heart attack will not relieve with rest.

Recognition

•         Chest pain: tightness in the chest or between the shoulder blades, often radiating intothe left arm, and the jaw

•         Nausea or indigestion (especially in women)

•         Pale, clammy skin

•         Ashen grey skin

•         Impending sense of doom

•         Denial

Treatment

Assist the victim with medication, if they have any. People with angina will often have medication to control it; either as pills or a spray. The pills should never be touched with bare skin by the rescuer, as they may cause a migraine headache, and they are placed under the tongue for absorption. The spray should be taken on the bottom of the tongue.

Only the victim should administer his medication. If he is unable to do so, then the rescuer should not do it for him. Helping to take the lid off or handing the bottle to the victim is fine, this should be documented if patient is transferred to other rescuers.

•         Call for an ambulance if they don't have medication, or if the medication doesn't help

•         Loosen tight clothing, especially around the neck

•         Assist the victim into a recumbent position, with the body leant back at about 45 degrees, with feet on the floor, but knees raised - this puts the patient in a 'W' position.

•         If the patient is not on any anti-coagulant medicine such as heparin or warfarin, then assist them in taking one dose of aspirin if they decide to do so.

•         Continue monitoring vitals

•         Be prepared to do CPR should the victim go into cardiac arrest.

Stroke & TIA

A Stroke is a small blockage in a blood vessel of the brain, which causes oxygen starvation to that part. This oxygen starvation can cause a loss of function, related to the area of the brain affected. Dependant on the length of time the area is blocked, the damage may become irreparable. The blockage is usually caused by a small blood clot, although incursions such as air bubbles can have the same effect.

There are two main types of stroke - a CVA (Cardiovascular Attack - sometimes called just a stroke or major stroke) and a TIA (Transient Ischaemic Attack - sometimes called a mini-stroke). The difference between a CVA and a TIA is simply the duration of the symptoms. If thesymptoms pass

Recognition

To test for the affected side of a stroke, have the victim squeeze your hands at the same time. You will notice a difference in pressure that they may not. The key recognition signs for a stroke can be remembered with the acronym FAST, which

stands for:

•         Facial Weakness - Can the person smile? has their eye or mouth drooped?

•         Arm Weakness - Can the person raise both arms and hold them parallel? If they squeeze your hands can they exert equal force?

•         Speech problems - Can the person speak clearly and understand what you say

•         Test all three symptoms The patient may also experience additional symptoms, which on their own do not indicate a stroke. These include:

•         Sudden blurred, dim or patchy vision

•         Sudden dizziness

•         Sudden, severe, unusual headache

Treatment

Conscious victim

•         Call for an ambulance

•         Reassure the victim

•         Encourage and facilitate the victim to move in to a position of comfort if possible. If they have significant paralysis, they may be unable to move themselves, so you should make them as comfortable as possible where they are. If possible, incline them to the unaffected side (if there is one), as this will help you relieve some symptoms such as a feeling of floating.

•         Take vitals, history and regular observations

Unconscious victim

•         Call for an ambulance

•         Assess the victim's ABCs (attempt CPR if not breathing)

•         Assist the victim into the recovery position on their unaffected side where gravity may assist blood to reach the injured side of the brain, which is below the unaffected side of the brain. Additionally, bleeding (if any) may drain out the ear.

Asthma & Hyperventilation

Introduction

Asthma attacks are characterized by inflammation of the airway, which constricts air exchange. Asthma is a medical condition which causes swelling of the airway, constricting airflow. Hyperventilation is simply breathing at an inappropriately high rate.

Recognition

Asthma is characterized by difficulty breathing, wheezing, increased secretions in the airway, and a history of asthma. Hyperventilation can be recognized by fast breathing which is inappropriate for the circumstances, a feeling of not being able to catch one's breath, and lightheadedness.

Treatment  For Asthma

Asthma inhalers come in several styles. The one on the left is not a fast-acting inhaler, and should not be administered in an asthma attack.

•         If the victim has a fast-acting inhaler for asthma attacks, encourage them to use it. You may assist with finding the inhaler.

•         Have the victim match your breathing patterns - calm the victim while slowing their breathing rate

•         Assist the casualty to sit in a position which relieves pressure on the chest. The tripod position is ideal - sitting up, leaning slightly forward, supporting their weight with their arms either on their knees or on a table or the like in front of them.

•         Call EMS if the victim's condition does not improve or if the victim's level of consciousness is lowered

For Hyperventilation The aim is to calm the casualty down, to reduce their rate of breathing, and if possible to increase the concentration of carbon dioxide in the air they breathe, perhaps by getting them to breathe into a paper bag.

Seizures

A seizure occurs when the electrical activity of the brain becomes irregular. When the electrical activity is severely irregular, the result may be a seizure. A seizure is a medical emergency. Seizures may be caused by either an acute or chronic condition such as epilepsy.

Risk Factors for Seizures:

•         Head trauma

•         Infections of the brain or spinal cord

•         Epilepsy

•         Stroke

•         Drug use or withdrawal

•         Hypoglycemia (Low Blood Sugar)

•         Heat Stroke

•         Fever in infants

Often before a seizure occurs, the victim may feel an aura, which is an unusual sensation that typically precedes seizures. Auras may come in many forms; often if the person is epileptic, they may be aware that a seizure is imminent and may tell others or sit or lie down to prevent injury.

Recognition

Typically seizures usually last no more than three minutes. Some common occurrences during a seizure include stopped or irregular breathing, body rigidness or convulsing, defecation, urination, and drooling.

Treatment

• Never try to restrain the seizure
• Never put anything in the mouth

Seeing a seizure may be a frightening experience which may cause you hesitation to act to aid the victim. However, it is very easy to care for the victim. Never attempt to hold them in any way to stop their seizure - the victim is unaware that it is occurring and is unable to control it. Attempting to restrain an individual having a seizure may result in injuries to both you and the victim. Also, do not attempt to stick anything into the victim's mouth - the victim will not swallow their tongue and sticking something in their mouth can cause further injury or death. The tongue may obstruct the airway during the seizure, but this is normal.

Care for Seizures:

1.       Call EMS or have someone call for you

2.       Move anything the victim can injure themselves with away from the victim such as

3.       chairs or other objects

4.       Gently support the victim's head to prevent it from hitting the ground

5.       Request that all bystanders move away (persons having a seizure are often embarrassed

6.       after their seizure)

7.       After the seizure has ended, roll the victim into the recovery position but only if you do not suspect a spinal injury

After the seizure, the victim will slowly "awaken." Ensure that bystanders are away and offer reassurance for the victim. Victims who have a seizure in public are often self-conscious about their condition. The victim will be very tired after his seizure. Continue to reassure the victim until he or she is fully aware of the surroundings or until EMS

arrives.

Airway Management

Airway Management

Airway management is the process of ensuring that:

1. there is an open pathway between a patient’s lungs and the outside world, and

2. the lungs are safe from aspiration

Manual methods

Head tilt/ Chin lift

The head-tilt chin-lift is the most reliable method of opening the airway. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat.

Jaw thrust

ILCOR no longer advocates use of the jaw thrust, even for spinal-injured victims. Instead, continue use of the head-tilt chin-lift. If there is no risk of spinal injury, it is preferable to use the head-tilt chin-lift procedure which is easier to perform and maintain.

Oral Airways

There are a variety of artificial airways which can be used to keep a pathway between the lungs and mouth/nose.

An oropharyngeal airway can be used to prevent the tongue from blocking the airway. When these airways are inserted properly, the rescuer does not need to manually open the airway. Aspiration of blood, vomitus, and other fluids can still occur.

It is only possible to insert an oral airway when the patient is completely unconscious or does not have a gag reflex. If the patient begins to gag after inserting the oral airway, remove it immediately.

Use and contraindications

The correct size is chosen by measuring against the patient's head (from the earlobe to the corner of the lips). The airway is then inserted into the patient's mouth upside down. Once contact is made with the back of the throat, the airway is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured. Measuring is very important, as the flared ends of the airway must rest securely against the lips to remain secure.

To remove the device, it is pulled out following the curvature of the tongue; no rotation is necessary. The airway does not remove the need for the recovery position: it does not prevent suffocation by liquids (blood, saliva, food, cerebrospinal fluid) or the closing of the glottis.

The mains risks of its use are:

•         if the patient has a gag-reflex they may vomit

•         when it is too large, it can close the glottis and thus close the airway

•         inproper sizing can cause bleeding in the airway

Bag- Valve- Mask (BVM)

A bag valve mask (also known as a BVM or Ambu bag, which is a brand name) is a hand-held device used to provide ventilation to a victim who is not breathing. The device is self-filling with air, although additional O2 can be added.

Use of the BVM to ventilate a victim is frequently called "bagging." Bagging is regularly necessary when the victim's breathing is insufficient or has ceased completely. The BVM is used in order to manually provide mechanical ventilation in preference to mouth-to-mouth resuscitation (either direct or through an adjunct such as a pocket mask).

Components

The BVM consists of a flexible air chamber, about the size of an American football, attached to a face

mask via a shutter valve. When the air chamber or "bag" is squeezed, the device forces air into the victim's lungs; when the bag is released, it self-inflates, drawing in ambient air or oxygen supplied from a tank. A bag valve mask can be used without being attached to an oxygen tank to provide air to the victim, but supplemental oxygen is recommended since it increases the amount of oxygen reaching the victim. Some devices also have a reservoir which can fill with oxygen while the patient is exhaling (a process which happens passively), in order to increase the amount of oxygen that can be delivered to the victim by about twofold. A BVM should have a valve which prevents the victim from re-breathing exhaled air and which can connect to tubing to allow oxygen to be provided through the mask.

Bag valve masks come in different sizes to fit infants, children, and adults. Some types of the device are disposable, while others are designed to be cleaned, disinfected, and reused.

Use

The BVM directs the gas inside it via a one-way valve when compressed by a rescuer; the gas is then delivered through a mask and into the victim's airway and into the lungs. In order to be effective, a BVM must deliver between 700 and 1000 milliliters of air to the victim's lungs, but if oxygen is provided through the tubing and if the victim's chest rises with each inhalation (indicating that adequate amounts of air are reaching the lungs), 400 to 600 ml may still be adequate. Squeezing the bag once every 5 seconds for an adult or once every 3 seconds for an infant or child provides an adequate respiratory rate (12 respirations per minute in an adult and 20 per minute in a child or infant).

Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed around the patient's face (that is, to ensure proper "mask seal"); otherwise, air escapes from the mask and is not pushed into the lungs. In order to maintain this seal, some protocols use a method of ventilation involving two rescuers: one rescuer to hold the mask to the patient's face with both hands and ensure a mask seal, while the other squeezes the bag. However, to make better use of available rescuers, the BVM can be operated by a single rescuer who holds the mask to the victim's face with one hand (using a C-grip), and squeezes the bag with the other.

When using a BVM, as with other methods of ventilation, there is a risk of overinflating the lungs. This can lead to pressure damage to the lungs themselves, and can also cause air to enter the stomach, causing gastric distention which can make it more difficult to inflate the lungs and which can cause the victim to vomit.

This can be avoided by care on behalf of the rescuer. Alternatively, some models of BVM are fitted with a valve which prevents overinflation, by blocking the outlet pipe when a certain pressure is reached, though they should all be able to be bypassed in a situation where more pressure is needed, such as in anaphylaxis.

Suction Devices

In the case of a victim who vomits or has other secretions in the airway, these techniques will not be enough. Suitably trained first aiders may use suction to clean out the airway, although this may not always be possible. A unconscious victim who is vomiting or has copious secretions in the mouth should be turned into the semi-prone position when there is no suction equipment available, as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea.

Oxygen Administration

Nasal Cannula

The nasal cannula is a thin tube with two small nozzles that protrude into the victim's nostrils. It can only provide oxygen at low flow rates: 2-6 liters per minute, delivering a concentration of 28-44%. Use of the nasal cannula at higher flow rates than 6 liters per minute can cause discomfort by drying the nasal passages and pain from the force of the oxygen.

Bag- Valve- Mask

The task of administrating oxygen with bag-valve-mask (BVM) is not very demanding, and requires only one hand to squeeze the bag and one to maintain a good seal with the mask.

Thus, this task can advantageously be achieved by one rescuer, who will then keep their mind free and, being at the head of the victim, have a good view of the overall situation.

The head of the victim can be secured between the knees of the BVM operator. The bag-valve-mask (BVM) is used for victims in critical condition who require pure oxygen. A reservoir bag is attached to a central cylindrical bag, attached to a valved mask that administers 100% concentration oxygen at 8-15LPM. The central bag is squeezed manually to ventilate the victim.

Non- rebreathing Mask

Caution

Do not allow grease or oils to come in contact with or be near oxygen tanks at ANY time. This can cause explosive combustion!

The non-rebreathing mask (NRB) is utilized for patients with multiple trauma injuries, chronic airway limitation/chronic obstructive pulmonary diseases, smoke inhalation, and carbon monoxide poisoning, or any other patient that requires high-flow oxygen, but does not require breathing assistance. It has an attached reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room or exhaled air.

This allows the administration of high concentrations of oxygen, between 65-85%. This device is set to 10-15 lpm, or at least enough to keep the reservoir inflated between breaths. Due to the poor seal on a patient's face, it is exceedingly difficult to obtain anything approaching 100% oxygen with this device. While some patients with Chronic Obstructuve Pulmonary Disease (COPD) rely on what is called hypoxic drive, high flow oxygen should never be witheld from COPD patients who require it.

Pocket Mask

The pocket mask is a small device that can be carried on one's person. It is used for the same victims that the BVM is indicated for, but instead of delivering breaths by squeezing a reservoir, the first aider must actually exhale into the mask. Pocket masks normally have one-way valves built into them to protect against cross-contamination. Many masks also have an oxygen intake built-in, allowing for administration of 50-60% oxygen.